Question 1

A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic and begins having chest pain.The primary care NP administers a nitroglycerin tablet and instructs the patient to lie down.The NP's next action should be to:

A) obtain an electrocardiogram.
B) administer oxygen at 2 L/minute.
C) give 325 mg of chewable aspirin.
D) call EMS.

Accepted Answer

When a patient experiences an acute attack of angina in the clinic,the primary care NP should be prepared to treat the condition.After giving nitroglycerin,oxygen should be administered.An electrocardiogram is not immediately indicated.Chewable aspirin is given if the angina is unrelieved and when the patient is being transported to the hospital.EMS should be activated if there is no pain relief 5 minutes after the first dose of nitroglycerin.

Question 2

A primary care NP prescribes a nitroglycerin transdermal patch,0.4 mg/hour release,for a patient with chronic stable angina.The NP should teach the patient to:&#10;A) change the patch four times daily.&#10;B) use the patch as needed for angina pain.&#10;C) use two patches daily and change them every 12 hours.&#10;D) apply one patch daily in the morning and remove in 12 hours.

Accepted Answer

To avoid tolerance,the patient should remove the patch after 12 hours.The transdermal patch is not changed four times daily or used on a prn basis.The patch is applied once daily.

Question 3

A patient who has a history of angina has sublingual nitroglycerin tablets to use as needed.The primary care nurse practitioner (NP)reviews this medication with the patient at the patient's annual physical examination.Which statement by the patient indicates understanding of the medication?

A) "I should call 9-1-1 if chest pain persists 5 minutes after the first dose."
B) "I should take 3 nitroglycerin tablets 5 minutes apart and then call 9-1-1."
C) "I should take aspirin along with the nitroglycerin when I have chest pain."
D) "I should take nitroglycerin and then rest for 15 minutes before taking the next dose."

"I should call 9-1-1 if chest pain persists 5 minutes after the first dose."

Accepted Answer

Although the traditional recommendation is for patients to take up to 3 nitroglycerin doses over 15 minutes before accessing emergency medical services (EMS),more recent guidelines suggest an alternative strategy to reduce delays in emergency care.These include instructions to call 9-1-1 immediately if pain persists for 5 minutes after the first dose.Aspirin is recommended when the patient is being transported to emergency care and is not recommended as an adjunct to nitroglycerin with each episode of chest pain.The three doses of nitroglycerin are given 5 minutes apart over 15 minutes.

Question 4

A 45-year-old patient who has a positive family history but no personal history of coronary artery disease is seen by the primary care NP for a physical examination.The patient has a body mass index of 27 and a blood pressure of 130/78 mm Hg.Laboratory tests reveal low-density lipoprotein,110 mg/dL; high-density lipoprotein,70 mg/dL; and triglycerides,120 mg/dL.The patient does not smoke but has a sedentary lifestyle.The NP should recommend:

A) 30 minutes of aerobic exercise daily.
B) taking 81 to 325 mg of aspirin daily.
C) beginning therapy with a statin medication.
D) starting a thiazide diuretic to treat hypertension.

Accepted Answer

This patient is overweight but not obese,and blood lipids are within normal limits.Blood pressure is not elevated.Exercise is recommended as an initial risk reduction strategy because of its positive effects on blood pressure and blood lipids.Aspirin is generally given to patients older than 55 to 65 who are at risk.Statin medications and thiazide diuretics are not indicated.

Question 5

The primary care NP is preparing to prescribe isosorbide dinitrate sustained release (Dilatrate SR)for a patient who has chronic,stable angina.The NP should recommend initial dosing of:&#10;A) 60 mg four times daily at 6-hour intervals.&#10;B) 40 mg twice daily 30 minutes before meals.&#10;C) 60 mg on awakening and 40 mg 7 hours later.&#10;D) 80 mg three times daily at 8:00 AM, 1:00 PM, and 6:00 PM.

Accepted Answer

Long-acting nitrates should be considered to treat chronic,stable angina.The main limitation is tolerance,which can be limited by providing a nitrate-free period of 6 to 10 hours each day.The medication should be taken on an empty stomach,30 to 60 minutes before a meal.An appropriate initial dose of isosorbide dinitrate is 40 mg every 12 hours.This dose can be increased as needed.Isosorbide mononitrate is given on awakening and again 7 hours later.The medication is not given four times daily.Dosing may be increased to 80 mg tid,and the dosing schedule of 8:00 AM,1:00 PM,and 6:00 PM.would be appropriate at that point.

Question 6

A patient who will begin using nitroglycerin for angina asks the primary care NP how the medication works to relieve pain.The NP should tell the patient that nitroglycerin acts to:&#10;A) dissolve atheromatous lesions.&#10;B) relax vascular smooth muscle.&#10;C) prevent catecholamine release.&#10;D) reduce C-reactive protein levels.

Accepted Answer

Nitrates relax vascular smooth muscle via stimulation of intracellular cyclic guanosine monophosphate production with the major effect being to reduce myocardial oxygen demand.Nitrates do not dissolve atheromatous lesions,prevent catecholamine release,or reduce C-reactive protein levels.

Question 7

A patient who has angina uses 0.4 mg of sublingual nitroglycerin for angina episodes.The patient brings a log of angina episodes to an annual physical examination.The primary care NP notes that the patient has experienced an increase in frequency of episodes in the past month but no increase in duration or severity of pain.The NP should:

A) increase the nitroglycerin dose to 0.6 mg per dose.
B) change from a sublingual to a transdermal patch nitroglycerin.
C) discontinue the nitroglycerin and order ranolazine (Ranexa ER).
D) contact the patient's cardiologist to discuss admission to the hospital.

Accepted Answer

Unstable angina is a change in pattern or pain,such as an increase in frequency,severity,or duration of pain and fewer precipitating factors.Patients with unstable angina should be admitted to a coronary care unit.The primary care NP should not change any medications without consultation with the patient's cardiologist.

Deck 18: Coronary Artery Disease and Antianginal Medications