A nurse is providing discharge teaching to a client who had an exacerbation of COPD. The client is prescribed a fluticasone by metered-dose inhaler. Which of the following instructions should the nurse include?

Anticipated:

• Metoprolol 5 mg every 2 to 3 min up to three doses
• Oxygen at 2 L/min via nasal cannula
• Draw electrolytes along with Hgb and Hct
• Morphine 6 mg IV bolus every 3 hr as needed for pain
• Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses

Nonessential:

• Obtain daily weight

Contraindicated:

• Atropine 0.5 mg IV bolus every 5 min up to 2 mg

Rationale:

• Metoprolol 5 mg every 2 to 3 min up to three doses: Beta-blockers reduce myocardial oxygen demand by decreasing heart rate and blood pressure, making them beneficial in acute coronary syndrome. They should be used cautiously in patients with signs of heart failure or bradycardia.
• Oxygen at 2 L/min via nasal cannula: Supplemental oxygen is recommended for clients with acute coronary syndrome when oxygen saturation is below 94% to optimize myocardial oxygen supply and prevent ischemia.
• Draw electrolytes along with Hgb and Hct: Electrolytes are critical in evaluating myocardial function, and hemoglobin/hematocrit levels help assess perfusion and oxygen-carrying capacity.
• Morphine 6 mg IV bolus every 3 hr as needed for pain: Morphine is used to relieve severe chest pain in myocardial infarction and reduce myocardial oxygen demand by decreasing anxiety and preload.
• Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses: Nitroglycerin dilates coronary arteries, improving oxygen delivery to the myocardium, and reduces preload and afterload, alleviating chest pain. It is a first-line treatment for angina and myocardial infarction but should be avoided in cases of hypotension.
• Obtain daily weight: Daily weight monitoring is primarily used for fluid balance assessment in conditions like heart failure rather than for acute myocardial infarction management.
• Atropine 0.5 mg IV bolus every 5 min up to 2 mg: Atropine is used to treat bradycardia. However, the client is tachycardic, so atropine would worsen the condition and is contraindicated.

A. Decorticate posturing: This is a late sign of increased intracranial pressure, indicating severe brain dysfunction and potential herniation. Early signs of increased ICP typically involve subtle neurological changes such as restlessness, confusion, or irritability before progressing to abnormal posturing.

B. Restlessness: An early sign of increased ICP, restlessness occurs due to decreased cerebral perfusion and oxygenation, leading to subtle changes in mental status. Clients may also exhibit irritability, confusion, or difficulty following commands before more severe symptoms develop.

C. Papilledema: Swelling of the optic disc, or papilledema, is a later sign of increased ICP and occurs due to prolonged pressure on the optic nerve. It is typically detected on an ophthalmic exam rather than presenting as an early symptom.

D. Projectile vomiting: Vomiting without nausea is a later sign of increased ICP, often associated with brainstem involvement. Early manifestations tend to involve altered mental status before progressing to severe symptoms such as vomiting or posturing.