Medications

Question 1

Which symptom would cause the nurse to suspect that the client is experiencing digitalis toxicity?

a. Abdominal cramping
b. Bradycardia
c. Polyuria
d. Hearing disturbances

Answer 1

ANS: B

This is a sign of digoxin toxicity, because digoxin (Lanoxin) slows and strengthens ventricular contraction.

Question 2

A nurse is preparing to administer nitroglycerin (NTG) via the sublingual route. The nurse knows that nitroglycerin tablets are administered sublingually to:

a. avoid the bitter taste.
b. prevent nausea and vomiting.
c. absorb readily into the circulation.
d. undergo first-pass metabolism.

Answer 2

ANS: C

Sublingual medications are absorbed quickly into the bloodstream and are ready for action earlier than oral medications.

Question 3

A client is ordered to receive a nitrate to relieve stable angina. What is(are) a common side effect(s) to anticipate in a client receiving this medication?

a. Nausea and vomiting
b. Increased blood pressure
c. Pruritus and skin rash
d. Pounding headache

Answer 3

ANS: D

the pounding headache is related to vasodilation of the cerebral vessels

Question 4

The client is being treated with Nitro-stat. She is also being treated with heparin. The nurse anticipates that the combination of the two medications will result in a(n) _____ effect of the _____.

a. increased; Nitro-stat
b. increased; heparin
c. decreased; Nitro-stat
d. decreased; heparin

Answer 4

ANS: D

The combination of nitroglycerin with heparin will result in a decrease in the effect of the heparin.

Question 5

A client has congestive heart failure and has been taking digoxin (Lanoxin) for 9 years. The client is admitted with signs and symptoms of digoxin toxicity. Which signs and symptoms are associated with digoxin toxicity? (Select all that apply.)

a. Scomota
b. Vomiting
c. Supraventricular tachycardia
d. Yellow halos in the visual field
e. Diarrhea
f. Insomnia

Answer 5

ANS: B, D, E

Vomiting, yellow halos in the visual field and diarrhea are classic signs of digoxin toxicity.

Question 6

Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer?

A) Isosorbide mononitrate (Isordil)
B) Meperidine hydrochloride (Demerol)
C) Morphine sulfate (Morphine)
D) Nitroglycerin transdermal patch

Answer 6

C
Feedback:
Morphine not only decreases pain perception and anxiety but also helps to decrease heart rate, blood pressure, and demand for oxygen. Nitrates are administered for vasodilation and pain control in clients with angina–type pain, but oral forms (such as Isordil) have a large first-pass effect, and transdermal patch is used for long-term management. Demerol is a synthetic opioid usually reserved for treatment of postoperative or migraine pain.

Question 7

The nurse cautions the patient taking nadolol (Corgard) for angina that they may experience what adverse effect?
A)Dry mouth
B)Decreased exercise tolerance
C)Constipation
D)Problems with urination

Answer 7

Ans:
B
Feedback:
Nadolol is a beta-blocker that can cause a decreased tolerance to exercise because of the inability to experience the effects of the stress reaction. Dry mouth, constipation, and problems with urination are effects often seen with anticholinergic drugs but not with beta-blockers.

Question 8

The nurse, caring for a patient taking a beta-blocker and a nitrate to treat angina, recognizes the need for careful monitoring as the result of what secondary diagnosis?
A)Chronic obstructive pulmonary disease (COPD)
B)Rheumatoid arthritis (RA)
C)Irritable bowel syndrome (IBS)
D)Chronic urinary tract infection (UTI)

Answer 8

Ans:
A
Feedback:
The nurse should assess for COPD, because the effect of beta-blockers in reducing effects of the sympathetic nervous system could exacerbate the respiratory condition. RA, IBS, and chronic UTI are not affected by the use of beta-blockers or nitrates to treat angina.

Question 9

A patient is being monitored with a Swan-Ganz catheter and is to receive the drug nitroprusside. In evaluating the effectiveness of the drug, the nurse should expect to find which of the following?

1. increased pulmonary artery wedge pressure
2. decreased systemic vascular resistance
3. increased right atrial pressure
4. decreased cardiac output

Answer 9

2

Rationale: Nitroprusside is a potent systemic vasodilator with primary action on decreasing afterload, which is measured by systemic vascular resistance. The wedge pressure, an indirect measure of left ventricular workload, should also decrease. Right atrial pressure or preload will decrease as vasodilation occurs. Although cardiac output may decrease in some patients, in actuality nitroprusside administration will decrease workload and may increase stroke volume and cardiac output.

Question 10

What assessment is most appropriate for the client receiving sodium nitroprusside?

A. Assess for chest pain.
B. Assess blood pressure every 15 minutes.
C. Monitor urinary output every 30 minutes.
D. Observe the client’s extremities for color and perfusion.

Answer 10

B
The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes. Higher doses can cause systemic vasodilation and increase shock.

Question 11

The nurse is preparing to administer sodium nitroprusside (Nipride) to a client. Which important action related to the administration of this drug does the nurse implement?

a. Assess the client’s respiratory rate.
b. Administer the medication with gravity tubing.
c. Protect the medication from light with an opaque bag.
d. Monitor for hypertensive crisis.

Answer 11

C
Sodium nitroprusside (Nipride) must be protected from light to prevent degradation of the drug. It should be delivered via pump. This medication does not have any effect on respiratory rate. Hypertension is a sign of milrinone (Primacor) overdose.

Question 12

A patient is admitted with left-sided heart failure and a blood pressure of 220/118 mm Hg. Which of the following drugs will be most effective in decreasing the blood pressure and reducing afterload?

a. Dopamine (Intropin) c. Propranolol (Inderal)
b. Verapamil (Calan) d. Sodium nitroprusside (Nipride)

Answer 12

D
Sodium nitroprusside (Nipride) is a potent, rapidly acting venous and arterial vasodilator, particularly suitable for rapid reduction of blood pressure in hypertensive emergencies and perioperatively. It also is effective for afterload reduction in the setting of severe heart failure. The drug is administered by continuous intravenous infusion, with the dosage titrated to maintain the desired blood pressure and systemic vascular resistance.

Question 13

Which medication may be administered to the patient with hypertensive crisis?

a. Digitalis c. Verapamil
b. Vasopressin d. Sodium nitroprusside

Answer 13

D
Sodium nitroprusside is frequently the first drug used to lower blood pressure in hypertensive emergency. Sodium nitroprusside is useful because of its half-life of seconds. It is not suitable for long-term use because of development of a metabolite that causes cyanide-like toxicity. Short-acting beta-blockers that are effective are labetalol and esmolol. Beta-blockers are especially effective if aortic dissection is present. Digoxin is frequently prescribed for atrial fibrillation.

Question 14

An older adult recovering from a myorcardial infarction (MI) has been taking subcutaneous heparin but is now to receive oral warfarin (Coumadin). The nurse prepares to teach the patient which topics? (Select all that apply.)

a. Administration of both medications for up to 5 days
b. Need to use a soft bristle toothbrush
c. Use of atropine as an antidote for exces-sive bleeding
d. Need to continue drawing partial throm-boplastin times
e. Need to drink at least eight cups of fluids daily

Answer 14

A, B, D
Heparin and warfarin (Coumadin) are anticoagulants used to prevent the enlargement of existing thrombi and new clot formation after an MI. Therapeutic effects of heparin are monitored by partial thromboplastin times; the antidote is protamine sulfate. Warfarin is monitored by the in-ternational normalized ratio (INR); the antidote is vitamin K. Patients who initially receive hepa-rin for anticoagulation and who need oral anticoagulation for maintenance usually take both forms of medication for 3 to 5 days to develop therapeutic blood levels. Bleeding is a complica-tion. Patients need to be taught bleeding precautions.

Question 15

A patient is admitted to the hospital with unstable angina and will undergo a percutaneous coronary intervention. Which drug regimen will the nurse expect to administer to prevent thrombosis in this patient?

a. Aspirin, clopidogrel, omeprazole
b. Aspirin, heparin, abciximab [ReoPro]
c. Enoxaparin [Lovenox], prasugrel [Effient], warfarin [Coumadin]
d. Heparin, alteplase, abciximab [ReoPro]

Answer 15

B

Abciximab, combined with ASA and heparin, is approved for IV therapy for patients undergoing PCI.

Question 16

The nurse is administering heparin, subcutaneous twice daily, for a patient in cardiogenic shock. The expected action of this drug is as:

1. an inotropic to improve cardiac contractibility.
2. an anticoagulant to prevent blood clots.
3. an antidysrhythmic to restore normal cardiac contractibility.
4. a vasopressor to increase blood pressure.

Answer 16

2

Cardiogenic shock may produce clots because of blood stasis and the heparin may prevent this.

Question 17

The nurse is reviewing the health history for a patient who may be a candidate for thrombolytic therapy for the treatment of an MI. The nurse knows that therapy is contraindicated in which circumstances?

1. Menses
2. A history of intracranial hemorrhage
3. Hemophilia
4. Liver disease
5. Peptic ulcer disease

Answer 17

2,3,4,5
Rationale 1: Menses is not a contraindication for thrombolytic therapy.
Rationale 2: A history of intracranial hemorrhage is a contraindication for thrombolytic therapy.
Rationale 3: Hemophilia, a clotting disorder, is a contraindication for thrombolytic therapy.
Rationale 4: Liver disease is a contraindication for thrombolytic therapy.
Rationale 5: Peptic ulcer disease is a contraindication for thrombolytic therapy.
Global Rationale: A history of intracranial hemorrhage is a contraindication for thrombolytic therapy. Hemophilia, a clotting disorder, is a contraindication for thrombolytic therapy. Liver disease and peptic ulcer disease are contraindications for thrombolytic therapy. Menses is not a contraindication for thrombolytic therapy.

Question 18

The client with acute MI had a stroke 1 month ago. Which of the following statements is correct regarding the administration of thrombolytic therapy?

A. The stroke should not affect administration of this therapy.
B. The stroke is a relative contraindication to administration of this therapy.
C. The stroke is an absolute contraindication for administration of this therapy.
D. The stroke indicates increased risk for an extension of the current MI.

Answer 18

C
Recent stroke (within 2 months) is an absolute contraindication to thrombolytic therapy

Question 19

Thrombolytic therapy is being prepared for administration to an older adult patient who has presented to the emergency department with an ST-segment elevation MI (STEMI). The nurse recognizes that the primary goal of this intervention is:

A) To restore the flow of blood through the coronary arteries
B) To restore function to infarcted myocardial cells
C) To relieve the patient’s symptoms of chest pain and dyspnea
D) To prevent the rupture of atheromas

Answer 19

A

Question 20

A client brought to the emergency room has been diagnosed with an acute myocardial infarction. The physician has ordered thrombolytic therapy with reteplase (Retavase). What is the indication for this therapy?

A. This therapy will reverse any myocardial damage if given within 2 hours of the event.
B. This therapy restores perfusion to the injured area, reducing the size of the infarct.
C. This therapy restores coronary reperfusion without risk of internal bleeding.
D. This therapy makes percutaneous transluminal coronary angioplasty (PTCA) un-necessary.

Answer 20

B
Thrombolytic therapy is indicated in MI to restore perfusion to the injured area, thereby limiting the size of the infarct. Establishing sustained reperfusion in the first few hours after an MI has resulted in a decreased incidence of mortality.

Question 21

A client presents to the emergency department complaining of chest pain that began 2 hours earlier; the client’s electrocardiogram (ECG) is consistent with acute myocardial infarction.
The nurse would know that the standard treatment at this time is
a. diazepam.
b. lidocaine.
c. streptokinase.
d. verapamil.

Answer 21

C
Clinicians treat acute MI with medications that lyse (dissolve) the clot that forms part of the blockage of the coronary artery. Thrombolytic therapy includes streptokinase, urokinase, tissue plasminogen activator (t-PA, alteplase), anisoylated plasminogen-streptokinase activator complex (APSAC, anistreplase), urokinase plasminogen activator, and the newest agent, reteplase. To qualify for thrombolytic agents, the client must present within 12 hours after the onset of chest pain, meet specific diagnostic criteria, and have no absolute contraindications for the therapy.

Question 22

The drug alteplase (t-PA) is given to the patient with a myocardial infarction (MI). The nurse is aware the drug will:

a. dissolve the obstruction in the coronary artery.
b. dilate vessels to relieve pain.
c. strengthen cardiac contraction.
d. increase cardiac output.

Answer 22

A

Alteplase (t-PA) is a thrombolytic drug that will dissolve the clot if given within 12 hours of the MI.

Question 23

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for

a. decreased blood pressure and heart rate.
b. fewer complaints of having cold hands and feet.
c. improvement in the strength of the distal pulses.
d. the ability to do daily activities without chest pain.

Answer 23

ANS: D
Because the medication is ordered to improve the patient’s angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective -adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.

Question 24

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention?

a. The patient’s most recent blood pressure (BP) reading is 158/91 mm Hg.
b. The patient’s pulse has dropped from 68 to 57 beats/minute.
c. The patient has developed wheezes throughout the lung fields.
d. The patient complains that the fingers and toes feel quite cold.

Answer 24

ANS: C
The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective -blockers) is occurring. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with -receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated. However, this is not as urgently needed as addressing the bronchospasm.

Question 25

For which of the following patients is the use of warfarin (Coumadin) most clearly indicated?

A) A 40-year-old man whose recent chest pain has been diagnosed as a pulmonary embolism
B) A woman who developed a deep vein thrombosis in her leg following surgery
C) A 78-year-old woman who has a history of atrial fibrillation
D) A 68-year-old man who has been diagnosed with an acute myocardial infarction

Answer 25

C

Question 26

A patient who has atrial fibrillation is taking digoxin. The nurse expects which medication to be given concurrently to treat this condition?

a. Hydrochlorothiazide (HydroDIURIL)
b. Inamrinone (Inocor)
c. Milrinone (Primacore)
d. Warfarin (Coumadin)

Answer 26

ANS: D
Digoxin is given for atrial fibrillation to restore a normal heart rhythm. To prevent thromboemboli, warfarin is given concurrently. Hydrochlorothiazide is a diuretic medication. Inamrinone and milrinone are inotropic agents that would be used instead of digoxin.

Question 27

The nurse is caring for an 82-year-old patient who takes digoxin to treat chronic atrial fibrillation. When caring for this patient, to monitor for drug side effects, what will the nurse will carefully assess?

a. Blood pressure
b. Heart rate
c. Oxygen saturation
d. Respiratory rate

Answer 27

ANS: B
Most of digoxin is eliminated by the kidneys, so a decline in kidney function can cause digoxin accumulation, which can cause bradycardia. Digoxin should not be given to any patient with a pulse less than 60 beats per minute.

Question 28

The client who is to receive cardioversion in 3 days for treatment of continuous atrial fibrillation has laboratory values of Na 139 mEq/L, K 4.0 mEq/L, and Cl 98 mEq/L and is receiving digoxin 0.125 mg daily. Before the procedure the nurse would

a. confirm an order for a digoxin level before cardioversion.
b. monitor blood pressure more frequently.
c. notify the physician regarding the potassium level.
d. proceed with preparation for cardioversion.

Answer 28

A
If the client has been taking a digitalis preparation, a therapeutic drug level must be present. Di-gitalis toxicity may predispose the client to the development of ventricular dysrhythmias during cardioversion.

Question 29

The nurse performs an electrocardiogram and finds the older adult patient is in atrial fibrillation (AF). Time of onset is unknown but could be as long as 3 months earlier when the patient was last assessed.
What drug will the nurse expect to be ordered?
A) Anticoagulant
B) Digoxin
C) Quinidine
D) Ibutilide

Answer 29

A
Feedback:
If the onset of AF is not known and it is suspected that the atria may have been fibrillating for longer than 1 week, the patient is better off staying in AF without drug therapy or electrocardioversion. Prophylactic oral anticoagulants are given to decrease the risk of clot formation and emboli being pumped into the system. In 2011, the American Heart Association and American College of Cardiology endorsed dabigatran (Pradaxa) as the anticoagulant of choice for prophylaxis in AF. Conversion in this case could result in potentially life-threatening embolization of the lungs, brain, or other tissues. Administration of other antiarrhythmics would not be indicated.

Question 30

A patient who takes spironolactone for heart failure has begun taking digoxin (Lanoxin) for atrial fibrillation. The primary care NP provides teaching for this patient and asks the patient to repeat back what has been learned.
Which statement by the patient indicates understanding of the teaching?
a. “I should avoid high-sodium foods.”
b. “I should eat foods high in potassium.”
c. “I need to take a calcium supplement every day.”
d. “I should use a salt substitute while taking these medications.”

Answer 30

A
Patients should be taught to reduce their overall sodium intake by avoiding salty foods and not adding salt while cooking. Spironolactone is a potassium-sparing diuretic and carries a risk of hyperkalemia, which can make the myocardium more sensitive to the effects of digoxin. Hypercalcemia can predispose the patient to digoxin toxicity. Salt substitutes are high in potassium.

Question 31

Which of the following cardiac arrhythmias would not be amenable to treatment with digoxin (Lanoxin)?

a. Atrial fibrillation
b. Premature ventricular contractions
c. Atrial flutter
d. Paroxysmal atrial tachycardia

Answer 31

ANS: B
In addition to treating heart failure, cardiac glycosides such as digoxin are occasionally used to control the ventricular rate of atrial fibrillation, atrial flutter, and paroxysmal atrial tachycardia (PAT).

Question 32

A nurse caring for a client with atrial fibrillation who is started on digoxin therapy is required to monitor plasma drug levels. The nurse would report which level to the primary health care provider?
A) 1.6 ng/mL
B) 1.8 ng/mL
C) 2.0 ng/mL
D) 2.2 ng/mL

Answer 32

Ans: D
Feedback:
A plasma digoxin level of more than 2 ng/mL would require the nurse to report to the primary health care provider; therefore, plasma digitalis levels of 2.2 ng/mL indicate digoxin toxicity. The therapeutic levels range from 0.5 to 2 ng/mL.

Question 33

A patient is diagnosed with atrial fibrillation. The nurse should be prepared to instruct the patient on which of the following?

1. anticoagulant therapy precautions
2. how to take a radial pulse before taking medications
3. the need to check blood pressure daily at home
4. the importance of daily weights

Answer 33

1

Rationale: Patients in atrial fibrillation require anticoagulation such as warfarin therapy so the nurse should be prepared to instruct the patient on anticoagulant therapy precautions. Counting the radial pulse before taking mediations might be indicated if the patient were prescribed digoxin. There is no evidence to suggest that the patient needs to measure a daily blood pressure or monitor daily weights.

Question 34

Which medication may be administered to the patient with hypertensive crisis?

a. Digitalis c. Verapamil
b. Vasopressin d. Sodium nitroprusside

Answer 34

D
Sodium nitroprusside is frequently the first drug used to lower blood pressure in hypertensive emergency. Sodium nitroprusside is useful because of its half-life of seconds. It is not suitable for long-term use because of development of a metabolite that causes cyanide-like toxicity. Short-acting beta-blockers that are effective are labetalol and esmolol. Beta-blockers are especially effective if aortic dissection is present. Digoxin is frequently prescribed for atrial fibrillation.

Question 35

A patient has been taking digoxin 0.25 mg and furosemide 40 mg daily. When a nurse enters the room, the patient states, “There are unusual yellow halos around the lights.” Select the nurse’s next action.

1. Assess the patient for other symptoms of digitalis toxicity.
2. Withhold the next dose of furosemide.
3. Administer both medications as prescribed.
4. Document the findings and reassess in 1 hour.

Answer 35

1

Question 36

The nurse is caring for a patient recently admitted to the ICU with heart disease. Which adverse effect of digoxin is considered the most life-threatening if digoxin (Lanoxin) toxicity develops?

a. Dysrhythmias
b. Heart murmur
c. Slow respiratory rate
d. Tachycardia

Answer 36

ANS: A
Dysrhythmias are the most serious adverse effect of digoxin. Patients should be monitored frequently for changes in heart rate (bradycardia) and rhythm (A-V conduction problems).
A heart murmur is not an indication of digoxin toxicity, nor is a slow respiratory rate.
Bradycardia is a more accurate indication of digoxin toxicity than tachycardia.

Question 37

The nurse has a prescription to give a client a scheduled dose of digoxin (Lanoxin). Prior to administering the medication, the nurse assesses for which of the following manifestations that could indicate digoxin toxicity?

1. Dyspnea, edema, and palpitations
2. Chest pain, hypotension, and paresthesias
3. Constipation, dry mouth, and sleep disorder
4. Double vision, loss of appetite, and nausea

Answer 37

ANS:4
Rationale: Double vision, loss of appetite, and nausea are signs of digoxin toxicity. Other signs of digoxin toxicity include bradycardia, visual alterations (such as green and yellow vision, or seeing spots or halos), confusion, vomiting, diarrhea, decreased libido, and impotence. The other options are incorrect because they do not identify manifestations of digoxin toxicity.

Question 38

A client has congestive heart failure and has been taking digoxin (Lanoxin) for 9 years. The client is admitted with signs and symptoms of digoxin toxicity. Which signs and symptoms are associated with digoxin toxicity? (Select all that apply.)

a. Scomota
b. Vomiting
c. Supraventricular tachycardia
d. Yellow halos in the visual field
e. Diarrhea
f. Insomnia

Answer 38

ANS: B, D, E

Vomiting, yellow halos in the visual field and diarrhea are classic signs of digoxin toxicity.

Question 39

A client is demonstrating signs and symptoms of digoxin toxicity. The nurse anticipates that the client will be treated with:

a. vitamin K.
b. digoxin immune Fab (Digibind).
c. inamrinone lactate (Inocor).
d. naloxone (Narcan).

Answer 39

ANS: B

Digoxin immune Fab (Digibind) is the antidote for digoxin toxicity.

Question 40

A male patient of African-American descent is prescribed hydralazine and isosorbide (BiDil) as treatment for heart failure. What should the nurse instruct the patient about this medication?
Select all that apply.
1. “Change positions slowly.”
2. “Dizziness and fainting are expected adverse effects of this medication.”
3. “You may have a headache when starting this medication, but it will subside.”
4. “Notify the healthcare provider if you have chest pain while taking this medication.”
5. “Do not take medications to treat erectile dysfunction while taking this medication.”

Answer 40

Correct Answer: 1, 3, 4, 5
This drug can cause a drop in blood pressure, particularly when changing positions from lying to sitting or sitting to standing. The patient should change positions slowly and use caution to prevent falls. Headache is a common adverse effect of this drug, particularly when first starting therapy. Headaches tend to subside with continued treatment. The doctor should be notified if chest pain develops while taking this medication. Drugs such as sildenafil (Viagra, Revatio), vardenafil (Levitra), or tadalafil (Cialis) are not to be taken while taking this medication because the combination may cause an extreme drop in blood pressure, leading to fainting, chest pain, or a heart attack. Dizziness and fainting should be reported to the healthcare provider as they may indicate a significant drop in blood pressure.

Question 41

The nurse is caring for an African American male who has just been diagnosed with hypertension and mild heart failure. The nurse anticipates that this patient will be started on which medications?

1. A combination drug like hydralazine and isosorbide dinitrate
2. A calcium channel blocker like nifedipine (Adalat)
3. An ACE inhibitor like enalapril (Vasotec)
4. A beta-adrenergic antagonist like atenolol (Tenormin)
5. An angiotensin-II receptor blocker like clonidine (Catapres)

Answer 41

1,2
Rationale 1: The combination drug BiDil, a fixed dose combination of hydralazine and isosorbide dinitrate is used to treat heart failure African American patients appear to show an enhanced response to this medication.
Rationale 2: Calcium channel blockers seem to provide the greatest blood pressure reduction in this population.
Rationale 3: Monotherapy with ACE inhibitors does not reduce blood pressure as effectively in African Americans as in other groups.
Rationale 4: Monotherapy with beta-adrenergic antagonists does not reduce blood pressure as effectively in African Americans as in other groups.
Rationale 5: Monotherapy with angiotensin-II receptor blockers does not reduce blood pressure as effectively in African Americans as in other groups.
Global Rationale: Thiazide diuretics seem to provide the greatest blood pressure reduction in this population. Calcium channel blockers seem to provide the greatest blood pressure reduction in this population. Monotherapy with ACE inhibitors does not reduce blood pressure as effectively in African Americans as in other groups.
Monotherapy with beta-adrenergic antagonists does not reduce blood pressure as effectively in African Americans as in other groups. Monotherapy with beta-adrenergic antagonists does not reduce blood pressure as effectively in African Americans as in other groups.

Question 42

A hospitalized patient complains of acute chest pain, which he rates as a 9 on a scale of 0 to 10. The nurse administered a 0.4 mg sublingual nitroglycerin tablet, and now finds his vital signs to be stable. The nurse’s next step is to

a. provide a second dose of nitroglycerin in 5 minutes.
b. continue dosing at 10-minute intervals.
c. obtain a transcutaneous pacer.
d. increase the dose to 1 mg.

Answer 42

ANS: A
An initial dose of sublingual nitroglycerin is given, and if the chest pain persists, such as in this case, the patient should take another dose of NTG in 5 minutes.
Dosing at 10-minutes interval is incorrect, because the time span is too long.
A transcutaneous pacer would be indicated for an abnormal heart rhythm, but there is no indication the heart rhythm is abnormal.
SL nitroglycerin is available in 0.3 to 0.6 mg doses, not 1 mg.

Question 43

A physician writes an order to teach a patient about nitroglycerin. A nurse correctly educates the patient that nitroglycerin (Select all that apply.)

1. Should be swallowed.
2. Is administered sublingually.
3. Is used in the treatment of angina.
4. Should be protected from light and moisture.
5. Should be placed under the tongue prior to chest pain.

Answer 43

2,3,4

Question 44

The post–percutaneous transluminal coronary angioplasty client complains of severe chest pain. What is the nurse’s best action?

A. Administer IV morphine as ordered PRN.
B. Administer sublingual nitroglycerin.
C. Notify the physician.
D. Perform a standard 12-lead ECG.

Answer 44

C
After PTCA, a small percentage of clients experience acute restenosis (closure) of the affected coronary artery. Chest pain similar to that experienced before the procedure may indicate acute restenosis. The client will need to return to the catheterization laboratory to have the procedure repeated and may also need stent placement to maintain a patent vessel lumen.

Question 45

A nurse is caring for a client admitted to the hospital with a complaint of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states that there is no change in the level of discomfort experienced.

What would be the nurse’s best action?
A. Place the client in a semi-Fowler’s position.
B. Administer oxygen via a nasal cannula.
C. Administer morphine sulfate IV.
D. Notify the health care provider.

Answer 45

D
When a client experiences chest discomfort unrelieved by nitroglycerin, the client may be expe-riencing a myocardial infarction. The health care provider should be notified and the client pre-pared for transfer to a unit prepared to provide specialized cardiac care.

Question 46

When the angina pectoris patient complains of chest pain at rest that takes three nitroglycerin (NTG) pills to relieve, the nurse assesses this as a major symptom of:

1. stable angina.
2. unstable angina.
3. full-blown acute MI.
4. pulmonary embolus.

Answer 46

2
An angina patient who has pain at rest that is not relieved with only one NTG is considered to have unstable angina, a precursor to an acute MI.

Question 47

A patient is brought into the emergency department (ED) by family members who tell the nurse the patient grabbed his chest and complained of substernal chest pain that feels like something is sitting on his chest.

The pain radiates to the jaw and the left shoulder. The nurse notes the patient is diaphoretic and short of breath. What is the nurse's priority action?
A) Notify the physician of a probable MI
B) Take vital signs
C) Give sublingual nitroglycerin
D) Administer oxygen

Answer 47

Ans: D
Feedback: Myocardial ischemia is a condition in which heart muscle cells receive less oxygen than needed. The nurse’s priority action would be to provide more oxygen to the myocardium. Once oxygen has been started, a cardiac monitor is attached to the patient, vital signs are taken, and sublingual nitroglycerin given. The physician would be notified by a staff member not involved with the patient’s care.

Question 48

Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer?

A) Isosorbide mononitrate (Isordil)
B) Meperidine hydrochloride (Demerol)
C) Morphine sulfate (Morphine)
D) Nitroglycerin transdermal patch

Answer 48

C
Feedback:
Morphine not only decreases pain perception and anxiety but also helps to decrease heart rate, blood pressure, and demand for oxygen. Nitrates are administered for vasodilation and pain control in clients with angina–type pain, but oral forms (such as Isordil) have a large first-pass effect, and transdermal patch is used for long-term management. Demerol is a synthetic opioid usually reserved for treatment of postoperative or migraine pain.

Question 49

The nurse is teaching a patient about the use of sublingual nitroglycerin. Which statement indicates understanding of the teaching plan?

A) “I must swallow the tablet whole without chewing.”
B) “I should take a tablet about 45 minutes before initiating a strenuous activity that causes angina.”
C) “I’ll keep the nitroglycerin in its original dark, airtight container.”
D) “I’ll take a tablet every 5 minutes until my chest pain stops.”

Answer 49

Ans: C
Feedback: To maintain potency, nitroglycerin should be kept in its original dark, airtight container. Sublingual nitroglycerin tablets should be placed under the tongue and allowed to dissolve; they shouldn’t be chewed or swallowed. Tablets may be placed under the tongue about 5 to 10 minutes before an activity known to cause angina. If angina occurs, one tablet should be placed under the tongue every 5 minutes until pain is relieved, up to a total of three tablets in 15 minutes. If the angina still isn’t relieved, the patient should seek immediate treatment.

Question 50

The nurse in the emergency department is assessing a 64-year-old patient experiencing substernal chest pain. The patient’s electrocardiogram shows evidence of myocardial ischemia.

Which statement indicates to the nurse that the patient may be a candidate for thrombolytic therapy?
A) “I have had chest pain for 2 days.”
B) “My chest pain started 3 hours ago.”
C) “My chest pain stops when I take a nitroglycerin pill.”
D) “I have had chest pain on and off all week.”

Answer 50

Ans: B
Feedback: Because it takes 4 to 6 hours for myocardial cells to die, thrombolytic therapy should be given within 6 hours of the onset of chest pain to achieve the best results in an acute myocardial infarction. The patient who has waited 2 days to be treated for chest pain won’t benefit from thrombolytic therapy. Chest pain that’s relieved by nitroglycerin is most likely due to angina and not an indication for thrombolytic therapy. Chest pain for 1 week is also beyond the 6-hour time limit.