Chapter 7: Cardiovascular Medications Answer key

7.5 Antiarrhythmics – Answer Key

1. Assess heart rate and blood pressure. Also assess for any weight gain, peripheral edema and fatigue. Listen to their lung sounds to see if any crackles, and ask about any shortness of breath.
2. Answer A
3. Answer: Hypotension with a systolic BP less than 90.   Pulse rate less than 50 beats/minute.  Follow agency protocol as the parameters to hold may be different.   Metoprolol can cause bradycardia and AV block.
4. It can be taken with or without food.  Avoid eating grapefruit or drinking grapefruit juice as it can increase the therapeutic levels of verapamil. Drinking small amounts is acceptable. Alcohol consumption will cause additive hypotensive effects.
5. Monitor the heart rate and rhythm as it will prolong the PR interval and widen the QRS. It may prolong the QT interval and report bradycardia. Monitor BP as hypotension can occur during the first few hours of IV therapy. Assess pulmonary status, such as dyspnea, cough and crackles.

 7.6 Cardiac Glycosides – Answer Key

1. A nurse should assess the apical pulse for a full minute before administering digoxin due to its positive inotropic action (it increases contractility, stroke volume, and, thus, cardiac output), negative chronotropic action (it decreases heart rate), and negative dromotropic action (it decreases electrical conduction of the cardiac cells).  These actions can lead to bradycardia.  If the client’s heart rate is less than 60 beats per minute, the nurse should notify the provider before administering digoxin unless other parameters are provided.
2. The nurse evaluates the effectiveness of digoxin based on the client’s blood pressure, apical pulse, and decreased symptoms of heart failure for which it is indicated.
3. The nurse should monitor the client’s serum potassium level because a decreased potassium level places the client at increased risk of digoxin toxicity.  Normal potassium level is 3.5 to 5.0 mEq/L, and a result less than 3.5 should be immediately reported to the provider due the the risk for sudden dysrhythmias. Serum digoxin levels should also be monitored, with a normal therapeutic range being 0.8 to 2 ng/mL.
4. The nurse should assess the client’s apical pulse and  withhold the administration of digoxin.  The nurse should also check for current lab results related to the serum digoxin and potassium levels.  The nurse should notify the provider of the client’s change in condition that could indicate digoxin toxicity and provide information regarding the client’s apical pulse and recent digoxin and potassium levels. An order for a serum digoxin level may be received from the provider. Based on the serum digoxin level, the client may receive a new order for digibind.  Digibind is used to treat digoxin toxicity.

7.7 Antianginal Drugs V2 – Answer Key

1. The nurse should monitor the client’s blood pressure and heart rate.  After 5 minutes, the pain level should be reassessed and a second dose of nitroglycerin administered if the client’s chest pain continues.  If there is no improvement in chest pain, emergency services should be obtained by calling 911 or the rapid response team.
2. Answers:
   1. It works by relaxing the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its work load.  It has minimal arterial dilation.
   2. Use at the first onset of chest pain.  Spray under your tongue. Wait 5 minutes, and if you still have pain, you can give yourself one more spray. Call 911 if pain has not subsided.  If pain continues 5 minutes after your 2nddose, give one more spray.  Use nitro sitting down as you might feel dizzy.
3. Answers:
   1. Transdermal patches are to prevent chronic angina for clients with coronary artery disease.
   2. The nurse should assess blood pressure, heart rate and if the client has experienced any chest pain.
   3. The patch is removed in the evening for a period of 8-12 hours. A new patch is reapplied in the morning. The purpose is to minimize tolerance to the med. Night time removal is done as most clients experience few angina attacks, whereas optimal nitrate sensitivity during the day.

7.8 Anti-hypertensives V2 – Answer Key

Activity 1

1. Metoprolol is a selective Beta-1 blocker that decreases the heart rate and force of contraction to reduce blood pressure.  Lisinopril is an ACE inhibitor that reduces blood pressure through vasodilation and reduces fluid retention. Verapamil is a calcium channel blocker that causes vasodilation to reduce blood pressure. Hydrochlorothiazide is a thiazide diuretic that reduces fluid retention.  For this client, all four medications may be required to maintain a blood pressure within normal range. Recall that triple therapy is considered standard therapy for clients with hypertension. This allows lower dosages, less side effects and the ability to treat hypertension in multiple ways.
2. The nurse should explain that each medication works in different ways within the body to treat high blood pressure.  It is vital to explain the importance of maintaining blood pressure within normal range to prevent additional complications such as a heart attack, heart failure, stroke, and kidney failure.

Activity 2

1. The normal potassium level is 2.5-5.0 mEq/L, so ideally they should be within this range. ACE inhibitors can cause hyperkalemia. If slightly elevated, dietary changes may be required. Consider if this client has renal insufficiency or they take NSAIDs regularly, which may be contributing the the higher potassium levels.
2. The plan would be to lower dietary potassium and to ensure they are not on any potassium supplements. Teach about potassium rich foods such as leafy green vegs, avocados and bananas, and eating them in moderation. They can also increase their fiber intake.  Teach about S&S hyperkalemia such as muscle weakness, cardiac arrhythmias (heart palpitations), fatigue, nausea and numbness/tingling in their hands or feet.
3. Amlodipine health teaching: monitor blood pressure regularly, especially if taking two anti-hypertensives. Assess for fluid retention in ankles. May cause dizziness with changing positions so change positions slowly.

7.9 Antilipemic Medications V2 – Answer Key

1. Answer: A – It is alright to take this med morning or evening, but it is only once a day as it has a long duration of action.
2. Answer C – With hypoactive bowel sounds and abdominal distention, a more thorough assessment should be completed to rule out the risk of bowel obstruction.
3. Answer D – Statins primarily work to lower LDLs and is currently the best medication for this action.
4. Answer A – Statins may cause muscle aches and tenderness. The client needs to report this change in their prescriber right away. Muscle pain can be an early sign of rhabdomyolysis, which  is a rare but life-threatening adverse effect.

7.10 Blood Coagulation Modifiers V2 – Answer Key

Activity 1

1. Warfarin will not dissolve the existing clot, but it will help prevent additional clot formation.
2. When a client is taking warfarin, the nurse should closely monitor INR and PT levels to verify they are in normal range to prevent bleeding complications. Specifically, the therapeutic range for INR is between 2.0 to 3.5 depending upon the indication.
3. Dietary instructions should be provided to maintain a consistent intake of foods high in vitamin K, like leafy green vegetables.  Daily changes in intake of foods that are high in vitamin K will influence the effectiveness of warfarin, as well as the client’s INR levels used to maintain the warfarin levels in therapeutic range.
4. Client education should emphasize bleeding precautions, avoidance of NSAIDs and aspirin, the need for routine therapeutic monitoring, and when to call the provider with signs of increased bleeding or clotting.
5. The reversal agent for warfarin is vitamin K.

Activity 2

1. Chewing aspirin will increase the absorption, so it will begin to work within 5 to 10 minutes.  Swallowing aspirin whole will take 15 to 20 minutes to obtain anti-platelet effects.  Two low-dose aspirins would only be 160 mg. He should be taking 325 mg instead to get the most benefit.
2. Answer: B. Rationale: The spray should be administered onto or under the tongue to allow for rapid absorption into the sublingual mucosa.
3. Answer: C. Rationale: Headache is a very common side effect due to the massive vasodilation of cerebral blood vessels.
4. The higher dose is the loading dose to bring up the client’s blood levels to reach a steady state quickly.  This med is an anti-platelet drug, a P2Y12 Inhibitor, that has similar effects as ASA. It is often given to clients with unstable angina and following coronary stents.
5. You are on two antiplatelet medications. You will likely be on both meds for the next 6-12 months.  Monitor for any significant bleeding such as severe nosebleeds, blood in the stool, or any bleeding that doesn’t stop. use a soft toothbrush to avoid bleeding.  Inform your dentist or other prescribers that you are on these meds, especially if you are going for any planned procedures such as dental work.  Avoid taking any NSAIDs such as ibuprofen.
6. Warfarin is an anticoagulant and is ordered to prevent venous clots, whereas aspirin or clopidogrel are ordered to prevent arterial clots.

7.11 Diuretics

Activity 1

1. Before administering a diuretic, the nurse should assess blood pressure, the daily weight trend, serum potassium and other electrolyte levels, hydration status including 24-hour input/output, and current renal function.
2. Signs of toxicity include blurred vision, nausea, and visual impairment (such as seeing green and yellow halos). A low potassium level can increase the risk of digoxin toxicity. If a client has digoxin toxicity, severe bradycardia and even death can occur if not treated promptly. The normal range for serum potassium is 3.5-5.0 mEq/L.
3. Furosemide (Lasix) is a loop diuretic. Clients receiving loop diuretics are at high risk of dehydration. Loop diuretics work in the loop of Henle where a great deal of sodium and water are either reabsorbed or eliminated by the kidney tubules. The nurse should assess for the development of dehydration in clients receiving diuretics by monitoring skin and mucus membranes for dryness, blood pressure for hypotension, heart rate for tachycardia, decreased urine output, concentrated urine, and increased serum sodium levels.
4. All electrolyte levels can be decreased in clients taking loop diuretics, but potassium in particular is at high risk for depletion due to the rapid water loss that occurs.
5. There is a close relationship between potassium and digoxin. Furosemide can deplete potassium levels, which then increases the risk for developing digoxin toxicity. This occurs because digoxin treats heart failure by inhibiting the Na-K ATPase pump in cardiac cells. Digoxin and potassium compete for binding sites on the heart muscle’s sodium-potassium pump. When furosemide causes low potassium levels, there is less competition, allowing more digoxin to bind to the heart muscle. This can lead to the risk of digoxin toxicity.

Activity 2

1. Answer C: It can cause hyperuricemia. So, inform the prescriber to ensure they are aware. If they need to be on this med, close follow up is required. Thiazides can also cause hyperglycemia so it is not ideal for diabetic clients.
2. Answer D: Spironolactone acts as an aldosterone antagonist, which can cause endocrine-related side effects, including breast tissue growth (gynecomastia) in men and menstrual irregularities in women. 

7.12 Clinical Reasoning and Decision Making Learning Activity – case study

1. Answer A and D. Rationale: CCB are used in the treatment of hypertension or in the prophylaxis of angina pectoris. Diltiazem is also used as an anti-arrhythmic. They block calcium entry into the cells of the vascular smooth muscle and myocardium, resulting in coronary artery dilation and inhibits coronary artery spasm. Diltiazem also decreases AV nodal conduction.
2. True: diltiazem can cause hypotension so tell the client to be careful with position changes to avoid a fall. Peripheral edema can occur due to the vasodilating effects of the med.
3. INR is monitored every 1-2 weeks for a therapeutic range of 2.0-3.0. For clients with a mechanical valve replacement, the therapeutic range is 2.5-3.5.
4. Answer:

• Caution the client to avoid activities that may lead to injury. Also, use a soft toothbrush and be careful with shaving. Anticipate the risk of bruising and report any unusual signs of bleeding such as dark stools and lots of bruising.
• Do not take any OTC meds unless approved by the prescriber including NSAIDs or aspirin.
• Limit alcohol and be consistent with intake. For example, two drinks may increase the anticoagulant effect.
• Be consistent with eating vitamin K rich foods. These foods include leafy greens, avocado, and soy. Some foods increase the risk of bleeding, such as cranberry juice, fish oil, garlic supplements, grapefruit and mango. Some food or supplements decrease the effect of warfarin including high doses of vitamin C, ginseng, and St John’s Wort.
• If sick with a fever, diarrhea or unable to eat, inform your prescriber as the INR testing may need to be increased and warfarin dose may need to be reduced.

5. Taken once a day, the best time is in the evening or bedtime. This is when the endogenous cholesterol is being produced.
6. Answer is A Rationale: a productive cough brought on by a cold is not related to taking ramipril. A dry persistent cough, that can begin a few weeks up to months after starting ramipril should be reported to the prescriber. The client will be then switched from an ACE inhibitor to an Angiotensin Receptor Blocker medication.
7. Common adverse effects include: dizziness, light-headedness, dehydration, constipation.

More significant adverse effects: tinnitus or hearing loss, muscle cramps, electrolyte imbalances (low potassium levels). These            should be reported to their prescriber for further assessment and follow up.