NUR 254 Exam 2 – Galen College of Nursing | 490+ Critical Care & Med-Surg NCLEX-Style Q&A

Why this document will help you pass NUR 254 Exam 2: 490+ exam-style multiple-choice & select-all-that-apply (SATA) questions 100% exam-focused – no filler, no outdated content Critical care and shock management – septic shock (lactate levels), hypovolemic shock, neurogenic shock Cardiovascular conditions – DVT (sudden SOB = PE), heart failure (digoxin toxicity, pulmonary crackles), MI (nitroglycerin, aspirin, beta-blockers), hypertension (ACE inhibitors, HCTZ) Respiratory conditions – COPD (pursed-lip breathing), asthma (peak flow meter, red zone), pulmonary embolism (spiral CT), tension pneumothorax (tracheal deviation), chest tube management Endocrine disorders – DKA (pH 7.3, HCO3 15), hyperthyroidism (exophthalmos, thyroid storm), hypothyroidism (levothyroxine), diabetes insipidus (desmopressin), SIADH (hyponatremia) Neurological conditions – increased ICP (Cushing's triad, late signs), stroke (NIHSS, dysphagia precautions), spinal cord injury (autonomic dysreflexia), Guillain-Barré (ascending paralysis), myasthenia gravis (anticholinesterase inhibitors) Renal & urinary disorders – acute kidney injury (prerenal, oliguria), chronic kidney disease (erythropoietin, dialysis), pyelonephritis (CVA tenderness), renal calculi (flank pain) Gastrointestinal disorders – pancreatitis (elevated amylase/lipase), cholecystitis (RUQ pain), appendicitis (McBurney's point), diverticulitis, cirrhosis (ascites, paracentesis), peptic ulcer disease (H. pylori) Hematologic conditions – DIC (oozing from IV sites), hemophilia A (Factor VIII), ITP (thrombocytopenia), sickle cell anemia (vaso-occlusive crisis, hydroxyurea) Psychiatric disorders – bipolar disorder (mania, lithium toxicity), schizophrenia (paranoid delusions, negative symptoms), depression (SSRIs, MAOIs), anxiety (panic attack, benzodiazepines) Emergency & prioritization – blood transfusion reactions (stop transfusion first), anaphylaxis (epinephrine), chest tube disconnection (submerge in sterile water), compartment syndrome (paresthesia, pain with passive stretch) Correct answers embedded – efficient self-testing No rationales – streamlined for fast memorization and exam simulation Topics covered include: Septic shock (increased lactate – earliest indicator of deterioration) DVT (sudden SOB – pulmonary embolism requires immediate intervention) Glipizide (consume regular diet, avoid skipping meals) Blood transfusion (ABO and Rh factor compatibility) Warfarin (avoid green leafy vegetables, monitor INR) SIADH (hyponatremia) Rhabdomyolysis (acute kidney injury from crush injury) Atelectasis (postoperative upper abdominal surgery – highest risk) Chest tube (intermittent bubbling in suction control chamber – normal) Digoxin toxicity (bradycardia) Oxygen for MI (decrease workload on heart) IV potassium chloride (dilute in large volume, never IV push) Addisonian crisis (IV hydrocortisone immediately) Increased ICP (Cushing's triad – wide pulse pressure, bradycardia, irregular respirations) DKA (pH 7.3, HCO3 15) Tracheostomy suctioning (break in sterile technique – contaminating catheter tip on bed linen) Ascites (sodium restriction 2g/day) MDI technique (exhale, press canister, inhale slowly, hold breath) Left-sided heart failure (pulmonary crackles) Pancreatitis (elevated serum amylase) Hyperthyroidism (exophthalmos) Tension pneumothorax (tracheal deviation to unaffected side – priority) Osteoporosis risk (post-menopausal female) Wernicke's encephalopathy (thiamine) NG tube (water-soluble lubricant to nares to prevent drying) Dysphagia (honey-thick liquids) Nitroglycerin patch (remove old patch before applying new one) Myasthenia gravis (anticholinesterase inhibitors) TPN (monitor serum triglycerides for lipid emulsion complications) SSRI (monitor for worsening suicidal ideation in first few weeks) Small bowel obstruction (foul-smelling, fecal-like drainage) Guillain-Barré (respiratory failure – priority) Increased ICP positioning (HOB 30 degrees, neck neutral) PAD (walk through pain to point of tolerance) Community-acquired pneumonia (macrolide – first-line outpatient) Compartment syndrome (paresthesia in fingers) Bipolar mania (overly optimistic and grandiose) Heparin (therapeutic aPTT 60 seconds) Hodgkin's lymphoma (Reed-Sternberg cells on lymph node biopsy) Thyroidectomy – hypocalcemia (late sign: laryngeal stridor) ARDS (impaired gas exchange – priority diagnosis) Blood tubing (blood administration set with a filter) Ileostomy (output liquid, avoid popcorn/nuts) Amiodarone (hyperthyroidism or hypothyroidism) Nephrotic syndrome (hypoalbuminemia) AMA (notify physician, have client sign AMA form) GCS score 3 (no response in any domain) Radical mastectomy (elevate affected arm above heart to prevent lymphedema) PUD (caused by H. pylori in some cases) Acute pyelonephritis (flank pain, CVA tenderness) Gout (avoid organ meats) Carpal tunnel syndrome (positive Phalen's maneuver) COPD with CO2 retention (Kussmaul respirations) Phenytoin (gingival hyperplasia – visit dentist regularly) C6 spinal cord injury (weakness in triceps and wrist extensors) Fluid volume excess (crackles in lung bases) NSAIDs (take with meals or milk) Acute pancreatitis complication with low calcium (tetany risk) Spironolactone (avoid foods high in potassium) Lorazepam for alcohol withdrawal (priority assessment – respiratory status) Nitroglycerin (if pain not relieved after 3 doses, call 911) Return of peristalsis (passage of flatus) Command hallucinations (protect client from harm – priority) Central line (clean port with alcohol for 30 seconds) Pulmonary embolism (spiral CT angiography – most specific) Bulimia nervosa (erosion of tooth enamel) Internal bleeding after liver biopsy (earliest sign – increasing heart rate) Levothyroxine (take on empty stomach in the morning) High output ileostomy (risk for metabolic acidosis) MRSA (strict hand hygiene and contact precautions) Furosemide (hypokalemia) Compartment syndrome (numbness and tingling in toes – report immediately) Alzheimer's wandering (install door alarms) Chest tube disconnected (place tube in bottle of sterile water) Aspirin for angina (prevents platelet aggregation) Convection heat loss (placing a fan in the room) Cholelithiasis (apply heat to abdomen for pain) Tracheostomy communication (picture board or writing pad) Appendicitis (rebound tenderness at McBurney's point) Lithium toxicity prevention (maintain adequate sodium intake) Ascending colon stoma (liquid stool) Mucositis (oral care with soft toothbrush and saline rinse) Aortic stenosis (exertional dyspnea and angina) Hepatitis A (transmitted through contaminated food and water) Urinary catheter insertion (clean from meatus outward) CKD low-protein diet (reduces workload on kidneys) DIC (oozing from IV sites and gums) Hypovolemic shock fluid resuscitation (urine output 0.5 mL/kg/hr – indicator of success) Diabetic nephropathy prevention (maintain strict glucose control) Fluoxetine (2-4 weeks for improvement) Chest tube water-seal chamber breaks (submerge distal end in sterile water) Diverticulitis acute phase (NPO then clear liquids) Stroke severity assessment (NIHSS) IBS triggers (caffeine and spicy foods) TPN hyperglycemia (Kussmaul respirations) Sickle cell crisis (analgesics for pain – priority) Myxedema coma (hypotension and bradycardia) Bipolar medication compliance (will stop when feel better – needs further teaching) PICC line (infection at insertion site) Terminal cancer pain (titrate doses to achieve pain relief) Moderate dehydration (sunken eyeballs and fontanelles) Ulcerative colitis (sulfasalazine – photosensitivity) Kidney transplant immunosuppressants (avoid crowds and ill individuals) Orthostatic hypotension (rise slowly from lying to standing) Schizophrenia negative symptoms (social withdrawal and flat affect) DVT signs (warmth, redness, swelling) Hypoglycemia (give orange juice – conscious patient) Ileostomy stoma care (clean skin with warm water) Thyroid storm (fever and hypertension – priority) Plaster cast drying (air dry, keep exposed to air) CKD metabolic acidosis (Kussmaul respirations) DNR patient stops breathing (document time of death, notify family) PJP in AIDS (Bactrim – treatment of choice) Right-sided heart failure (peripheral edema) Bacterial meningitis (frequent neurological assessments – priority) Cirrhosis esophageal varices (propranolol to reduce portal hypertension) Multiple sclerosis urinary incontinence (anticholinergic medications) Clopidogrel (avoid grapefruit) Acute pancreatitis (elevated amylase and lipase) Tracheostomy airway obstruction prevention (change inner cannula daily) MAOI (avoid aged cheese and red wine – hypertensive crisis) Hyperkalemia (peaked T waves on ECG – immediate intervention) Bone marrow biopsy site (posterior iliac crest) NG tube nausea (check patency first) Lithium toxicity early signs (mild tremors and diarrhea) Appendicitis initial pain (periumbilical region) Pheochromocytoma crisis (phentolamine) Chest tube collection chamber full (change the drainage system) Dysphagia stroke (sitting upright at 90 degrees) CHF diet (limit salt to 2 grams per day) Hospice morphine (reduces pain and shortness of breath) Acute glomerulonephritis (hematuria and proteinuria) Burn hypovolemic shock (increased capillary permeability) Anaphylaxis (stop infusion, prepare for emergency treatment) Urinary catheter resistance (stop and notify physician) Severe anemia lightheadedness (assist with ambulation, slow position changes) Hemodialysis (hypotension from rapid fluid removal) Hypertension home remedy interference (garlic supplements) SLE flare (butterfly rash on face) Thrombocytopenia (use soft-bristle toothbrush) Gallbladder function (stores and concentrates bile) ACS mortality reduction (atorvastatin) Dementia wandering (large print signs to identify rooms) Blood transfusion allergic reaction (stop transfusion, maintain IV with saline) Hepatic encephalopathy (restrict protein intake) Right-sided heart failure (peripheral edema) Parkinson's gait (remove throw rugs – prevent falls) Heart failure daily weight (call doctor if gain 3 pounds in a day) Pneumonia (deep breathing and coughing to clear secretions) Aortic aneurysm (pulsatile abdominal mass – most concerning) Panic attack (stay with client, calm environment) CVP reading 2 mmHg (hypovolemia) Chronic bronchitis (vibration and postural drainage for secretions) Lisinopril (dry, persistent cough – report) Ulcerative colitis exacerbation (monitor fluid and electrolyte balance – priority) Sickle cell crisis trigger (dehydration and infection) Anorexia nervosa (potassium 2.5 mEq/L – requires immediate intervention) Terminal cancer family (Watson's Theory of Human Caring) Hyperparathyroidism elevated calcium (kidney stones) Ileostomy wafer (cut opening to exact size of stoma) Diabetes insipidus (dilute urine with low specific gravity) Acute respiratory failure (PaO2 55, PaCO2 50) Buck's traction (reduces muscle spasms before surgery) Diabetes insipidus medication (desmopressin – DDAVP) Ascites removal (paracentesis) Heparin antidote (protamine sulfate) Command hallucinations (protect client from harm – priority) Gout prevention (drink water, avoid alcohol) Bacterial meningitis (droplet precautions) Hemophilia A (Factor VIII deficiency) MI propranolol contraindication (bradycardia) HHS priority (severe dehydration) Fat embolism syndrome earliest sign (dyspnea and hypoxia) Type 2 diabetes (body becomes resistant to insulin) TKR DVT prevention (ankle pump exercises) Radioactive iodine (limit close contact with others for a few days) Acute pancreatitis NPO (IV fluids and parenteral analgesics – priority) Risperidone EPS (dystonia) Hypertension salt substitute (potassium chloride) Myocarditis (elevated troponin) Right-sided heart failure (peripheral edema) Addison's disease fludrocortisone (regulates sodium and potassium levels) CPAP (clean mask daily with soap and water) Sciatica (pain radiating down the leg) Prerenal AKI cause (dehydration and hypovolemia) Bipolar depression (ensuring safety and monitoring for suicide risk – priority) Pyelonephritis prevention (drink plenty of fluids, avoid holding urine) Diabetic neuropathy foot care (inspect feet daily) Chest tube water-seal chamber vigorous bubbling (air leak in system) ESA adverse effect (hypertension) Cushing's syndrome (moon face and buffalo hump) LABA (provides long-term control) Severe sepsis priority (administer broad-spectrum antibiotics) Peptic ulcer night pain relieved by food (duodenal ulcer) ESRD refusing treatment (respect client's autonomy) Multiple sclerosis optic neuritis (blurred vision or vision loss) Warfarin (limit spinach and broccoli) PCI pre-procedure medication (abciximab – ReoPro) Guillain-Barré priority (ineffective breathing pattern) Thyroidectomy preoperative (iodine – Lugol's solution) Severe dehydration isotonic solution (0.9% Normal Saline) Hydroxyurea for sickle cell (increases fetal hemoglobin levels) Clozapine (monitor CBC for agranulocytosis) Autonomic dysreflexia (check for bladder distention or bowel impaction – immediate action) Generalized tonic-clonic seizure (protect head, turn to side) Stroke dysarthria (speak slowly, encourage gestures) Alendronate (take with full glass of water, remain upright for 30 minutes) Acute angle-closure glaucoma (sudden eye pain, halos around lights, nausea) Benzodiazepine for panic disorder (short-term use only) Myocarditis PVCs (lidocaine – Xylocaine) Stroke left-sided neglect (place objects on right side) Chronic bronchitis (pursed-lip breathing) AIDS Kaposi's sarcoma (reddish-purple raised lesions) Paracentesis position (sitting on edge of bed) Renal calculi pain (opioids) Warfarin DVT (avoid ibuprofen – Motrin) Schizophrenia paranoid delusion (provide factual information about reality) Blood transfusion identification (ask client's name and date of birth) AV fistula complications (infection, steal syndrome, thrombosis – all of the above) Uncontrolled hypertension damages (eyes, heart, kidneys, brain – select all that apply) SLE early organ involvement (hematuria – renal) Pneumonia hypoxia effective treatment (PaO2 90 mm Hg) Decorticate posturing (flexion of arms, extension of legs) Nonmodifiable CAD risk factor (family history) Small bowel obstruction vomit (foul-smelling and fecal-like) Fluoxetine to MAOI waiting period (5 weeks) Hyperaldosteronism (hypernatremia and hypokalemia) Compensatory stage of shock (restlessness and tachycardia) BPH prostate size reduction (finasteride – Proscar) Peak flow meter red zone (below 50% of personal best – immediate medical attention) Epoetin alfa adverse effect (hypertension) Mandible fracture sign (malocclusion) Tardive dyskinesia (involuntary movements of face and tongue) Postoperative ileus (absent bowel sounds) Brain tumor increased ICP position (promote venous drainage from head) Gout (avoid beer) Addison's disease weakness (administer prescribed corticosteroids) Acute pancreatitis elevated (serum amylase) Guillain-Barré early respiratory distress (decreased tidal volume) DASH diet (low sodium, high fruits and vegetables) Buck's traction neurovascular complication (pain, pallor, pulselessness – all of the above) Tuberculosis (airborne precautions) Alcohol withdrawal delirium tremens (chlordiazepoxide – Librium) Myasthenia gravis muscle strength (anticholinesterase inhibitors) Methimazole toxicity (sore throat and fever) Halo vest skin care (monitor for skin breakdown under padding) Stroke hemiparesis (use unaffected limb to assist affected limb) Digoxin for heart failure (improves heart's pumping ability) H. pylori noninvasive test (stool antigen test) Severe burn metabolic rate reduction (beta-blockers) Ulcerative colitis ileostomy (liquid and continuous output) Ectopic pregnancy most concerning (sharp, stabbing lower abdominal pain) Norepinephrine adverse effect (hypertension) Diabetic nephropathy limit (bananas) Autonomic dysreflexia distended bladder (perform intermittent catheterization) MI PVCs (lidocaine) Brain tumor increased ICP (pupils fixed and dilated) DVT prevention (avoid crossing legs) Multiple sclerosis bladder spasms (oxybutynin – Ditropan) Blood transfusion tubing (blood administration set with a filter) Parkinson's fall prevention (remove throw rugs and clutter) HCTZ for hypertension (removes excess fluid and sodium) Stroke dysphagia (avoid thin liquids) Magnesium sulfate toxicity antidote (calcium gluconate) Carbon monoxide poisoning (cherry-red skin color) ECT common side effect (memory loss) ARF oliguric (monitor fluid balance strictly – priority) Hyperthyroidism exophthalmos (use artificial tears and wear sunglasses) Subarachnoid hemorrhage nimodipine (prevents cerebral vasospasm) Tracheostomy communication (tracheostomy speaking valve) Type 1 diabetes sick day rules (monitor blood glucose more frequently, test urine ketones) Fat embolism syndrome first sign (dyspnea) Peritoneal dialysis complication (peritonitis) Risperidone side effect (orthostatic hypotension) MI inferior wall (nausea and vomiting common) Severe dehydration initial IV fluid (0.9% Normal Saline) Osteoarthritis (heat or cold therapy) Cerebral aneurysm complications (rupture, vasospasm, hydrocephalus – all of the above) Severe burn face (airway management – priority) Peptic ulcer pain relieved by food, occurs 1-2 hours after meals (duodenal ulcer) Heart failure daily weight (weigh before breakfast in light clothing) Autonomic dysreflexia (distended bladder or bowel) Acute pancreatitis NPO purpose (reduce gastric stimulation and pancreatic secretions) Schizophrenia paranoid delusion ("I do not see anyone in the room, but I understand you are frightened") Hypertension limit (sodium) Compartment syndrome (numbness and tingling in toes – report immediately) Terminal cancer moaning (severe uncontrolled pain) Erythropoietin adverse effect (hypertension) Spinal cord injury diagnosis (MRI – confirms) Blood transfusion allergic reaction (stop transfusion, administer diphenhydramine) Asthma prevention (avoid triggers, take controller medications daily) Decerebrate posturing (extension of arms and legs) Severe preeclampsia impending eclampsia (hyperreflexia and clonus) Thrombolytic therapy complication (bleeding) Parkinson's disease (move slowly and deliberately) Autonomic dysreflexia kinked catheter (unkink the catheter – first action) Severe burn urinary output 30 mL/hr (increase IV fluid rate) Diabetes insipidus excessive urine output (desmopressin – DDAVP) Heart failure daily weight (call doctor if gain 2 pounds in a day) Buck's traction (weights hang freely) Brain tumor seizures (phenytoin – Dilantin) Myasthenia gravis dysphagia (administer anticholinesterase medication) Pilocarpine for glaucoma (pupillary constriction) Bone marrow biopsy site (sternum or iliac crest) Severe depression insomnia (encourage restful environment) Stroke dysphagia feeding (position client upright, allow time to chew) DVT compression stockings (prevent blood from pooling in legs) Terminal dying moaning (secretions in the throat) Severe burn escharotomy (reduce pressure and improve circulation) Heparin monitoring (aPTT) Chronic bronchitis pursed-lip breathing (keeps airways open during exhalation) Autonomic dysreflexia elevate HOB (lowers blood pressure) Head injury HOB elevated (reduces intracranial pressure) Tracheostomy communication (magic slate) Hemoglobin A1C (reflects blood glucose control over past 3 months) Stroke hemiplegia positioning (prevents contractures and pressure ulcers) Severe preeclampsia magnesium sulfate (prevents seizures) Skeletal traction complications (infection at pin sites, DVT, pneumonia – all of the above) Heart failure limit (sodium) Traumatic brain injury vomiting (turn client to side – immediate action) Severe burn pain (morphine sulfate) MI nitroglycerin sublingual (rapid absorption) Osteoporosis exercise (weight-bearing) Autonomic dysreflexia T12 (distended bladder or bowel, increased BP, bradycardia – all of the above) Subarachnoid hemorrhage complications (vasospasm, rebleeding, hydrocephalus – all of the above) Severe burn graft (donor site) Diabetes insipidus (polyuria and polydipsia) Stroke hemianopsia (turn head to affected side) Severe burn electrolyte imbalance (hyperkalemia, hyponatremia, hypocalcemia – all of the above) Buck's traction purpose (reduce muscle spasms) ACE inhibitor side effect (dry cough – report) Hospice care (listening to family concerns – all of the above) Beta-blockers for MI (reduce heart rate and blood pressure) Asthma spacer (increases medication delivery to lungs, reduces side effects, improves coordination – all of the above) Stroke aphasia communication (speak slowly, use pictures, ask yes/no questions – all of the above) Severe burn assessment (fluid volume deficit, infection, pain – all of the above) Fractured hip prophylactic antibiotics (within 1 hour before incision) DVT prevention (wear compression stockings, avoid prolonged sitting, take anticoagulants – all of the above) Terminal pain opioids (relieve pain, reduce anxiety, promote sleep – all of the above) Traumatic brain injury increased ICP late sign (Cushing's triad) Stroke dysphagia avoid (thin liquids) Heart failure sodium limit (2 grams per day) Autonomic dysreflexia immediate action (elevate head of bed) Severe burn acute phase priorities (wound care, pain management, nutritional support – all of the above) Statins for MI (lower cholesterol, reduce inflammation, stabilize plaque – all of the above) COPD prevention (flu shot and pneumonia vaccine – both A and B) Terminal illness dying process (provide honest information, offer reassurance, listen to concerns – all of the above) Stroke hemiparesis exercises (maintain muscle strength, prevent contractures, improve circulation – all of the above) Severe burn infection signs (increased pain, redness, purulent drainage – all of the above) Skeletal traction (weights hang freely, ropes not frayed, pulleys functioning – all of the above) Hypertension discharge teaching (monitor BP, take medication, low-sodium diet – all of the above) Traumatic brain injury post-traumatic amnesia (normal after head injury) Subarachnoid hemorrhage bed rest (reduces risk of rebleeding) Severe burn hypermetabolism (high-calorie, high-protein diet) Diabetes mellitus foot checks (cuts, redness, blisters – all of the above) Stroke emotional lability (explain it is common after a stroke) Severe burn fluid status (urine output, vital signs, edema – all of the above) Fractured hip surgery prep (informed consent, remove jewelry/dentures, insert Foley – all of the above) DVT discharge teaching avoid (prolonged sitting, smoking, crossing legs – all of the above) Terminal dyspnea (elevate HOB, cool room, use fan – all of the above) Traumatic brain injury increased ICP most significant sign (change in level of consciousness) Stroke aphasia communication (speak slowly, simple sentences, give time to respond – all of the above) Heart failure reportable symptoms (weight gain 3 lbs/week, ankle swelling, SOB – all of the above) Autonomic dysreflexia priority (identify and remove noxious stimulus) Severe burn pain medication (around the clock) Aspirin for MI (prevents blood clots) Asthma trigger avoidance (dust, smoke, cold air – all of the above) Hospice focus (comfort and quality of life) Stroke hemiplegia exercises (prevents muscle atrophy, contractures, promotes circulation – all of the above) Severe burn electrolyte imbalance (hypokalemia, hypernatremia, hypomagnesemia – all of the above) Buck's traction purpose (reduction of muscle spasms) Beta-blocker side effects (bradycardia, fatigue, dizziness – all of the above) Terminal pain opioids (relieve pain, promote comfort, improve quality of life – all of the above) Traumatic brain injury increased ICP late signs (decreased LOC, pupillary changes, posturing, Cushing's triad – all of the above) Stroke dysphagia (thickened liquids, pureed foods, soft solids – all of the above) Heart failure fluid limit (2 liters per day) Autonomic dysreflexia BP 200/120 (elevate HOB, check for bladder distention – immediate actions) Severe burn wound assessment (erythema, edema, drainage – all of the above) Nitroglycerin storage (cool, dry place) COPD prevention (avoid smoking, flu shot yearly, avoid crowds – all of the above) Terminal illness dying process (listen, provide honest information, offer reassurance – all of the above) Stroke hemiparesis use affected limb (prevents learned nonuse, improves strength, promotes recovery – all of the above) Severe burn infection signs (fever, increased pain, purulent drainage – all of the above) Skeletal traction (weights hang freely, ropes not frayed, pulleys functioning – all of the above) Hypertension discharge (monitor BP, take medication, low-sodium diet – all of the above) Traumatic brain injury post-traumatic amnesia (normal after head injury) Subarachnoid hemorrhage bed rest (reduces risk of rebleeding) Severe burn hypermetabolism (high-calorie, high-protein diet) Diabetes mellitus foot checks (all of the above) Stroke emotional lability (explain it is common after a stroke) Severe burn fluid status (all of the above) Fractured hip surgery prep (all of the above) DVT discharge teaching avoid (all of the above) Terminal dyspnea (all of the above) Traumatic brain injury increased ICP most significant sign (change in level of consciousness) Stroke aphasia communication (all of the above) Heart failure reportable symptoms (all of the above) Autonomic dysreflexia priority (identify and remove noxious stimulus) Severe burn pain medication (around the clock) Aspirin for MI (prevents blood clots) Asthma trigger avoidance (all of the above) Hospice focus (comfort and quality of life) Stroke hemiplegia exercises (all of the above) Severe burn electrolyte imbalance (all of the above) Buck's traction purpose (reduction of muscle spasms) Beta-blocker side effects (all of the above) Terminal pain opioids (all of the above) Traumatic brain injury increased ICP late signs (all of the above) Stroke dysphagia (all of the above) Heart failure fluid limit (2 liters per day) Autonomic dysreflexia BP 200/120 (elevate HOB, check for bladder distention) Severe burn wound assessment (all of the above) Nitroglycerin storage (cool, dry place) COPD prevention (all of the above) Terminal illness dying process (all of the above) Stroke hemiparesis use affected limb (all of the above) Severe burn infection signs (all of the above)