ACHPN practice questions: 30 free APRN-level items

A patient with metastatic cancer tells the APRN they have been estranged from their parents for years and have lived with their partner for 20 years without marrying. Which question should the APRN ask FIRST to assess social support?

Mark a letter. The key, plus a line on every option, opens at once.

1. "Would you like us to contact your parents about your illness?"

   Offering to contact the parents assumes estranged relatives are the support system and may cause distress.
2. "Who do you consider family and want involved in your care?"

   Asking whom the patient considers family lets the patient define the support system, here a partner of 20 years, before the team assumes who counts.
3. "Are you legally married or in a registered domestic partnership?"

   Legal marital status tells the APRN about paperwork, not about who actually supports the patient.
4. "Who is your next of kin according to your medical record?"

   The next of kin in the record is a legal default and may not be the people the patient relies on.

A patient on long-term hemodialysis has exquisitely painful, net-like violaceous plaques on both thighs, one of which now has a black necrotic center. There is no fever. The APRN recognizes

1. cellulitis.

   Cellulitis is warm, red and spreading, often with fever, and does not form net-like purpura with black necrosis.
2. calciphylaxis.

   Very painful net-like violaceous plaques with a necrotic center over the fatty thighs of a dialysis patient are typical of calciphylaxis.
3. leukocytoclastic vasculitis.

   Leukocytoclastic vasculitis usually causes small palpable purpura on the lower legs rather than large necrotic plaques on the thighs.
4. a pressure injury.

   A pressure injury forms over a bony prominence, not as net-like plaques on both thighs.

An incarcerated patient with metastatic liver cancer is hospitalized, and two correctional officers remain in the room. The APRN needs to hold a goals-of-care conversation. What should the APRN do FIRST?

1. defer the conversation until the patient is released

   Waiting for release may mean the conversation never happens.
2. request privacy within the facility's security rules

   The patient keeps the right to a confidential medical conversation, so the APRN first negotiates as much privacy as security allows, such as officers stepping just outside the door.
3. ask the warden to make the treatment decisions

   The warden has no authority to make the patient's treatment decisions.
4. hold the conversation with the officers in the room

   Talking with officers present gives up confidentiality before any attempt to protect it and can make the patient less candid.

A patient on hemodialysis reports fatigue, itching, poor appetite and restless legs. The APRN wants a brief, validated tool the patient can self-rate at every visit to track how much each of these complaints bothers them. Which tool is MOST appropriate?

1. the Kidney Disease Quality of Life 36-item survey

   The 36-item kidney quality-of-life survey measures health-related quality of life and is usually given about once a year, not as a brief symptom check at each visit.
2. the Palliative Performance Scale

   The Palliative Performance Scale rates function and helps with prognosis; it does not capture symptoms such as itching or poor appetite.
3. the Karnofsky Performance Status scale

   The Karnofsky scale rates overall functional performance, not the burden of individual symptoms.
4. the Edmonton Symptom Assessment System–revised: Renal

   The renal version of the revised Edmonton Symptom Assessment System adds itching to the core symptoms and is validated for quick, repeated self-rating in people on dialysis.

A patient with ALS has dyspnea at rest and orthopnea and declines both ventilation and a feeding tube. Which finding BEST supports eligibility for the Medicare hospice benefit?

1. 3% weight loss with adequate oral intake

   A small weight loss while intake stays adequate does not meet the nutrition criterion, which needs dysphagia with progressive weight loss or intake too low to sustain life.
2. new dysarthria with intelligible speech

   Slurred but intelligible speech marks progression without critical respiratory or nutritional failure.
3. vital capacity of 28% predicted

   A vital capacity of 28% with dyspnea at rest meets critically impaired breathing under both versions of the hospice ALS criteria in use (VC under 30% in L34538; FVC under 40% with two or more respiratory signs in L33393).
4. vital capacity of 45% predicted

   A vital capacity of 45% shows respiratory decline but is above the threshold in every current hospice ALS criterion (30% or 40%).

A patient with newly diagnosed mild Alzheimer's disease has named a health care agent and wants to finish advance care planning now. Which topic is MOST important to add because of this diagnosis?

1. organ and tissue donation after death

   Organ and tissue donation is a fair topic for anyone, but it does not prepare the agent for the medical choices that late dementia brings.
2. tube feeding and hospital care in late dementia

   Alzheimer disease brings predictable later choices, such as tube feeding, hospital transfer and antibiotics, that the agent will face once the patient cannot speak, so these are what this diagnosis adds to the plan.
3. choosing an assisted living facility for later

   Picking an assisted living facility is a housing decision; it gives the agent no guidance on the medical choices ahead.
4. attempting CPR if cardiac arrest occurred this week

   A CPR preference for a sudden arrest is part of any directive and is not the gap this diagnosis creates.

During a home visit to a bedbound hospice patient cared for by her son, which finding MOST suggests caregiver neglect rather than disease progression?

1. Soiled bedding even with ample clean supplies

   Soiled bedding even with ample clean supplies at hand points to care not being given, which disease progression does not explain.
2. Confusion that worsens late in the day

   Confusion that worsens late in the day fits delirium or advancing disease, not a failure of care.
3. A new sacral wound that appeared within a day

   A sacral wound that appears within a day can be a terminal (Kennedy) ulcer of skin failure near death, not proof of neglect.
4. Sleeping most of the day with brief awakenings

   Sleeping most of the day with brief awakenings is a usual change in the last weeks of life.

The APRN explains the likely course of illness to the family of a patient with advanced heart failure. Which trajectory BEST describes this course?

1. Stable function, then a rapid final decline

   Stable function followed by a short, steep decline is the typical cancer course.
2. Steady function until sudden death

   Sudden death does occur in heart failure, but steady function ending in sudden death is not the usual course to describe.
3. Gradual decline with acute exacerbations

   Heart failure usually follows a slow decline broken by exacerbations, any of which may be fatal, which makes timing hard to predict.
4. Prolonged slow dwindling over years

   Slow dwindling over years fits frailty and dementia.

A patient with advanced heart failure has been taking furosemide every other day instead of daily and ran out of apixaban 2 weeks ago. Which question should the APRN ask FIRST?

1. "Would a weekly pill organizer help you remember doses?"

   A pill organizer fixes forgetting, which no one has shown is the reason for the missed doses.
2. "Can your daughter take over managing your medicines?"

   Handing the medicines to the daughter assumes the patient cannot manage them and skips finding out why doses were skipped.
3. "Do you understand why these medicines are so important?"

   Asking whether the patient understands why the medicines matter presumes a knowledge gap and can sound accusatory.
4. "What makes it hard to take these medicines as prescribed?"

   Asking what makes it hard to take the medicines is an open, nonjudgmental question that finds the real barrier, such as cost, urgency from furosemide or doubts about the drugs.

A hospice patient with advanced COPD has had four hospitalizations for exacerbations in the past year and wants to avoid returning to the hospital. Which intervention does the APRN put in place?

1. Continuous oxygen at 4 L/min

   Oxygen is titrated to a target saturation, often 88% to 92% in COPD, and a fixed 4 L/min does not prevent exacerbations.
2. Daily peak flow monitoring diary

   Peak flow tracks asthma better than COPD and does not reliably signal a COPD exacerbation.
3. Action plan with a rescue pack

   A written action plan with standby steroids and antibiotics lets the patient start treatment at the first sign of an exacerbation, which reduces hospital use.
4. Chronic prednisone 10 mg PO daily

   Long-term low-dose prednisone adds myopathy, infection and bone loss without preventing exacerbations.

A home hospice patient with head and neck cancer has used a fentanyl 50 mcg/h patch for a month with good pain control and normal alertness. Today the patient has aspiration pneumonia with a temperature of 40 °C (104 °F), is hard to keep awake, and has pinpoint pupils and a respiratory rate of 9. No medicine has been started or changed. Which mechanism BEST explains the new opioid toxicity?

1. Weight loss increasing fentanyl uptake from the skin

   Cachexia and weight loss tend to lower absorption from a patch, so they would weaken the effect rather than cause toxicity.
2. An active fentanyl metabolite building up

   Fentanyl metabolites are inactive; toxic metabolite build-up is a morphine problem, especially in renal failure.
3. Faster liver clearance of fentanyl during infection

   Faster clearance would lower fentanyl levels and lessen sedation, the opposite of what is happening.
4. Fever increasing fentanyl uptake from the skin

   Heat raises skin permeability and drug release from the patch; at about 40 °C serum fentanyl can rise by roughly one third, enough to tip a stable dose into toxicity.

A patient with ovarian cancer and inoperable complete proximal small-bowel obstruction keeps vomiting several times a day despite dexamethasone, octreotide and haloperidol. Ascites is minimal. The prognosis is weeks to a few months, and the patient wants to go home without a nasal tube. What does the APRN recommend?

1. metoclopramide infusion

   The prokinetic push of metoclopramide is avoided in complete obstruction, where it can worsen colic and vomiting.
2. venting gastrostomy tube

   For vomiting from inoperable obstruction that persists despite medical therapy, a venting gastrostomy drains the stomach without a nasal tube and lets the patient go home and sip fluids.
3. total parenteral nutrition

   Total parenteral nutrition does nothing for vomiting and rarely helps when survival is weeks.
4. long-term nasogastric tube

   A long-term nasogastric tube is uncomfortable and is exactly the tube the patient wants to avoid.

A bedbound hospice patient (70 kg) taking morphine 120 mg per day has had no bowel movement for 5 days despite senna two tablets twice daily and daily polyethylene glycol. Bowel sounds are present, there is no impaction, and there are no signs of obstruction. Which order does the APRN write?

1. Docusate 100 mg PO three times daily

   Docusate adds little when a stimulant and an osmotic laxative have already failed.
2. Methylnaltrexone 12 mg SC now

   Methylnaltrexone, a peripheral opioid antagonist, treats opioid-induced constipation that resists a stimulant and an osmotic laxative once obstruction is ruled out; 12 mg SC is the dose for 70 kg.
3. Rotate morphine to oxycodone

   Oxycodone acts on the same gut mu receptors, so rotating to it is unlikely to relieve the constipation.
4. Psyllium 1 tablespoon PO twice daily

   Bulk fiber such as psyllium needs good fluid intake and can cause impaction in a bedbound patient.

A patient with a fungating breast tumor has oozing that starts every time the gauze dressing is pulled off. Platelets and INR are normal. Odor is controlled with metronidazole gel. Which change does the APRN order?

1. non-adherent dressing with topical tranexamic acid

   Oozing that starts when gauze is pulled off comes from trauma to a friable surface, so a non-adherent dressing removes the cause and topical tranexamic acid helps the ooze clot.
2. dressing changes twice daily to monitor for bleeding

   Changing the dressing twice daily means more trauma to the tumor surface and more bleeding.
3. dry gauze packed firmly into the wound bed

   Dry gauze sticks to the wound bed and tears it again at the next change.
4. vigorous saline irrigation at each change

   Forceful irrigation disrupts fragile tumor vessels and provokes bleeding.

A home hospice patient with liver cancer lives 90 miles from the nearest 24-hour pharmacy. Pain is currently controlled. What should the APRN do to prevent an after-hours symptom crisis?

1. admit to general inpatient care as a precaution

   General inpatient care is for symptoms that cannot be managed at home, not for a crisis that has not happened.
2. prescribe only long-acting oral opioids

   Long-acting opioids alone leave no rescue dose for breakthrough pain at night.
3. replace RN home visits with telehealth visits

   A telehealth visit cannot give a drug that is not in the home.
4. place an emergency medication kit in the home

   An emergency kit with small amounts of drugs for pain, breathlessness, agitation, nausea and seizures lets the on-call team treat a crisis at once, far from a pharmacy.

A hospice team invites a cultural broker to a family meeting. What is the cultural broker's role?

1. Bridging beliefs and meanings for both sides

   Bridging beliefs and meanings is the broker's role: helping the team and the family understand each other's expectations so they can plan care together.
2. Making care decisions on the family's behalf

   A broker supports understanding but does not make decisions for the family.
3. Leading the family's religious rituals

   Religious rituals belong to the family's faith leaders or a chaplain, not the broker.
4. Interpreting each statement word for word

   Interpreting word for word is the medical interpreter's job; the broker works on cultural meaning.

A dying veteran with combat-related PTSD becomes agitated when staff approach from behind or wake him at night. What should the APRN teach the staff?

1. Wake him with a quick touch on the shoulder.

   An unexpected touch while he is asleep is exactly the kind of startle that sets off his agitation.
2. Announce yourselves and stay within his line of sight.

   Announcing yourselves and staying in his line of sight is trauma-informed care: it avoids startling a veteran with PTSD and removes the trigger for agitation.
3. Remind him firmly that the war is now long over.

   Arguing with a veteran who is re-experiencing combat escalates fear rather than grounding him.
4. Rotate a different aide to him at each visit.

   Rotating aides takes away the familiar, predictable caregivers that help a veteran with PTSD feel safe.

A 5-year-old whose father is dying at home asks the APRN, "When Daddy dies, when will he come back?" Which response is MOST appropriate?

1. "When Daddy dies, he goes away on a long trip and will miss you."

   Describing death as a long trip suggests Daddy may return and can leave the child waiting for him.
2. "That's a big question you'll understand when you're older."

   Putting the question off leaves the child to fill the gap with his own fears and guesses.
3. "When Daddy dies, his body stops working, and that is forever."

   Honest, concrete words that use "dies" and say the body stops working for good give a preschooler an accurate picture to build on.
4. "When Daddy dies, he goes to sleep for a very long time."

   Comparing death to sleep can make the child afraid of going to sleep.

The APRN meets with the family of a patient whose death is expected in the next one to two days. Which statement BEST conveys this clearly?

1. "I think he is dying, and it may happen within a day or two."

   Using the word dying together with the time frame says plainly what is happening, so the family can prepare and gather.
2. "He may slip away from us within a day or two."

   Slipping away is a euphemism; even with the time frame, the family may not hear that he is dying.
3. "There is really nothing more that we can do for him now."

   Saying there is nothing more to do is untrue, since comfort care continues, and it sounds like abandonment.
4. "He is getting weaker, and the next day or two will be hard."

   Saying he is getting weaker and the next day or two will be hard names the time frame but never says that he is dying.

The APRN is invited to speak about hospice at a church whose older African American members report mistrust of the health care system. Which approach is BEST?

1. Focus the talk on hospice cost savings to Medicare

   Leading with savings to Medicare can sound like rationing to an audience that already distrusts the system.
2. Co-present with a trusted leader from the congregation

   Co-presenting with a trusted leader from the congregation builds credibility and makes room to address mistrust rooted in real historical harm.
3. Present national data on hospice use by race

   National data on hospice use do not address why the audience distrusts care.
4. Explain that hospice means stopping all care

   Saying hospice means stopping all care is false; comfort care continues and often intensifies.

The 5-year-old brother of a child dying of leukemia tells the APRN that his sister got sick because he once wished she would go away. The APRN recognizes this belief as

1. magical thinking typical of his age.

   Preschoolers often believe their wishes can cause events, so this guilt is expected magical thinking, met with a clear statement that nothing he thought caused her illness.
2. unusual guilt that needs psychiatric referral.

   This kind of guilt is common at his age and does not by itself call for psychiatric referral.
3. an early sign of prolonged grief disorder.

   Prolonged grief disorder is diagnosed months after a death, not before it.
4. evidence he understands death is permanent.

   Believing a wish caused the illness says nothing about whether he understands that death is final.

At the end of a family meeting, the patient's wife asks the APRN, "What would you do?" The APRN should

1. explain that the decision rests with the family alone.

   Telling her the decision rests with the family alone leaves her carrying its full weight.
2. describe what the APRN would want for their own parent.

   What the APRN would want for a parent is a personal preference; the standard is the patient's values.
3. offer a recommendation based on the patient's values.

   Families often want guidance, and a recommendation grounded in the patient's stated values eases the burden of choosing alone.
4. review the risks of each option again in neutral terms.

   Repeating the risks in neutral terms does not answer her question about what to do.

An APRN auditing a palliative program against the NCP Clinical Practice Guidelines finds no routine assessment of caregivers' needs, finances or living situation. Which NCP domain does this gap fall under?

1. Social Aspects of Care

   Caregiver needs, finances and living situation fall in the Social Aspects of Care domain of the NCP guidelines.
2. Psychological and Psychiatric Aspects

   The psychological and psychiatric domain covers mental health, coping and grief; caregiver strain has an emotional side, but finances and housing are social.
3. Cultural Aspects of Care

   The cultural domain addresses culture, language and cultural humility, not finances or living arrangements.
4. Structure and Processes of Care

   Structure and processes cover the team, the assessment process and continuity, not the content of a social assessment.

A patient with multiorgan failure has been ventilated in the ICU for 3 weeks. The surrogate demands full treatment including CPR. The team believes continued life support is potentially inappropriate, though it could keep the patient alive. What is the recommended approach?

1. write a DNR order over the surrogate's objection

   A DNR order written over the surrogate's objection is reserved for treatment that cannot work physiologically, which is not the situation described, and it skips the fair process.
2. seek a court order replacing the surrogate

   Disagreement alone does not justify a court order replacing the surrogate.
3. begin a fair process with intensive negotiation

   Beginning a fair process fits when treatment could keep the patient alive but the team judges it inappropriate; the process runs through intensive negotiation, second opinions, committee review and an offer of transfer.
4. continue all treatment indefinitely as demanded

   Continuing all treatment indefinitely ignores the team's duty to address potentially inappropriate treatment.

A patient who practices Buddhism has moderate cancer pain but declines opioids, explaining that she wants a clear mind for meditation as death approaches. The APRN should

1. document the refusal and stop addressing pain.

   Documenting the refusal and dropping pain care is neglect, not respect.
2. ask her family to persuade her to accept opioids.

   Enlisting family pressure overrides her autonomy and her spiritual goal.
3. explain that opioids are needed for a peaceful death.

   Telling her opioids are needed for a peaceful death is untrue and dismisses her stated values.
4. honor her goal and offer less-sedating options.

   Honoring her goal of a clear mind means offering less-sedating options: non-opioid and adjuvant analgesics, nondrug measures and, if she later chooses, low opioid doses titrated to alertness.

In a state without a medical aid-in-dying law, a patient with advanced ALS tells the APRN she has decided to stop eating and drinking to hasten death. She is clear and consistent, and depression screening is negative. What is the APRN's BEST response?

1. Plan mouth care for thirst and treatment for delirium

   With capacity clear, stopping food and fluids is a lawful refusal; the APRN supports it with frequent mouth care for thirst and a plan for the delirium that often comes as death nears.
2. Decline to take part where aid in dying is illegal

   Refusing food and fluids is lawful whether or not aid in dying is legal, and declining to help leaves the patient without symptom care.
3. Recommend a feeding tube to prevent dehydration

   A feeding tube is a treatment this patient may refuse; recommending it overrides a capacitated decision.
4. Request a court order before the team supports the plan

   No court order is needed for a patient with capacity to refuse food and fluids.

A dying patient with refractory agitated delirium is started on a midazolam infusion titrated to relieve distress. A staff nurse objects that this is "the same as euthanasia." The APRN explains that the practice is justified by

1. the principle of futility.

   Futility concerns treatment that cannot reach its goal, while this sedation does reach its goal of relief.
2. the standard of substituted judgment.

   Substituted judgment describes how a surrogate decides for a patient who cannot; it says nothing about whether sedation itself is ethical.
3. the principle of distributive justice.

   Distributive justice is about sharing scarce resources fairly, which has no bearing on this one patient's sedation.
4. the principle of double effect.

   Double effect permits an act meant to relieve suffering whose possible bad effect is foreseen but not intended, if the act is proportionate; sedation titrated to relief meets these conditions.

A hospice patient with advanced dementia repeatedly pulls at an indwelling urinary catheter that was placed for incontinence. Night staff ask the APRN for an order for soft wrist restraints. What is the APRN's BEST response?

1. Order scheduled haloperidol for the pulling

   Haloperidol given only to stop a behavior is a chemical restraint and raises mortality in dementia.
2. Keep the catheter and apply hand mitts

   Hand mitts that keep the patient from using the hands are also a restraint, and keeping the catheter leaves the trigger in place.
3. Remove the catheter and use less restrictive measures

   A catheter placed only for incontinence is not needed in a comfort plan and is what triggers the pulling, so removing it with briefs and skin care is the least restrictive answer.
4. Order soft wrist restraints with checks every 2 hours

   Wrist restraints increase agitation, falls and injury in dementia and come only after less restrictive measures fail.

A 58-year-old with head and neck cancer in palliative care has lost weight and has pain on swallowing. The APRN wants the validated nutrition assessment that serves as a reference standard in oncology and also gives a triage score for how intensive nutrition care should be. Which tool should the APRN use?

1. Malnutrition Universal Screening Tool

   The Malnutrition Universal Screening Tool is a brief screen of BMI, weight loss and acute illness, not a full assessment with intervention triage levels.
2. Mini Nutritional Assessment–Short Form

   The Mini Nutritional Assessment–Short Form is a screen built for older adults, not the oncology reference standard.
3. Subjective Global Assessment with a clinician rating

   The Subjective Global Assessment with a clinician rating is the near-miss: it grades nutrition A, B or C but gives no triage score for intervention.
4. Patient-Generated Subjective Global Assessment

   The Patient-Generated Subjective Global Assessment is the reference nutrition assessment in oncology, and its total score sorts patients into triage levels from no intervention to urgent symptom and nutrition care.

An APRN on the inpatient palliative care service is consulted by a hospitalist for 'recommendations only' on pain for a patient with renal failure. The APRN concludes that morphine should be switched to hydromorphone. What does the APRN do next?

1. write the hydromorphone order directly

   Writing the order oversteps the consult agreement and blurs who is accountable for the patient.
2. document the advice and discuss it with the hospitalist

   Documenting the advice and discussing it with the hospitalist respects a recommendations-only consult, in which the requesting team keeps prescribing authority.
3. have the nurse get the hospitalist's verbal order

   Having the nurse get the hospitalist's verbal order skips the clinician-to-clinician conversation the consult requires.
4. ask pharmacy to substitute hydromorphone by therapeutic interchange

   Therapeutic interchange is a pharmacy formulary process, not a way to deliver a consult recommendation.