The ACHPN study guide below is organized around decisions: for each of the four domains on HPCC's current outline, what the APRN is asked to judge, the reasoning errors that cost points, and sample items to try. A closing section explains how the posted 2027 outline would move weight into evaluation and management.
The 150 scored questions come from a 2021 job analysis of hospice and palliative APRN work, and they are split unevenly. Assessment and Data Collection is the biggest block at 44 items, and Intervention and Management the smallest at 32 items. On the current outline, assessment and prognosis weigh at least as much as drug choice.
Current ACHPN outline, scored questions per domain.
1Assessment and Data Collection. Medical history and review of systems; physical examination; functional assessment; psychosocial and spiritual assessment; standardized assessment and prognostic tools; signs and symptoms of serious illness; advance care planning; disease progression and prognostication; signs of imminent death; unique needs of specific populations.
44 items
44
2Intervention and Management. Diagnostic tests and procedures; pharmacologic therapies; non-pharmacologic interventions; complementary and alternative interventions; disease process and plan of care; hospice and palliative care emergencies; palliative sedation; life support devices.
32 items
32
3Education and Communication. Age-appropriate teaching methods; communication theory and principles within the context of hospice and palliative care; strategies to overcome communication barriers; cultural and spiritual competence; grief, loss, and bereavement.
36 items
36
4Professionalism and Practice. Principles of biomedical ethics; professional boundaries; scope of practice; opioid stewardship; national hospice and palliative care standards and guidelines; self-care (burnout, compassion fatigue, moral distress); clinical decision making; continuous quality improvement; hospice criteria; professional development.
38 items
38
Weights from ACHPN Computer Based Examination Candidate Handbook [1]; HPCC: ACHPN Detailed Content Outline, current exam [2]. Read on Nov 11, 2026.
Assessment and Data Collection, 44 items
Here the APRN gathers data and turns it into a diagnosis and a prognosis. The outline lists the history and review of systems, the physical exam, functional, psychosocial and spiritual assessment, standardized assessment and prognostic tools, signs of serious illness, advance care planning, disease progression and prognosis, signs of imminent death, and the needs of specific populations.
Prognostic tools deserve the most time. Know what the Palliative Performance Scale, the FAST stages and the Karnofsky scale each measure, and which disease-specific findings support a hospice prognosis in heart failure, COPD, ALS, dementia and end-stage kidney disease. "Specific populations" is broad: think of children, people with intellectual disability, incarcerated patients and veterans.
Palliative care is not a waiting room for hospice
Palliative care fits any stage of serious illness and can run alongside disease-directed treatment; the Medicare hospice benefit needs a terminal prognosis and an election. An answer that delays a palliative referral until the patient is "ready for hospice" gets the order backward.
Intervention and Management, 32 items
The prescribing domain: which test is worth ordering when the goal is comfort, which drug fits the symptom and the patient's kidneys and liver, and when a non-drug or complementary approach is the better first step. The outline also names hospice and palliative emergencies, palliative sedation and life-support devices.
Build drug tables by symptom rather than by class: pain (opioid choice in organ failure, rotation and conversion, methadone, adjuvants), dyspnea, nausea by mechanism, secretions, delirium, bowel obstruction and bleeding. For emergencies, know the first steps for hypercalcemia, cord compression, catastrophic bleeding and superior vena cava obstruction, and when the patient's goals make the usual workup the wrong choice.
Devices are treatments, not fixtures
Turning off an implanted defibrillator or stopping a ventilator at the request of the patient or surrogate is withdrawing a treatment, which carries the same ethical and legal weight as not starting it. The APRN's job is the symptom plan for during and after, not a debate about whether stopping is allowed.
Education and Communication, 36 items
How the APRN shares information and decisions: teaching suited to age and literacy, communication principles in serious illness, getting past language, hearing, cognitive and cultural barriers, cultural and spiritual competence, and grief, loss and bereavement. Expect family meetings, serious news delivered in steps, questions such as "how long do I have", and children facing a death in the family.
Frameworks help sort the options: a stepwise model for breaking bad news (SPIKES is a common one), asking permission before giving information, and responding to emotion before adding facts.
Interpreters, not relatives
When the patient and clinician do not share a language, a trained medical interpreter is the standard. A family member, and above all a child, should not be the one interpreting serious news, even when the family offers.
Professionalism and Practice, 38 items
A wide domain on the current outline: biomedical ethics, professional boundaries, scope of practice, opioid stewardship, national standards and guidelines, self-care (burnout, compassion fatigue, moral distress), clinical decision making, quality improvement, hospice criteria and professional development.
Ethics questions are the hardest to guess. Know the four principles and where they collide, how decision-making capacity is judged for one decision at a time, and the substituted-judgment standard for surrogates.
Moral distress is not burnout
Moral distress means knowing the right action and being blocked from taking it, by policy, hierarchy or a family's demands. Burnout is exhaustion from cumulative load. Options that offer rest for moral distress miss the point: the remedy is to address the barrier, for example through an ethics consultation.
Current weights against the posted 2027 outline
The biggest change is in management. In the 2027 outline posted by HPCC, that domain would become the largest block and professional practice the smallest; the table below has the counts and what moves where.
No effective date had been announced as of Nov 11, 2026, so today's weights still decide your study plan.
Fact
Detail
Source
Content outline in force
Detailed Content Outline from the 2021 job analysis, printed in the December 2025 handbook
ACHPN Computer Based Examination Candidate Handbook [1][2]
Upcoming change
HPCC has posted a 2027 content outline but no date when it takes effect. Checked on the credential page (read Nov 11, 2026).
ACHPN (Advanced Practice RN) credential page [3][4]
Next outline (posted)
2027 ACHPN Exam Content Outline: Assessment and Data Collection 42, Evaluation and Management 49, Education and Communication 38, Professionalism and Practice 21 scored questions. The management domain is renamed Evaluation and Management and grows from 32 to 49 items, taking in opioid stewardship and complex clinical decision making; Professionalism and Practice drops from 38 to 21. Hospice criteria move to assessment, and "hospice versus palliative care" joins Education and Communication.Posted without a start date (read Nov 11, 2026).
A hospitalized patient with advanced cancer has a Palliative Performance Scale of 30%, eats only mouthfuls, and has edema, dyspnea at rest and delirium. The APRN wants a bedside tool built from exactly these findings to estimate whether survival is under 3 weeks. Which tool is it?
Mark a letter. The key, plus a line on every option, opens at once.
Palliative Prognostic Index
The Palliative Prognostic Index scores exactly these items (performance status, oral intake, edema, dyspnea at rest and delirium), and a high score predicts survival under about 3 weeks.
Palliative Prognostic Score
The Palliative Prognostic Score is the near-miss: it relies on a clinician survival estimate and white-cell counts, which are not among these findings.
Charlson Comorbidity Index
The Charlson index weighs long-term comorbidity burden and is not a bedside tool for survival measured in weeks.
Eastern Cooperative Oncology Group scale
The Eastern Cooperative Oncology Group scale rates performance status alone, without intake, edema, breathlessness or delirium.
Professional practice · 38 itemsQ2 of 12
Which behavior by a hospice nurse caring for a long-term patient is a warning sign of over-involvement that the APRN should address?
visiting the patient on days off without telling the team
Unreported visits on days off are secret contact outside the care role, a classic sign of over-involvement for the APRN to address.
holding the patient's hand during a painful dressing change
Holding the patient's hand during a painful procedure is supportive touch within the care role.
attending the patient's funeral with the team's knowledge
Going to the funeral openly, with the team aware, is accepted hospice practice that supports closure.
calling the family once after the death as part of bereavement
One planned bereavement call is part of the program's follow-up, not a boundary crossing.
Assessment · 44 itemsQ3 of 12
A patient with advanced heart failure has been hospitalized four times in 6 months. Which statement BEST signals that the patient is ready to discuss hospice?
"My weight is up, but I feel better this week."
Weight gain with a good week is a symptom report that calls for a diuretic review, not a cue to change the plan of care.
"I'm tired of going back to the hospital."
Being tired of going back to the hospital is the patient's own statement of a shift in priorities, which opens a talk about goals and hospice.
"I want to ask about the new heart pump trial."
Asking about a heart pump trial shows the patient is still pursuing life-prolonging options.
"My daughter keeps pushing me about hospice."
Feeling pushed by the daughter describes family pressure; the patient has not said that they want to change course.
Intervention · 32 itemsQ4 of 12
A patient with advanced Alzheimer's disease (FAST 7c) eats less, pockets food, and coughs with thin liquids. The daughter asks for a feeding tube to prevent pneumonia. What does the APRN recommend?
Gastrostomy tube placement now
A gastrostomy does not prevent aspiration, because saliva and refluxed feeds are still aspirated, and it adds restraint use and pressure injuries.
Nasogastric feeding for a 2-week trial
A nasogastric tube is uncomfortable, is often pulled out in dementia, and carries the same aspiration risk as other tube feeding.
Careful hand feeding focused on comfort
In advanced dementia, careful hand feeding matches tube feeding for survival and aspiration while keeping the comfort of taste and contact; guidelines advise against feeding tubes here.
Keep nothing by mouth; give IV fluids
Keeping nothing by mouth takes away the pleasure of eating, and IV fluids do nothing to stop aspiration of secretions.
Intervention · 32 itemsQ5 of 12
A patient with a prognosis of days has severe dyspnea and agitation. The family asks the APRN to "put him to sleep so he is not suffering." Before recommending palliative sedation, the APRN must establish that
the hospice prognosis is 6 months or less.
A 6-month prognosis defines hospice eligibility; sedation is tied to a refractory symptom and a far shorter expected survival.
his written advance directive specifically requests it.
A directive may reflect his values, but none is required, and a written request does not make the symptom refractory.
the family unanimously requests sedation.
Family agreement, unanimous or not, is part of consent, not proof that other treatment has failed.
the symptom is refractory to tolerable therapy.
Palliative sedation is justified only for a refractory symptom, one that tolerable treatment cannot relieve in an acceptable time; a family request does not establish that.
Intervention · 32 itemsQ6 of 12
A hospice patient with a centrally located lung tumor had a small herald episode of hemoptysis yesterday. The family wants the patient to die at home. Which is the APRN's BEST preparation?
Arrange home transfusion if bleeding recurs
A massive bleed ends too quickly for transfusion, and blood replacement does not fit a comfort-only plan.
Tell the family to call 911 for bleeding
Calling 911 brings resuscitation and transport, which conflicts with the wish to die at home.
Plan bronchoscopy and embolization for the next bleed
Bronchoscopy and embolization are hospital procedures that cannot be arranged in the minutes a terminal hemorrhage allows.
Stock dark towels and a crisis dose of midazolam
A herald bleed can precede a massive hemorrhage that is fatal within minutes, so stocking dark towels to mask the blood and a crisis dose of a fast-acting sedative prepares for comfort.
Education and communication · 36 itemsQ7 of 12
Using the Serious Illness Conversation Guide, which question explores the patient's tradeoffs?
"How much does your family know about your priorities and wishes?"
Asking what the family knows explores family awareness, a separate part of the conversation.
"How much are you willing to go through for the possibility of more time?"
This is the guide's tradeoffs question: how much burden the patient will accept for a chance at more time.
"What are your biggest fears and worries about the future with your health?"
Fears and worries are their own domain of the guide; they reveal concerns, not what the patient would trade for time.
"What abilities are so critical that you can't imagine living without them?"
Critical abilities name outcomes the patient would find unacceptable, close to tradeoffs but a different question.
Education and communication · 36 itemsQ8 of 12
A patient with moderate COPD is admitted with pneumonia and is fully alert. The patient's advance directive says only "no heroic measures." What should the APRN do FIRST?
ask the patient what that phrase means
An alert patient can explain a vague phrase, so the APRN asks what it means for antibiotics, noninvasive ventilation, intubation and CPR.
withhold antibiotics in line with the directive
Withholding antibiotics reads a meaning into the directive that the patient may never have intended.
ask the ethics committee to interpret the directive
An ethics committee cannot know what the patient meant better than the patient, who is fully alert.
treat the patient as a full code
Defaulting to full code ignores the written wish and the chance to ask the patient directly.
Education and communication · 36 itemsQ9 of 12
A 19-year-old with relapsed osteosarcoma asks the APRN about planning for the future. Which approach to advance care planning is BEST?
Use Voicing My CHOiCES with the patient
Voicing My CHOiCES was built with adolescents and young adults and covers what matters at this age, such as how they want to be remembered and who should speak for them.
Complete a POLST form at this visit
A POLST turns treatment choices into medical orders; it follows a values conversation and does not cover what this young adult wants to plan.
Defer planning until treatment ends
Deferring planning until treatment ends ignores a request the patient is making now, during a relapse.
Have the parents complete the planning instead
At 19 the patient is an adult who can speak for themselves; having the parents complete the planning removes the patient's voice.
Professional practice · 38 itemsQ10 of 12
A patient with end-stage COPD elects the Medicare hospice benefit and names their longtime nurse practitioner as attending. Who signs the initial certification of terminal illness?
the nurse practitioner alone, as the designated attending
Being the designated attending does not let the nurse practitioner certify terminal illness under Medicare.
any two physicians who have examined the patient in person
Medicare names who signs, the hospice physician plus a physician attending if there is one; it has no rule for two examining physicians.
the nurse practitioner together with the hospice medical director
Pairing the nurse practitioner with the medical director fails because the second signature must come from a physician attending; a nurse practitioner cannot certify.
the hospice medical director or physician member of the IDG
A nurse practitioner may be the attending but cannot certify terminal illness, so the hospice medical director or a physician on the IDG signs.
Professional practice · 38 itemsQ11 of 12
An APRN asks: 'In adults with chemotherapy-induced peripheral neuropathy, does duloxetine reduce pain scores more than gabapentin?' In PICO terms, gabapentin is the
intervention.
The intervention is duloxetine, the option being tested; reading the second drug as another intervention is the usual slip.
population.
The population is adults with chemotherapy-induced peripheral neuropathy, not either drug.
comparison.
Gabapentin is the comparison, the alternative that duloxetine is measured against.
outcome.
The outcome is the change in pain scores that the question measures.
Assessment · 44 itemsQ12 of 12
An 89-year-old with frailty, mild dementia and several chronic conditions has lost function slowly over 3 years, with no single dramatic event. When discussing prognosis with the family, the APRN describes which illness trajectory?
short, steep decline after stable function
A short, steep decline after stable function is the usual cancer trajectory.
stepwise decline with acute flares
A stepwise decline with acute flares, any of which may be fatal, fits organ failure such as heart failure or COPD.
prolonged dwindling with low function
Prolonged dwindling with low function is the frailty and dementia course: slow loss over years without one dramatic event.
sudden death without prior decline
Sudden death without prior decline does not match a patient who has been losing function for 3 years.
Not on the current outline. The domain that lists pharmacologic therapies is the smallest, at 32 items. The posted 2027 outline would make it the largest.
Does the ACHPN test pediatric palliative care?
There is no pediatric domain, but the outline names age-appropriate teaching and the needs of specific populations, so children and adolescents can appear inside the four domains.
Where do ethics questions sit in the ACHPN outline?
In Professionalism and Practice, which covers biomedical ethics, scope of practice and decision making; palliative sedation is listed under management.