Antianginal Drugs

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Which instruction should be included in the discharge teaching for a patient with a transdermal nitroglycerin patch? A. "Apply the patch to a nonhairy, nonirritated area of the upper torso or arms." B. "Apply the patch to the same site each day to maintain consistent drug absorption." C. "If you get a headache, remove the patch for 4 hours and then reapply." D. "If you get chest pain, apply a second patch right next to the first patch."

A A nitroglycerin patch should be applied to a nonhairy, nonirritated area for the best and most consistent absorption rates. Sites should be rotated to prevent skin irritation, and the drug should be continued if headache occurs because tolerance will develop. Sublingual nitroglycerin should be used to treat chest pain.

A patient who is prescribed sublingual nitroglycerin (Nitrostat) reports after six months that the medication does not sting or burn when placed under the tongue. The nurse instructs the patient to obtain a new prescription from the primary health care provider. What is the purpose of obtaining a new prescription? A. The drug has lost its potency. B. The patient has developed drug tolerance. C. The patient needs a lower drug dose. D. The drug can cause toxicity.

A If nitroglycerin (Nitrostat) does not sting or burn under the tongue, it indicates that the drug has lost its potency and thus a new prescription is needed for therapeutic benefits. The nurse should advise the patient to store the drug in its original container in a cool and dry place so that it does not lose potency. Drug tolerance is indicated if the potent drugs do not have the desired effect on the patient. A lower dose is prescribed if the patient has any adverse effects. Toxic levels are more of a concern if the patient's hepatic function is impaired.

Nitrates relieve angina pain by reducing preload. How would the nurse explain the term preload to a patient? A. It is the blood volume within the heart. B. It is the pressure within the superior vena cava. C. It is the pressure against which the heart must pump. D. It is the oxygen demand of the heart.

A Preload is determined by the amount of blood in the ventricle just before contraction.

Which event is likely to induce a cardiac event in a patient who is prescribed sublingual nitroglycerin (Nitrostat)? A. Sexual intercourse B. Syncope C. Migraine D. Late-night dinner

A Sublingual nitroglycerin (Nitrostat) is prescribed for patients in whom any physical activity may cause an unexpected angina episode. Sexual intercourse is a physical activity that may cause chest pain or angina in the patient. Syncope and migraine are side effects of the drug and do not cause a cardiac event. Large meals, not a late-night dinner, may be stressful for the patient with angina and may induce a cardiac event.

When titrating intravenous nitroglycerin, which assessment findings does the nurse monitor? (Select all that apply.) A. Blood pressure B. Heart rate C. Chest pain D. Respiratory rate

A, B, C Intravenous nitroglycerin can cause hypotension and tachycardia. Relief of chest pain and/or systolic blood pressure

Which classes of drugs are used in the treatment of angina pectoris? Select all that apply. A. Nitrates and nitrites B. Beta blockers C. Calcium channel blockers (CCBs) D. Diuretics E. Antihistamines

A, B, C Nitrates and nitrites minimize the frequency of angina attacks by dilating all blood vessels. Beta blockers are effective after a myocardial infarction to minimize the negative effects of catecholamines. Calcium channel blockers help decrease the afterload and reduce the workload of the heart. Diuretics are not prescribed for the treatment of angina pectoris but to increase the patient's fluid output. Antihistamines are used to reduce the physiologic and pharmacologic effects of histamine.

The nurse is reviewing drug interactions with a male patient who has a prescription for isosorbide dinitrate (Isordil) as treatment for angina symptoms. Which substances listed below could potentially result in a drug interaction? a. A glass of wine b. thyroid replacement hormone c. tadalafil (Cialis), an erectile dysfunction drug d. metformin (Glucophage), an antidiabetic drug e. carvedilol (Coreg), a beta blocker

A, C, E

Which statement indicates that the patient understands discharge teaching about nitroglycerin? A. "I will need to refill my prescription once a year in order to maintain potency." B. "I will need to keep the nitroglycerin stored in the bottle it comes in." C. "I will take a nitroglycerin tablet every 15 minutes until my chest pain is gone." D. "I should take a nitroglycerin tablet 2 hours before I want to engage in activity that will cause chest pain."

B Nitroglycerin needs to be stored away from heat, humidity, and light, all of which can decrease its potency. Keeping it in the brown light-resistant bottle helps achieve this. It should be replaced every 3 to 6 months in order to maintain potency. Nitroglycerin is used every 5 minutes for pain relief or just before engaging in activity that is known to cause chest pain.

A 68-year-old male patient has been taking nitrate isosorbide dinitrate (Isordil) for 2 years for angina. He recently has been experiencing erectile dysfunction and wants a prescription for sildenafil (Viagra). Which response would the nurse most likely hear from the prescriber? a. "He will have to be switched to isosorbide mononitrate if he wants to take sildanefil." b. "Taking sildenafil with the nitrate may result in severe hypotension, so a contraindication exists." c. "I'll write a prescription, but if he uses it, he needs to stop taking the isosorbide for one dose." d. "These drugs are compatible with each other, so I'll write a prescription."

B

When applying nitroglycerin ointment, the nurse should perform which action? A. Use the fingers to spread the ointment evenly over a 3-inch area. B. Apply the ointment to a nonhairy part of the upper torso. C. Massage the ointment into the skin. D. Apply two thick lines of ointment over the prescribed measured area on the nitroglycerin paper.

B Absorption is best over a nonhairy portion of skin. The upper torso is the preferred site of application. The nurse should wear gloves when applying to prevent transdermal absorption by the applier. The ointment is measured as one straight line on the nitroglycerin patch and is gently spread over paper and applied, but not rubbed, into the skin. Rubbing would increase absorption and risks of side effects.

The patient asks how nitroglycerin should be stored while traveling. What is the nurse's best response? A. "You can protect it from heat by placing the bottle in an ice chest." B. "It's best to keep it in its original container away from heat and light." C. "You can put a few tablets in a resealable bag and carry in your pocket." D. "It's best to lock them in the glove compartment of your car to keep them away from heat and light."

B Although nitroglycerin needs to be kept in a cool, dry place, it should not be placed in an ice chest where it could freeze. It should also not be locked up and needs to be kept away from light, not in a clear plastic bag.

A patient receiving intravenous nitroglycerin at 20 mcg/min complains of dizziness. Nursing assessment reveals a blood pressure of 85/40 mm Hg, heart rate of 110 beats/min, and respiratory rate of 16 breaths/min. What is the nurse's best action? A. Assess the patient's lung sounds. B. Decrease the intravenous nitroglycerin by 10 mcg/min. C. Increase the intravenous nitroglycerin by 10 mcg/min. D. Recheck the patient's vital signs in 1 hour.

B Nitroglycerin, as a vasodilator, causes a decrease in blood pressure. Because it is short-acting, decreasing the infusion rate will allow the blood pressure to rise. The patient should be monitored every 10 minutes while changing the rate of the intravenous nitroglycerin infusion.

The nurse observes that administration of a topical nitrate drug (Nitro-Dur) has resulted in skin inflammation in a patient with angina. The nurse documents the reaction but does not stop the medication. What is the reason for the nurse's action? A. The patient doesn't complain of any pain. B. The reaction is a contact dermatitis. C. The reaction is normal in the initial doses. D. The allergy is caused due to drug-food interaction.

B Skin inflammation in the patient is caused by the dosage delivery system and not by the drug. It may not be an allergic reaction to the drug, but a contact dermatitis. Hence, the nurse need not discontinue the dose. Rashes and inflammation are an indication of allergic reactions, not pain. Skin inflammation is not normal in the initial doses; hence the nurse needs to assess the reaction carefully. The nurse should understand that the allergic reaction is not due to food-drug interaction but is a contact dermatitis.

A patient with coronary artery disease reports chest pain. On assessment, the nurse learns that the patient does not engage in strenuous physical activity. What else will the nurse need to assess to understand the cause of the chest pain? A. Fluid intake B. Caffeine intake C. Pulse oximetry readings D. Pulse readings

B The nurse should assess the caffeine intake of the patient who complains of chest pain. Caffeine increases heart rate and contractility, which increases oxygen demand and, as a result, may cause chest pain. Fluid intake needs to be assessed in a patient who is at risk for dehydration. Pulse readings do not help the nurse understand the cause of chest pain. Instead, chest pain or angina may cause a fluctuation in the pulse readings. Pulse oximetry readings will help the nurse understand the oxygen saturation levels in a patient; however, they can be assessed once the cause of chest pain is determined.

Which are common side effects of nitroglycerin? (Select all that apply.) A. Blurred vision B. Flushing C. Headache D. Hypotension

B, C, D Common side effects of nitroglycerin include flushing, headache, and hypotension.

A nurse with adequate knowledge about the administration of intravenous nitroglycerin will recognize which statement is correct? A. Intravenous form is given by IV push injection B. Because the intravenous forms are short-lived, the dosing must be every 2 hours. C. Intravenous nitroglycerin must be protected from exposure to light through use of special tubing. D. Intravenous nitroglycerin can be given via gravity drip infusions.

C

A patient has a new prescription for transdermal nitroglycerin patches. The nurse teaches the patient that these patches are most appropriately used for what reason? A. To relieve exertional angina B. To prevent palpitations C. To prevent palpitations D. To stop an episode of angina

C

Calcium channel blockers reduce myocardial oxygen demand by reducing afterload. How would the nurse explain afterload to the patient? A. It is the blood volume within the heart. B. It is the pressure within the heart. C. It is the pressure against which the heart must pump. D. It is the contractility of the heart muscle.

C Afterload is determined by the pressure in the aorta just before systole.

A patient who is taking sublingual nitroglycerin is complaining of flushing and headaches. What is the nurse's best response? A. "This is a normal response to your chest pain." B. "Stop taking the nitroglycerin because you are probably allergic to it." C. "These are the most common side effects of nitroglycerin. They should subside with continued use of nitroglycerin." D. "These symptoms are not related to your sublingual nitroglycerin. You should notify your doctor for diagnostic testing."

C Headache and flushing are the most common side effects of nitroglycerin and will subside with continued use.

What is included in the priority assessment before administering isosorbide mononitrate (Imdur)? A. Serum electrolytes B. Blood urea nitrogen (BUN) and creatinine C. Blood pressure D. Level of consciousness

C Mononitrate is a vasodilator and thus can cause hypotension. It is important to assess blood pressure before administering.

When caring for a patient with angina, the nurse would question an order for a noncardioselective beta blocker in a patient with what coexisting medical diagnosis? A. Hypertension B. Atrial fibrillation C. Bronchial asthma D. Myocardial infarction

C Noncardioselective beta blockers should be used with caution in patients with bronchial asthma since any level of blockade of beta2-receptors can promote bronchoconstriction through unopposed parasympathetic (vagal) tone.

Which patient is likely to be prescribed beta blockers? A. A diabetic patient who is experiencing chest pain B. A cardiac patient who has a history of asthma C. A cardiac patient who has had a myocardial infarction D. A cardiac patient with peripheral vascular disease

C The beta blockers block all the harmful effects of the circulating catecholamines that increase the heart rate after a myocardial infarction. Beta blockers can cause both hypoglycemia and hyperglycemia in diabetic patients and should not be used. Beta blockers are not used in patients with asthma as they cause bronchoconstriction and increased airway resistance. Beta blockers can also compromise cerebral or peripheral blood flow in patients with peripheral vascular disease.

What is the duration of action of a nitroglycerin transdermal patch (Nitro-Dur)? A. 3 to 5 minutes B. 0.5 to 1 hour C. 8 to 12 hours D. 4 to 6 hours

C The duration of action of a nitroglycerin transdermal patch (Nitro-Dur) is 8 to 12 hours. The duration of action of intravenous nitroglycerin (Nitro-Bid) is 3 to 5 minutes. The duration of action of a sublingual tablet (Nitrostat) is 0.5 to 1 hour. The duration of action of an immediate-release tablet (Isordil) is 4 to 6 hours.

What does the nurse instruct a patient who is prescribed nitroglycerin patches (Nitro-Dur), to prevent the development of tolerance to nitrates? A. "Apply the nitroglycerin patch every other day." B. "Use sublingual nitroglycerin if your systolic blood pressure is 140 mm Hg." C. "Apply the nitroglycerin patch each day, and remove it for 10 hours at night." D. "Use the nitroglycerin patch for acute episodes of angina only."

C Tolerance can be prevented by maintaining an 8- to 12-hour nitrate-free period each day. Applying the patch every other day will not have the therapeutic effects. Sublingual nitroglycerin (Nitrostat) is more effective for chest pain. The patch is removed for 8 hours every night, and a new patch is applied in the morning. Sublingual nitroglycerin is administered for treating acute episodes of angina.

In order to prevent the development of tolerance, the nurse instructs the patient to perform which action? A. Apply the nitroglycerin patch every other day. B. Switch to sublingual nitroglycerin when the patient's systolic blood pressure elevates to >140 mm Hg. C. Apply the nitroglycerin patch for 16 hours each and remove for 8 hours at night. D. Use the nitroglycerin patch for acute episodes of angina only.

C Tolerance can be prevented by maintaining an 8-hour nitrate-free period each day.

While assessing a patient with angina who is to start beta blocker therapy, the nurse is aware that the presence of which condition may be a problem if these drugs are used? a. Hypertension b. Essential tremors c. Exertional angina d. Asthma

D

It is most important to instruct a patient prescribed nitroglycerin to avoid which substance(s)? A. Antacids B. Grapefruit juice C. Thiazide diuretics D. Erectile dysfunction medications

D Concurrent administration of erectile dysfunction medications such as sildenafil citrate (Viagra) can cause an acute exacerbation of nitrate-related hypotension.

Patient teaching regarding sublingual nitroglycerin should include which statement? A. "You can take up to five doses every 3 minutes for chest pain." B. "Chew the tablet for the quickest effect." C. "Keep the tablets locked in a safe place until you need them." D. "Sit or lie down after you take a nitroglycerin tablet to prevent dizziness."

D Nitroglycerin is a vasodilator and can cause orthostatic hypotension, resulting in dizziness. It should be kept in a readily accessible location for immediate use should chest pain occur. Three tablets may be taken 5 minutes apart. It should be placed under the tongue and allowed to dissolve.

Which statement by the patient demonstrates a need for further education regarding nitroglycerin? A. "If I get a headache, I should keep taking my nitroglycerin and use Tylenol for pain relief." B. "I should keep my nitroglycerin in a cool, dry place." C. "I should change positions slowly to avoid getting dizzy from the nitroglycerin's effect on my blood pressure." D. "I can take up to four tablets at 5-minute intervals for chest pain."

D Patients are taught to take up to three tablets 5 minutes apart. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after one dose, the patient (or family member) must call 911 immediately.

Which statement made by the patient demonstrates a need for further instruction regarding the use of nitroglycerin? A. "If I get a headache, I should keep taking nitroglycerin and use acetaminophen (Tylenol) for pain relief." B. "I should keep my nitroglycerin in a cool, dry place." C. "I should change positions slowly to avoid getting dizzy." D. "I can take up to five tablets at 3-minute intervals for chest pain if necessary."

D Patients are taught to take up to three tablets every 5 minutes. If no relief from chest pain is obtained after one tablet, they should seek medical assistance and take up to two more tablets. All other responses demonstrate a good understanding by the patient.

The nurse is monitoring a patient during intravenous (IV) nitroglycerin infusion. Which assessment finding will cause the nurse to take action? A. Blood pressure 110/90 mm Hg B. Flushing C. Headache D. Chest pain

D The patient should not continue to have chest pain while on IV nitroglycerin. This would prompt the nurse to intervene. Blood pressure of 110/90 mm Hg is not cause for concern and is expected with nitroglycerin. Headache and flushing are common side effects of nitroglycerin.

Which nitrate preparation or dosage form has the longest duration of action? A. Sublingual nitroglycerin B. Sublingual isosorbide dinitrate C. Oral isosorbide dinitrate D. Transdermal nitroglycerin patch

D The transdermal patch has an 8- to 12-hour duration of action, compared with 0.5 to 6 hours for the other choices.

Which statement by the patient reflects the need for additional patient education about the calcium channel blocker diltiazem (Cardizem)? a. "I can take this drug to stop an attack of angina." b. "I understand that food and antacids alter the absorption of this oral drug." c. "When the long-acting forms are taken, the drug cannot be crushed." d. "This drug may cause my blood pressure to drop, so I need to be careful when getting up."

a

A patient with angina has been given a prescription for a calcium channel blocker. The nurse knows that this class of drugs is used to treat which type of angina? a. effort b. unstable c. crescendo d. vasospastic

d