Beta Blockers and ACE Inhibitors: Pulse Checks, Safe Discontinuation, Potassium, and Angioedema
For a beta blocker, teach the client to check the pulse, report a rate under 60/min or dizziness, and never stop the drug suddenly. For an ACE inhibitor, teach slow position changes, reporting of a persistent dry cough, potassium and kidney function checks, avoidance in pregnancy, and a 911 call for swelling of the face, lips, tongue, or throat.
Who needs this teaching
Clients who take a beta blocker, an ACE inhibitor, or both for hypertension, heart failure with reduced ejection fraction, or after myocardial infarction, and the caregiver. Both drug classes lower blood pressure and protect the myocardium. Both require daily use even without symptoms.
The priority teaching points
- Purpose of each drug. Beta blockers (generic names end in -lol, such as metoprolol and carvedilol) lower heart rate, contractility, and blood pressure, and reduce myocardial oxygen demand. ACE inhibitors (generic names end in -pril, such as lisinopril) block angiotensin II formation, cause vasodilation, reduce aldosterone, and limit ventricular remodeling. Take both every day, including when the client feels well.
- Beta blocker monitoring. Check the pulse and blood pressure as instructed. Call the provider before the dose when the pulse is under 60/min, below the prescribed limit, or with dizziness. Fatigue is common early in therapy. Report wheezing, new dependent edema, or weight gain during dose increases.
- Never stop a beta blocker suddenly. Abrupt withdrawal causes rebound tachycardia, hypertension, angina exacerbation, and myocardial infarction. The provider tapers the dose over 1 to 2 weeks. Keep refills current.
- Diabetes. Beta blockers mask the tachycardia and tremor of hypoglycemia. Diaphoresis remains. Check blood glucose when the client feels shaky, sweaty, hungry, or confused, and treat a reading below 70 mg/dL.
- ACE inhibitor: first doses and cough. First-dose hypotension occurs, especially with diuretic therapy or volume depletion. Rise slowly. A persistent dry, nonproductive cough results from bradykinin accumulation. Report it; the provider switches to an angiotensin II receptor blocker (ARB).
- Angioedema. Swelling of the face, lips, tongue, or throat, or difficulty swallowing or breathing, requires a 911 call. Angioedema occurs at any time, even after years of therapy, and occurs more often in Black clients. The client never takes an ACE inhibitor again after angioedema.
- Potassium, kidneys, and pregnancy. ACE inhibitors cause hyperkalemia. Avoid potassium supplements, potassium-containing salt substitutes, and potassium-sparing diuretics unless prescribed. Check serum potassium (normal 3.5 to 5.0 mEq/L) and serum creatinine 1 to 2 weeks after starting or a dose change, then as ordered. Report vomiting, diarrhea, or poor fluid intake. Ask before NSAIDs. ACE inhibitors cause fetal toxicity; report a possible pregnancy immediately.
Red flags the client reports
| Call the provider the same day | Call 911 or the local emergency number |
|---|---|
| Pulse under 60/min or below the prescribed limit | Swelling of the face, lips, tongue, or throat |
| Dizziness or lightheadedness on standing | Difficulty swallowing or breathing |
| Persistent dry cough | Syncope |
| Weight gain, new dependent edema, or wheezing | Chest pain or severe shortness of breath |
| Vomiting, diarrhea, or a possible pregnancy | Severe muscle weakness with an irregular pulse |
Teach-back questions
- "What pulse rate means you call before your beta blocker dose?"
- "What will you do if you run out of your beta blocker?"
- "How will you know your blood sugar is low?"
- "Which salt substitutes and supplements will you avoid?"
- "What will you do if your lips or tongue swell?"
Teaching tips
- Provide a blood pressure and pulse log, and observe a return demonstration.
- Write the pulse limit and laboratory dates on the handout.
- Teach the -lol and -pril endings so the client recognizes each class.
- Review contraception with clients who can become pregnant.
Read more on NCLEXPace
- Cardiac Drugs on the NCLEX: Digoxin, ACE Inhibitors and Nitrates
- Beta Blockers vs Calcium Channel Blockers on the NCLEX
- NCLEX Drug Suffixes: The Endings That Answer Questions For You
Sources
- Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapters: Hypertension; Heart Failure.
- Jones DW, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Hypertension. 2025;82(10):e212-e316.
- Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation. 2022;145(18):e895-e1032.
- Metoprolol Succinate Extended-Release Tablets and Lisinopril Tablets: FDA prescribing information (DailyMed).
Why this matters for the NCLEX
Teaching is effective when the client states, "I will not stop my metoprolol suddenly," and "I will call 911 if my lips or tongue swell." Statements requiring further teaching include, "I will use a salt substitute instead of salt," "I will stop my beta blocker when my blood pressure is normal," and "A dry cough means I need cough syrup, not a call."
Frequently asked questions
Does a dry cough from an ACE inhibitor require stopping all blood pressure treatment?
No. The client reports the cough, and the provider switches to an ARB. The client does not stop treatment independently.
Why does a client with diabetes need extra teaching about beta blockers?
Beta blockers mask the tachycardia and tremor of hypoglycemia. The client checks blood glucose when symptoms are unclear.
More patient teaching on Cardiovascular
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