Chapter 23 Antianginals

Before administering isosorbide mononitrate (Imdur) sustained-release tablet to a patient, what is the priority nursing intervention? A. Obtain a blood pressure reading. B. Remind the patient to take the tablet before meals. C. Emphasize that the patient should swallow the tablet whole. D. Advise the patient that Tylenol is used to treat headache.

A

The patient states to the nurse, "My friend said nitroglycerin relieves angina pain by reducing preload. What is preload?" Which statement by the nurse explains preload to this patient? A. "It is the blood return to the heart." B. "It is the oxygen demand of the heart." C. "It is the pressure against which the heart must pump." D. "It is dilation of arteries and veins throughout the body."

A

The nurse understands that a patient receiving nitroglycerin should be monitored for which common adverse effects associated with this medication? (Select all that apply.) A. Flushing B. Headache C. Dizziness D. Hypotension E. Blurred vision

A,B,C,D

For a patient receiving IV nitroglycerin (Tridil), what are the priority nursing interventions? (Select all that apply.) A. Check the heart rate. B. Monitor blood pressure. C. Auscultate lung sounds. D. Measure intake and output. E. Assess for worsening chest pain.

A,B,E

1. A patient will be receiving metoprolol (Lopressor) 5 mg IV push for angina. The medication is available in a strength of 1 mg/mL. Identify how much medication will the nurse draw up for each dose. _______

ANS: 5 mL DIF: COGNITIVE LEVEL: Applying (Application) REF: N/A TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

7. When applying transdermal nitroglycerin patches, which instruction by the nurse is correct? a. "Rotate application sites with each dose." b. "Use only the chest area for application sites." c. "Temporarily remove the patch if you go swimming." d. "Apply the patch to the same site each time."

ANS: A Application sites for transdermal nitroglycerin patches need to be rotated. Apply the transdermal patch to any nonhairy area of the body; the old patch should first be removed. The patch may be worn while swimming, but if it does come off, it should be replaced after the old site is cleansed. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 374 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

4. A 74-year-old professional golfer has chest pain that occurs toward the end of his golfing games. He says the pain usually goes away after one or two sublingual nitroglycerin tablets and rest. What type of angina is he experiencing? a. Classic b. Variant c. Unstable d. Prinzmetal's

ANS: A Classic, or chronic stable, angina is triggered by either exertion or stress and usually subsides within 15 minutes with either rest or drug therapy. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 363 TOP: NURSING PROCESS: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. A patient arrives in the emergency department with severe chest pain. The patient reports that the pain has been occurring off and on for a week now. Which assessment finding would indicate the need for cautious use of nitrates and nitrites? a. Blood pressure of 88/62 mm Hg b. Apical pulse rate of 110 beats/min c. History of renal disease d. History of a myocardial infarction 2 years ago

ANS: A Hypotension is a possible contraindication to the use of nitrates because the medications may cause the blood pressure to decrease. The other options are incorrect. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 364 TOP: NURSING PROCESS: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

1. The nurse is providing education about the use of sublingual nitroglycerin tablets. She asks the patient, "What would you do if you experienced chest pain while mowing your yard? You have your bottle of sublingual nitroglycerin with you." Which actions by the patient are appropriate in this situation? (Select all that apply.) a. Stop the activity, and lie down or sit down. b. Call 911 immediately. c. Call 911 if the pain is not relieved after taking one sublingual tablet. d. Call 911 if the pain is not relieved after taking three sublingual tablets in 15 minutes. e. Place a tablet under the tongue. f. Place a tablet in the space between the gum and cheek. g. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three total.

ANS: A, C, E, G With sublingual forms, the medication is taken at the first sign of chest pain, not delayed until the pain is severe. The patient needs to sit down or lie down and take one sublingual tablet. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient can take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate a myocardial infarction. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved. Placing a tablet between the gum and cheek is the buccal route. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 372 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

2. A patient with a history of angina will be started on ranolazine (Ranexa). The nurse is reviewing the patient's history and will note potential contraindications to this drug therapy if which condition is present? (Select all that apply.) a. Type 2 diabetes mellitus b. Prolonged QT interval on the electrocardiogram c. Heart failure d. Closed-angle glaucoma e. Decreased liver function

ANS: B, E Ranolazine is contraindicated in patients with pre-existing QT prolongation or hepatic impairment. The other options are not contraindications. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 370 TOP: NURSING PROCESS: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

3. A patient has been diagnosed with angina and will be given a prescription for sublingual nitroglycerin tablets. When teaching the patient how to use sublingual nitroglycerin, the nurse will include which instruction? a. Take up to 5 doses at 15-minute intervals for an angina attack. b. If the tablet does not dissolve quickly, chew the tablet for maximal effect. c. If the chest pain is not relieved after one tablet, call 911 immediately. d. Wait 1 minute between doses of sublingual tablets, up to 3 doses.

ANS: C According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient may take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 373 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Management of Care

10. While assessing a patient who is taking a beta blocker for angina, the nurse knows to monitor for which adverse effect? a. Nervousness b. Hypertension c. Bradycardia d. Dry cough

ANS: C Adverse effects of beta blockers include bradycardia, hypotension, dizziness, lethargy, impotence, and several other effects, but not dry cough or nervousness. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 367 TOP: NURSING PROCESS: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

1. When the nurse is administering topical nitroglycerin ointment, which technique is correct? a. Apply the ointment on the skin on the forearm. b. Apply the ointment only in the case of a mild angina episode. c. Remove the old ointment before new ointment is applied. d. Massage the ointment gently into the skin, and then cover the area with plastic wrap.

ANS: C The old ointment should be removed before a new dose is applied. The ointment should be applied to clean, dry, hairless skin of the upper arms or body, not below the elbows or below the knees. The ointment is not massaged or spread on the skin, and it is not indicated for the treatment of acute angina. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 372 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Management of Care

11. When teaching a patient who has a new prescription for transdermal nitroglycerin patches, the nurse tells the patient that these patches are most appropriately used for which situation? a. To prevent low blood pressure b. To relieve shortness of breath c. To prevent the occurrence of angina d. To keep the heart rate from rising too high during exercise

ANS: C Transdermal dosage formulations of nitroglycerin are used for the long-term prophylactic management (prevention) of angina pectoris. Transdermal nitroglycerin patches are not appropriate for the relief of shortness of breath, to prevent palpitations, or to control the heart rate during exercise. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 366 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

8. A patient has been taking a beta blocker for 4 weeks as part of his antianginal therapy. He also has type II diabetes and hyperthyroidism. When discussing possible adverse effects, the nurse will include which information? a. "Watch for unusual weight loss." b. "Monitor your pulse for increased heart rate." c. "Use the hot tub and sauna at the gym as long as time is limited to 15 minutes." d. "Monitor your blood glucose levels for possible hypoglycemia or hyperglycemia."

ANS: D Beta blockers can cause both hypoglycemia and hyperglycemia. They may also cause weight gain if heart failure is developing, and decreased pulse rate. The use of hot tubs and saunas is not recommended because of the possibility of hypotensive episodes. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 367 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control

6. A calcium channel blocker (CCB) is prescribed for a patient, and the nurse provides instructions to the patient about the medication. Which instruction is correct? a. Chew the tablet for faster release of the medication. b. To increase the effect of the drug, take it with grapefruit juice. c. If the adverse effects of chest pain, fainting, or dyspnea occur, discontinue the medication immediately. d. A high-fiber diet with plenty of fluids will help prevent the constipation that may occur.

ANS: D Constipation is a common effect of CCBs, and a high-fiber diet and plenty of fluids will help to prevent it. Grapefruit juice decreases the metabolism of CCBs. Extended-release tablets must never be chewed or crushed. These medications should never be discontinued abruptly because of the risk for rebound hypertension. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 373 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

2. The nurse is giving intravenous nitroglycerin to a patient who has just been admitted because of an acute myocardial infarction. Which statement is true regarding the administration of the intravenous form of this medication? a. The solution will be slightly colored green or blue. b. The intravenous form is given by bolus injection. c. It can be given in infusions with other medications. d. Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used.

ANS: D The non-PVC infusion kits are used to avoid absorption and/or uptake of the nitrate by the intravenous tubing and bag and/or decomposition of the nitrate. The medication is given by infusion via an infusion pump and not with other medications. It is not given by bolus injection. If the parenteral solution is discolored blue or green, it should be discarded. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 372 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Management of Care

9. What action is often recommended to help reduce tolerance to transdermal nitroglycerin therapy? a. Omit a dose once a week. b. Leave the patch on for 2 days at a time. c. Cut the patch in half for 1 week until the tolerance subsides. d. Remove the patch at bedtime, and then apply a new one in the morning.

ANS: D To prevent tolerance, remove the transdermal patch at night for 8 hours, and apply a new patch in the morning. Transdermal patches must never be cut or left on for 2 days, and doses must not be omitted. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 365 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

A patient receiving IV 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 IV nitroglycerin by 10 mcg/min. C. Increase the IV nitroglycerin by 10 mcg/min. D. Recheck the patient's vital signs in 1 hour.

B

The nurse is teaching treatment of acute chest pain for a patient prescribed nitroglycerin (Nitrostat) sublingual tablets. Which instructions should the nurse include? A. Take five tablets every 3 minutes for chest pain. B. Sit or lie down before taking medication. C. Chew or swallow the tablet for the quickest effect. D. Keep the tablets locked in a safe place until you need them.

B

The patient asks the nurse, "How should sublingual nitroglycerin be stored when I travel?" 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 it in your pocket." D. "Keep it in the glove compartment of your car to prevent exposure to heat."

B

When applying nitroglycerin (Nitro-Bid) ointment, the nurse should perform which action? A. Massage and then gently rub the ointment into the skin. B. Apply the ointment to a nonhairy part of the upper torso. C. Apply a thick layer of ointment on the nitroglycerin paper. D. Use the fingers to spread the ointment evenly over a 3-inch area.

B

Which dosage form of nitroglycerin has the longest duration of action? A. Sublingual tablet B. Transdermal patch C. Intravenous (IV) infusion D. Immediate-release tablet

B

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

B

A patient who is taking nitroglycerin (Nitrostat) sublingual tablets is complaining of flushing and headaches. What is the nurse's best response? A. "Put a cold wet washcloth or use an icepack on your forehead and lie down in a quiet place." B. "Stop taking the nitroglycerin because you are experiencing an allergic reaction to the medication." C. "These are the most common adverse effects of nitroglycerin. They should subside with continued use of nitroglycerin." D. "Immediately notify your health care provider because these symptoms are not related to the sublingual nitroglycerin."

C

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

C

It is MOST important for the nurse to instruct a patient prescribed nitroglycerin to avoid which substance? A. Antacids B. Grapefruit juice C. Erectile dysfunction drugs D. Potassium-sparing diuretics

C

The nurse is providing discharge teaching for a patient with a new prescription for nitroglycerin (Nitrostat) sublingual tablets. Which statement by the patient indicates an understanding of the nurse's discharge instructions about this medication? A. "My nitroglycerin tablets are not affected by cold or heat." B. "I can take some aspirin if I get a headache related to nitroglycerin." C. "I will keep my nitroglycerin tablets in their original glass container." D. "I will need to refill my prescription when I feel burning under my tongue."

C

To prevent the development of tolerance to nitroglycerin (Nitro-Bid) transdermal patch, the nurse instructs the patient to perform which action? A. Apply a new nitroglycerin patch every other day. B. Use the nitroglycerin patch for acute episodes of angina only. C. Apply the nitroglycerin patch in the morning and remove it at night for 8 hours. D. Switch to sublingual nitroglycerin when the systolic blood pressure is greater than 140 mm Hg.

C

When caring for a patient with angina pectoris, the nurse would question a prescription for a noncardioselective beta blocker in a patient with which preexisting condition? A. Hypertension B. Atrial fibrillation C. Bronchial asthma D. Myocardial infarction

C

Which instruction should be included in the discharge teaching for a patient with a transdermal nitroglycerin (Nitro-Dur) patch? A. "If you get chest pain, apply a second patch next to the first patch." B. "If you get a headache, remove the patch for 4 hours and then reapply." C. "Make sure to rub a lotion or cream on the skin before putting on a new patch." D. "Apply the patch to a hairless, nonirritated area of the chest, upper arm, back or shoulder."

D