2024 Edition

CHPN Practice Exam

Take this free CHPN practice test to get a sample of the types of questions on the actual Hospice and Palliative Nurse certification exam.

The CHPN exam is a 3 hour exam covering 150 multiple choice questions. The CHPN exam focuses on five domain practice areas: Life-limiting Conditions in Adult Patients, Pain Management, Symptom Management, Patient and Family Care and Practical Issues.

You can also try the Complete 750 Question CHPN Practice Exam Kit with fully explained answers, testing tips and more.

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Patient Care: Assessment and Planning

1.	The hospice nurse is assessing a patient while on a routine visit. The patient reports pain while swallowing. The nurse assesses the patient's mouth and throat, noting moist mucous membranes and white curd-like plaques near the back of the tongue. The nurse will call the provider with which suggestion?
		a. Swab tongue for culture
		b. Increased hydration
		c. Nothing by mouth for 24 hours
		d. Antifungal swish and swallow
This patient is exhibiting signs of an active fungal infection, candidiasis. Cultures are not recommended as this can be treated based on clinical findings. Increased hydration would only be appropriate if the odynophagia was caused by dehydration. Avoiding certain foods may bring comfort, but NPO status is not needed. Incorrect answer. Please choose another answer.

2.	The nurse is reviewing the plan of care for a patient receiving general inpatient care. Though the patient's level of consciousness has decreased, symptoms of discomfort have been managed. The patient's family expresses satisfaction with the care at this level and would like to continue with general inpatient care. What is the appropriate level of care for this patient?
		a. Routine home care
		b. Continuous home care
		c. Inpatient respite care
		d. General inpatient care
Routine home care is the appropriate setting for this patient. This patient no longer qualifies for general inpatient hospice care based on the lack of symptoms. A reduced level of consciousness is expected and can be managed in the home. Respite is not appropriate, as the patient is presently inpatient. Continuous home care would require a higher symptom burden. Incorrect answer. Please choose another answer.

3.	The nurse is talking about goals of care with a patient who has terminal cancer of unknown origin. Which of the following patient priorities most indicates a hospice referral will be appropriate?
		a. "I want to figure out what caused this cancer."
		b. "I want to be at home with my family."
		c. "I want to live one more year."
		d. "I have nothing to look forward to."
"I want to be home with my family," indicates that the patient's priority is quality of life over length of life. Having nothing to look forward to is a signifier of depression, not acceptance. A psychological or spiritual referral would be more appropriate. If the patient wants to live one more year, realistic or not, hospice is inappropriate. If the patient is focused on the cause of the cancer, it indicates his priority is not on quality of life. Incorrect answer. Please choose another answer.

4.	The nurse is assessing a dying patient who has been unresponsive for the last 18 hours. The nurse informs the family death is imminent. Which assessment finding would most support this determination?
		a. Concentrated urine
		b. Increasing FLACC score
		c. Oxygen saturation of 80%
		d. Pulseless radial artery
All of these findings may be present, but pulselessness of the radial artery is most associated with imminent death. Increased FLACC score indicates more pain which is not expected nor a sign of imminent death. Oxygen saturation and concentrated urine are expected findings throughout the dying process. Incorrect answer. Please choose another answer.

5.	A hospice patient with advanced COPD expresses the desire to attend a rodeo two counties away. The nurse understands that the rodeo will have animals, dust in the air, and many people in attendance. How should the nurse address this desire in the plan of care?
		a. The patient may attend based on personal goals.
		b. The patient may not attend due to infection risk.
		c. The patient may attend but with a chaperone.
		d. The patient may not attend for physical safety concerns.
The patient's desire to attend the rodeo should take priority in the plan of care. Educating the patient about the risks associated with this outing would be recommended. There is nothing in the question to indicate that the patient will need a chaperone. Incorrect answer. Please choose another answer.

6.	The nurse is caring for a patient with metastatic lung cancer. Which sign most indicates the patient is experiencing an oncologic emergency?
		a. Dependent edema
		b. Increase in dilute urine
		c. Constipation
		d. Upper body swelling
Upper body swelling is an indicator of superior vena cava syndrome (SVCS). Concentrated urine, not dilute, is a sign of syndrome of inappropriate diuretic hormone (SIADH), another oncologic emergency. Though constipation may indicate hypercalcemia or bowel obstruction, which is common in many cancer patients. Dependent edema is also a non-emergent finding. Incorrect answer. Please choose another answer.

7.	Alzheimer disease is associated with what characteristics?
		a. Pre-clinical and symptomatic phases
		b. Lewy body deposits
		c. A more accelerated decline in older patients
		d. Slow, irreversible organ failure
Alzheimer disease is one type of dementia, with a known pre-clinical phase during which pathophysiologic changes begin to occur, followed by a symptomatic phase where cognitive and functional decline becomes noticeable. Lewy body deposits in the brain are associated with Lewy body dementia only. The degree of dementia progression often depends on underlying factors, although there is some evidence suggesting that early-onset Alzheimer patients progress more rapidly. Irreversible organ failure is not a hallmark characteristic; instead, pain, constipation, and behavioral changes are the most common symptoms. Incorrect answer. Please choose another answer.

8.	You are the nurse on-call and receive a call from a continuous care nurse who states that her patient has started to have "rattling" secretions and the patient's wife is very concerned. You know from report that this patient is actively dying. What would be the most appropriate response?
		a. Reposition patient on his side
		b. Administer furosemide
		c. Suction the patient
		d. Order oxygen for the patient
Noisy, congested respirations (known as "terminal secretions") are very common during the dying process, and are also sometimes referred to as a “death rattle”. Typically, they do not cause discomfort for the patient, but can be very distressing to family members. Repositioning the patient by turning him on his side can be helpful to decrease the noise associated with this situation. Anticholinergics can also be administered, but typically, once the secretions start, anticholinergic effectiveness is limited. Incorrect answer. Please choose another answer.

9.	Which characteristics are most closely associated with end-stage renal disease?
		a. 20% or less of normal renal function exists; consequence of coronary artery disease
		b. Consequence of alcohol misuse; only treatment is dialysis
		c. 10% or less of normal renal function exists; consequence of diabetes
		d. Affects Hispanic population disproportionately; symptoms include polyuria
End-stage renal disease (ESRD) is diagnosed when <10% of normal renal function exists, and is often a consequence of diabetes or hypertension. Alcohol misuse or comorbidities such as coronary artery disease, peripheral vascular disease, or malnutrition may be present, but are not causative factors. Treatment includes dialysis, but also kidney transplantation. African Americans, not Hispanic populations, are disproportionately affected by ESRD. Oliguria, not polyuria, is a symptom of ESRD. Incorrect answer. Please choose another answer.

10.	Mary is a 73-year-old patient with a 50-year history of smoking and a diagnosis of emphysema. She is very thin with a barrel chest, has intermittent dyspnea both at rest and with exertion, and supraclavicular retractions on exertion. What non-pharmacologic intervention would likely improve dyspnea in this patient?
		a. Lowering the head of the bed
		b. Positioning in the tripod position
		c. Slow, deep meditative breathing through the nose
		d. Guided imagery
Patients with emphysema may find some relief from dyspnea by leaning forward while sitting, and placing arms over a table (“tripod position”), due to the lengthened tension-state of the diaphragm in this position. Lowering the head of the bed would likely worsen dyspnea; pursed mouth-breathing, rather than deep nose-breathing, would be of greater benefit to lessening dyspnea; although guided imagery may improve mood, evidence does not demonstrate that it affects dyspnea directly. Incorrect answer. Please choose another answer.

11.	John is a new hospice patient with heart failure. John reports a six-pound weight gain since his discharge from the hospital 3 days ago. The nurse notes that John has dependent peripheral edema 2 +, and he reports feeling nauseated and with poor appetite. Based on these findings, what is the pathophysiology of John's heart disease?
		a. Systolic dysfunction, with poor cardiac output
		b. Diastolic dysfunction, with poor ventricle filling
		c. Decreased ejection fraction
		d. Generalized organ perfusion failure
John's symptoms are due to right sided (diastolic) heart failure, when the ventricle does not fill adequately, leading to a generalized edema of the extremities and the hepatic system. Symptoms of right sided failure include nausea, anorexia, peripheral edema, ascites, weakness, and weight gain. Poor cardiac output, decreased ejection fraction, organ perfusion failure are indicative of left-sided heart failure. Incorrect answer. Please choose another answer.

12.	A nurse is meeting a patient for the first time. When introducing himself, the nurse notes a series of symptoms that are concerning for acute stroke. Which symptoms are associated with acute stroke?
		a. Hyperventilation and bowel incontinence
		b. Difficulty understanding speech and blurry vision
		c. Vomiting and dyspnea
		d. Generalized weakness and dysphagia
Acute stroke is associated with aphasia (which may include difficulty with both understanding and with verbalizing speech), ataxia, numbness or paralysis of limbs or face, vision disturbances, and headaches, which may illicit vomiting. The other symptoms are not indicative of acute stroke symptoms. Incorrect answer. Please choose another answer.

Patient Care: Pain Management

13.	A hospice patient has been receiving hydrocodone by mouth but will be changing to parenteral morphine. After calculating the equianalgesic dose, what knowledge will guide the new dose?
		a. Increase dose because of dependence.
		b. Decrease dose to assess cognition.
		c. Increase dose due to anticipated pain.
		d. Decrease dose due to cross tolerance.
When changing analgesics, a dose reduction is recommended for cross-tolerance. Recommendations vary, but reduction can be up to 50% of the original dose. Increases in doses are possible in the future, but not at the time of conversion and not without more assessment data. Though tolerance is a concern with conversion of opioids, dependence is not. Assessing cognition is not indicated. Incorrect answer. Please choose another answer.

14.	The nurse is caring for a patient who is actively dying and is in persistent pain. The patient's spouse says, "I think we should stop giving the morphine. It doesn't seem to be working anymore." Which of the following is an appropriate response?
		a. "He has become physically dependent. We should stop the morphine."
		b. "He has developed an addiction. We should titrate off morphine slowly."
		c. "He has developed tolerance. We should increase the dose of morphine."
		d. "He is nearing the end of life. There is no need to change the morphine."
The patient has pain and it needs to be treated. Since morphine has worked in the past, the most likely scenario is that the patient has developed a tolerance and the dose needs to be increased. The next step would be to try another opioid. Stopping the opioid would cause withdrawal and increase discomfort. Titrating off of morphine would only be indicated if there was no more pain. Addiction is not a concern for this patient. Incorrect answer. Please choose another answer.

15.	A nurse is reporting to the provider about a patient with advanced breast cancer. New findings include shooting pain down the left leg, increased respiratory rate, bilateral crackles in lungs, and drowsiness. Amitriptyline is among the new medications ordered. How will the nurse determine if this medication is effective?
		a. Reduction in respiratory rate
		b. Increase in alertness
		c. Decrease in pain
		d. Clear breath sounds
Amitriptyline is a tricyclic antidepressant often used as an adjuvant analgesic for neuropathic pain. The pain in the question was described as shooting, which is a hallmark of neuropathic pain. The other outcomes listed may be welcome, but not used as an evaluation of amitriptyline. Incorrect answer. Please choose another answer.

16.	A patient on hospice has been receiving increasingly high doses of morphine over the last 2 months to manage pain. During a weekly visit, the hospice nurse recognizes pronounced muscle twitching. How will the nurse proceed?
		a. Plan opioid rotation.
		b. Administer supplementary hydration.
		c. Provide massage of affected muscles.
		d. Provide education on expectations.
This patient is most likely experiencing myoclonus related to high opioid doses. The nurse should work with the providers to rotate to a new opioid. Supplementary hydration would be a solution if this myoclonus is related to hypercalcemia. Massage and education may help but will not address the root cause of the myoclonus. Incorrect answer. Please choose another answer.

17.	Which of the following most accurately describes "breakthrough" pain?
		a. Associated with pathological fractures
		b. Refers to a new psychological or spiritual insight
		c. Can occur as end-of-dose failure
		d. An aspect of opioid pseudo-addiction
Breakthrough pain is intermittent episodes of pain that occur in patients with chronic pain. This type of pain can be related to some type of activity, of unknown origin, or can occur as analgesic failure at the end of a pain medication's period of effectiveness. Opioid regimens for pain management in the hospice and palliative care setting should include a long-acting agent, once dosing need is established, and a short-acting agent to cover episodes of breakthrough pain. Incorrect answer. Please choose another answer.

18.	Madge is an 88 year-old with end stage colon cancer, who is transitioning. She has been minimally responsive for the past six hours, but opens her eyes in response to her name. She is restless at times with furrowing of her brow. She is still swallowing her secretions, and sucks on the oral sponge when mouth care is provided. Prior to her change in status, she was receiving Oxycontin 40 mg po tablets q12 hr ATC with liquid oxycodone 8-12 mg po q2hrs prn for breakthrough pain. In light of Madge's change in level of consciousness, what changes should be made to her pain management regimen?
		a. Convert to IV infusion
		b. Convert to subcutaneous infusion
		c. Convert to liquid dosing orally
		d. Convert to fentanyl patch
Since the oral route is always preferred if possible, Madge should be converted to liquid dosing of her current long-acting pain medication q 4hrs ATC (convert from Oxycontin® to liquid oxycodone), while maintaining the same dosing as currently ordered for breakthrough pain. Since most liquid forms are quite concentrated, even patients who are minimally responsive can tolerate such small volumes in the buccal space and typically maintain excellent pain control. Incorrect answer. Please choose another answer.

19.	Which patient is at most risk for under-treatment of pain symptoms?
		a. 86-year old female with COPD, living in an assisted living facility
		b. 74-year old male with congestive heart failure, living with his wife
		c. 51-year old male, recently diagnosed with ALS; a former weight lifter
		d. 42-year old female with early-onset dementia, living with her sister.
A frequent misconception is that younger patients with few co-morbidities are at greatest risk for under-treatment for pain, but in fact the elderly, minorities, and women are most at risk for under-treatment. Of the four case scenarios, the 86-year old has two of the three risk factors. Incorrect answer. Please choose another answer.

20.	Margaret is an 87-year old with breast cancer that has metastasized to bone and brain. She lives alone, and is checked in on by a neighbor every other day. During a home visit, Margaret complains of dull, constant pain in her back and breastbone. The nurse notes that the oxycodone tablets that he had counted out for her for the last two days are still in the pill box; Margaret cannot explain why she did not take them as prescribed. This is the second occasion when the nurse has found tablets not taken. What is an appropriate pain management strategy for Margaret?
		a. Margaret should be admitted to an inpatient hospice for pain control.
		b. The oxycodone should be replaced with equianalgesic transdermal fentanyl.
		c. The oxycodone should be replaced with an equianalgesic liquid morphine.
		d. A neighbor should be tasked to give Margaret her medications.
Transdermal fentanyl, also known as a fentanyl patch, is a good choice for individuals with pain who cannot swallow or do not remember to take their medication, and would need to be titrated to effect for this patient. It is a particularly good choice for Margaret because she may be forgetful due to her brain metastasis, which would not improve by providing liquid morphine instead of tablets. As she does not live with a caregiver, depending on the neighbor to assure adequate pain management is not an effective plan. As Margaret is not in pain crisis, symptom control efforts should be initiated and the effect evaluated before referral to an inpatient hospice setting. Incorrect answer. Please choose another answer.

21.	What should be prescribed concurrently with any opioid regimen?
		a. Ondansetron
		b. Diphenhydramine
		c. Senna
		d. Pamidronate
As constipation is a significant side effects of opioid therapy, any patient on an opioid should also be prescribed a prophylactic bowel regimen to prevent or manage constipation. Senna is a simulant laxative that chemically stimulates the bowel to increase motility. Ondansetron HCl is a 5-HT3 receptor antagonist, used to prevent nausea and vomiting; diphenhydramine is an antihistamine used to treat opioid- induced pruritus; pamidronate is a bisphosphonate used as an adjuvant to opioids for bone pain. Incorrect answer. Please choose another answer.

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22.	Jordan is taking continuous-release morphine every 12 hours for pain control, and has a short-acting prn opioid for break through pain. He is experiencing end-of-dose failure at 9-10 hours. What would be the most appropriate intervention to manage Jordan's pain?
		a. The dose should be decreased every 12 hours, but the short-acting prn dose should be increased by 25%.
		b. An adjuvant therapy such as a corticosteroid should be added.
		c. Jordan should be switched to an equianalgesic alternative opioid
		d. The dosing interval of the continuous-release morphine should be decreased to every 8 hours, at the same dose, with no change in the prn dosing
Jordan is experiencing end-of-dose failure, which indicates that in the last hours of the dosing cycle, the blood levels of the drug are decreasing before uptake of the next scheduled dose. This is different than breakthrough pain, characterized by episode of pain despite control of continuous baseline pain. By shortening the round-the-close drug interval, Jordan will experience more stable drug blood levels. Increasing the prn dosing would only result in a short-acting bolus just prior to the next dosing cycle and could cause sedation and other side effects. A switch to another opioid is not necessary as this is typically done due to an undesirable side effect. A corticosteroid would not provide the desired pain management result in the last hours of the dosing cycle. Incorrect answer. Please choose another answer.

Patient Care: Symptom Management

23.	An unresponsive, bedbound patient has developed a pressure injury on the left heel. A large amount of purulent exudate is present. What is the nurse's first action?
		a. Apply alginate dressing for absorption of exudate.
		b. High-pressure irrigation to clean the wound.
		c. Ensure family understands importance of turning.
		d. Call provider to report infectious process.
The nurse may consider all these actions, but the priority will be to irrigate the wound. The presence of purulent drainage does indicate infection, but further assessment cannot be done until the wound is clean. After it is clean and the wound bed assessed, the nurse would choose the appropriate dressing. Any calls to the provider and patient education could occur after the wound is cared for. Incorrect answer. Please choose another answer.

24.	A hospice nurse and the provider are discussing a patient who suffered a traumatic brain injury (TBI) and has increased intracranial pressure (ICP). They have exhibited somnolence, periodic seizures, and a high FLACC score. Which of the following orders will the nurse question?
		a. Tramadol
		b. Lorazepam
		c. Propranolol
		d. Gabapentin
Tramadol should not be used as it may lower the seizure threshold. Lorazepam would be recommended on a prn basis for agitation or extended seizures. Propranolol may be warranted for the regulation of blood pressure which could impact the ICP. Gabapentin or another antiseizure medication would be expected to control or prevent seizures. Incorrect answer. Please choose another answer.

25.	A new hospice nurse is caring for a patient with constipation likely induced by opioid use. The nurse calls her preceptor to discuss the plan of care. Which recommendation addressing the constipation will cause the preceptor to intervene?
		a. Manual evacuation
		b. Oral osmotic laxative
		c. Rectal stimulant laxative
		d. Fiber supplementation
Fiber supplementation is considered a bulk-forming laxative. This is not generally recommended in hospice due to the water required to be effective. Inadequate water availability would worsen constipation and potentially lead to obstruction. The other options are appropriate. Incorrect answer. Please choose another answer.

26.	Of the following, which may indicate a poor prognosis for the hospice patient with a diagnosis of end-stage cardiac disease?
		a. Infection
		b. Edema
		c. Bleeding
		d. Unexplained syncope
Unexplained syncope, as well as previous cardiac arrest with resuscitation, and an embolic stroke originating from the cardiac system are all indicators of poor prognosis in this patient population. Incorrect answer. Please choose another answer.

27.	When a hospice patient is facing increasing weakness, with increased fatigue and decreased mobility, which of the following is an important aspect of supporting the patient's care needs?
		a. Prioritizing energy use
		b. Honoring the wishes of family members
		c. Remaining as mobile as possible
		d. Seeing as many visitors as possible
Prioritizing energy use is an important aspect of supporting the hospice patient who is experiencing progressive weakness and fatigue. Helping the patient to identify which activities are most important to physical, emotional and spiritual needs empowers the patient to spend limited energy on those aspects that matter most to them. Incorrect answer. Please choose another answer.

28.	Terri has an indwelling pleural catheter in place for intermittent drainage of her pleural effusion. The nurse is present to provide teaching on the use of the catheter at home. Which point is important for the nurse to stress to Terri to avoid vasovagal symptoms?
		a. The drainage should occur slowly and continuously over an 8-hour period.
		b. No more than 1-1.5 liters of fluid should be removed at any one time.
		c. It is important to fully drain the pleural space each time the catheter is accessed.
		d. The catheter can only be accessed by a nurse.
To avoid vasovagal symptoms (tachycardia, hypotension, fainting), it is important to draw the fluid off slowly with no more than 1-1.5 liters removed at any one time. Fully draining the pleural space (if more than 1.5 liters is present) could result in pain, vasovagal responses, and cough. In the palliative setting, it is ideal to have a caregiver instructed on how to properly access the catheter. Drainage should never occur over an 8-hour period, as prolonged catheter access can result in infection or embolus. Incorrect answer. Please choose another answer.

29.	Daryl has an incomplete bowel obstruction secondary to metastatic ovarian cancer. She is experiencing significant abdominal pain and is vomiting fecal matter. She and her family want non-pharmacologic interventions only. Which intervention is likely to be the most effective?
		a. Bowel rest
		b. High fiber diet
		c. Foley catheter
		d. Nasogastric tube
Insertion of a nasogastric tube for decompression venting and emptying of stomach contents is the most appropriate intervention at this stage of obstruction. Bowel rest is necessary, but bowel rest alone will not empty the stomach contents and hopefully reduce vomiting. A Foley catheter will not improve the obstruction; introduction of food while the obstruction is present will only complicate the situation. Incorrect answer. Please choose another answer.

30.	Michelle has metastatic head/neck cancer and is in the last stages of life. She is cared for at home by her niece. In the last 24 hours she has become increasingly restless, and is repetitively attempting to get out of bed, while calling out in distress. Which group of interventions would be the most appropriate for Michelle at this time?
		a. Transfer Michelle from home to an inpatient hospice unit; begin IV morphine.
		b. Confine Michelle to bed; discontinue her neuroleptics.
		c. Dim the lights in Michelle's room; administer haloperidol.
		d. Raise the head of Michelle's bed; obtain a 24-hour sitter.
Michelle is experiencing hyperactive delirium, commonly seen at end of life just prior to non-responsiveness. Dimming the lights will reduce sensory stimulation and may calm Michelle. Haloperidol is commonly administered for this symptom and is typically effective. Transferring Michelle immediately would likely exacerbate her symptoms; although morphine would cause sedation, it is not the most appropriate drug for these symptoms. Confining Michelle is inappropriate; discontinuing any current medications would only exacerbate symptoms. A sitter is an appropriate intervention as Michelle may be at risk for falls, but raising the head of the bed is ineffective for these symptoms. Incorrect answer. Please choose another answer.

Care of Patient and Family

31.	Which service for the hospice patient would be paid for by the Hospice Medicare/Medicaid benefit?
		a. Room and board in a nursing home facility.
		b. Treatment intended to cure the hospice-qualifying terminal illness
		c. Care for the terminal illness from more than one hospice provider
		d. Transportation and visits to the emergency room that are arranged by the hospice provider
The Hospice Medicare and Medicaid Benefit pays for outpatient services such as emergency room visits when arranged by the hospice team. The benefit does not cover room and board for hospice services in a private home or room and board in a nursing home; it does not cover prescription drugs or treatment intended to cure the terminal illness. The benefit also requires that all care for the terminal illness is given by the hospice provider chosen, with the exception of the patient's regular doctor or nurse practitioner, chosen to be the attending physician for the hospice care. Incorrect answer. Please choose another answer.

32.	After a patient's death, how long are bereavement services available to families and other individuals associated with the patient?
		a. Based on the degree of bereavement risk assessed, services can continue indefinitely.
		b. Up to 6 months for family members and up to 6 weeks for other individuals associated with the patient.
		c. Up to 1 year following the death of the patient.
		d. Hospices have no obligation to provide bereavement services for any specific period of time.
Medicare hospice regulations require that the hospice must provide bereavement services to the family and any other individuals that are identified on the bereavement care plan for up to 1 year following the patient's death. There is no distinction between direct family members and other individuals associated with the patient. Incorrect answer. Please choose another answer.

33.	Heidi is in her last days of life, being cared for by her husband and adult children. Over the last week she has increased her sleep from 16 to 20 hours per day and is taking only sips of water and juice. Her daughter calls the nurse, concerned that Heidi suddenly became alert and clearly demanded that she needs to get up and get into line with people outside who are waiting for her. These statements by Heidi have upset the family, but Heidi is comforted by them. What is an appropriate intervention for this family?
		a. Instruct the family that speaking in metaphors when patients near end of life is common, and that Heidi may be trying to communicate that she is ready to die.
		b. Encourage the family to clearly state to Heidi that there are no people outside waiting for her
		c. Inform the family that Heidi is delusional due to the pain medication she is receiving and that they should not respond to these statements
		d. Instruct the family to increase the pain medication dose that Heidi is receiving, as this is an indicator of pain
Patients may use allegory or metaphors to describe end of life experiences, to include descriptions of visions or discussions with others, and preparatory statements such as getting ready for a trip, packing, meeting old friends and family, or standing in line preparing to go somewhere. Denying Heidi's beliefs would likely upset her without positive effect; although it is possible that Heidi has delirium, her behavior/statement does not warrant increasing her pain medication; likewise, ignoring her statements would likely upset Heidi. Incorrect answer. Please choose another answer.

34.	Ayaan has metastatic pancreatic cancer and is cared for at home by his wife and adult children. During a recent visit, the nurse notes that his symptoms have dramatically worsened and he is nearing the last days of life. The nurse knows that the family's spiritual beliefs hold that speaking about dying is considered "giving up", and is not acceptable. However, after the nurse's assessment, Ayaan's wife asks the nurse how he is doing, and happily reports that she thinks he is "improving". What would be the most appropriate response from the nurse?
		a. "It's time to begin talking about Ayaan's death."
		b. "I wish that I had better news to tell you."
		c. "Let's call the medical director to give you an update."
		d. "You are not helping Ayaan by avoiding the facts."
Using terms such as "I wish" and "I had hoped" acknowledge the changes that are obvious while respecting the family's spiritual wishes to not discuss death directly. Confronting the wife by accusing her of not being helpful or not being ready to talk about death devalues their beliefs about death; diverting the discussion to the medical director may be helpful, but is not the most appropriate choice. Incorrect answer. Please choose another answer.

Education and Advocacy

35.	A hospice patient with metastatic hepatocellular carcinoma is no longer eligible for any life-prolonging treatments. Though she is alert and oriented, she is physically declining rapidly and may be days from death. During a routine visit, the patient tells the hospice nurse they would like to reverse the DNR and be full code. The patient's family strongly protests this decision. How will the nurse reply?
		a. "You cannot change your code status at this time."
		b. "Your family will be able to change it once you lose consciousness."
		c. "We will get your code status changed."
		d. "We can call the chaplain to come talk about this."
The decision to elect code status is the patient's decision. It is legally and ethically reversible. It would be unethical for the family to go against the patient's clearly stated wishes. In this case, the family should engage in further discussion with the patient. A visit from the chaplain may be beneficial for this family, but the decision to reverse the DNR is the patient's only. Incorrect answer. Please choose another answer.

36.	The hospice nurse is admitting a 65-year-old patient with heart disease related to Down syndrome. Which of the following can the nurse expect when communicating with them and their family?
		a. Planning will be easier due to the life-long diagnosis.
		b. The patient will be making decisions about their medical care.
		c. Code status change will have to be approved by the court.
		d. Increased grief support will be needed by the family.
The grief experienced by families of patients with Down syndrome is complicated and warrants increased support. Life-long diagnoses are often harder to plan for, not easier. Due to cognitive deficits, it is not likely for the patient to be the primary decision maker at 65 years old, though this would need to be confirmed. The patient should be included in the plan of care and their input valued. Code status may need a guardian, though it is not an expectation. Incorrect answer. Please choose another answer.

37.	Eric is a 69-year-old with end-stage esophageal cancer who has just returned home from the hospital after having a PEG tube placed. His wife, Margaret, will be caring for him, and states that she learned how to give him his tube feedings in the hospital. What is the most effective manner of assessing Margaret's ability to perform this task?
		a. Ask her to tell you how she performs it.
		b. Ask her to show you how she performs it.
		c. Ask her to describe the instructions she was given.
		d. Ask her husband if she is performing it correctly.
Asking her to show you how she performs the skill is the most effective means of demonstrating competency. After instructing patients/caregivers regarding any given skill or task, the following should occur, as a minimum: (1) Request a statement of understanding; (2) Watch a return demonstration if appropriate; and (3) Document the response. These are essential aspects of ensuring adult learning and patient safety. Incorrect answer. Please choose another answer.

38.	If a patient and family are struggling financially, which member of the IDT may be most helpful in identifying available community resources for support?
		a. Hospice chaplain
		b. Hospice social worker
		c. Hospice aide
		d. Hospice director
The hospice social worker would the most appropriate member of the IDT to help a patient and family who are struggling financially. Hospice social workers hold a unique knowledge of community resources and expertise for accessing them. Incorrect answer. Please choose another answer.

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39.	Lorna has metastatic ovarian cancer, and is in her final days of life. Throughout her hospice benefit period she has rated her pain as 8 or 9 out of 10 consistently, and has required increasing doses of pain medication to be comfortable. In the last 24 hours she has become non-verbal. Her son is concerned that she will not be able to communicate her suffering to him. What would be the most appropriate educational point to make to her son?
		a. "At this point she is no longer feeling any pain."
		b. "We assume that her pain will escalate, so will just keep increasing her pain medication from this point on."
		c. "When patients cannot communicate verbally, we look for behavioral changes that indicate that pain is present."
		d. "Once a patient is non-verbal, we initiate terminal sedation as a way to manage pain."
Changes at end of life may distress family members, to include loss of direct communication with the patient. It is important to educate families that the patient's behavior will then be the best indicator of pain and may include behaviors such as restlessness, muscle rigidity, grimacing, guarding, crying, moaning, irritability, diaphoresis, passivity, or aggression. A patient who has experienced pain up to the point of being non-verbal is unlikely to stop having pain, and the nurse should assume that pain management must remain a priority; likewise, there is no reason to assume that pain will escalate, so ongoing assessment is necessary. Initiating terminal sedation simply for becoming non-verbal is inappropriate. Incorrect answer. Please choose another answer.

Interdisciplinary / Collaborative Practice

40.	Which statement is most accurate regarding palliative/hospice interdisciplinary teams (IDT)?
		a. All team members can voice opinions, but the medical director is the final decision-maker
		b. Centers for Medicare & Medicaid Services (CMS) requires the palliative IDT to include a volunteer as a member of core services
		c. Patients and their families are considered members of the IDT.
		d. Each professional discipline operates independently to provide the most expansive care
The IDT includes patients and families as members to maintain the patient/family centered focus; all treatment plans are developed with the patient and family. The medical director is not the only leader in IDTs; decision-making is accomplished through coordination among all team members. CMS requires hospice IDTs to include a volunteer, not palliative IDTs. When professional disciplines operate independently, they function as a multidisciplinary team, but are not interdisciplinary, functioning interdependently and often with overlapping roles. Incorrect answer. Please choose another answer.

41.	According to Medicare guidelines, how often does a registered nurse need to make a visit to the patient's home for the purpose of supervising a hospice aide?
		a. Once every 30 days
		b. Once every 7 days
		c. Once every 14 days
		d. Once every benefit period
According to the Medicare Conditions of Participations for Hospices, a registered nurse must make a visit to the patient's home no less frequently than every 14 days for the purpose of supervising the care of the hospice aide. The hospice aide does not need to be present during the visit, unless an area of concern has been discovered. Incorrect answer. Please choose another answer.

42.	What would be the best option for involving the patient and family in the IDT discussion in the hospice residential setting, if they would like to participate?
		a. Ask them to attend the meeting in the conference room.
		b. Hold the meeting in the hall outside the patient's room.
		c. Hold the meeting at the patient's bedside.
		d. Ask them to attend the meeting in the manager's office.
The best option for involving the patient and family in the IDT discussion in the hospice house setting would be to hold the meeting at the patient's bedside. This would allow all parties to participate within the privacy of the patient's room. Incorrect answer. Please choose another answer.

Practice Issues

43.	What is the best practice regarding use of the electronic health record in patient care?
		a. Point of service documentation
		b. Documentation for all patients in one sitting
		c. Documenting in the office
		d. Documenting before the end of the day
Point of service documentation is documentation performed during the patient care visit and is the best practice regarding use of the electronic health record in patient care. Since hospice and palliative care is provided in an interdisciplinary manner, several professionals may be accessing the same record to review collaborative notes within the same day. Delayed documentation creates a barrier to optimal patient care by making vital information inaccessible to other care providers. There are many benefits to point of service documentation, including increased accuracy in the patient care record, and decreased staff burn-out. When documentation is completed during the patient care visit, instead of after hours, hospice staff can enjoy personal time for self-care, instead of patient care. Incorrect answer. Please choose another answer.

44.	You have recently started caring for a new patient who is a member of your church, and the patient permitted news of her hospice admission to be added to the weekly church announcements. At Bible study, a mutual friend asks how she is doing. What is the most appropriate response?
		a. Provide an update on your patient's condition.
		b. Ask her to talk to the pastor.
		c. Kindly reinforce that you cannot share personal information.
		d. Ask the group to pray for her.
HIPAA regulations protect patient privacy in all settings, so it would not be appropriate to share any information regarding your patient's condition. In addition to the protection that this affords your patient, this also lets others know that if they or a loved one ever needs hospice care, their information will also remain confidential. Incorrect answer. Please choose another answer.

45.	Although some variations in state laws exist, generally, a therapy, including palliative and end of life care, can be withheld or withdrawn under which condition?
		a. The patient's legal surrogate refuses it.
		b. Only when the patient themselves refuses it.
		c. The interdisciplinary team determines that further therapy causes existential pain.
		d. Only when an ethics committee investigation is conducted.
In general, withholding or withdrawing therapy, also known as allowing natural death, can be ethically justified and can be determined by the patient's legal surrogate or the patient themselves. The interdisciplinary team alone does not have the authority to initiate withholding or withdrawing therapy; an ethics committee meeting may be helpful to define the situation, but is not required. Incorrect answer. Please choose another answer.

46.	The family of a hospice patient with advanced dementia requests the use of their Medicare benefit for continuous home care. The patient is bedbound, non-verbal, incontinent of urine, and exhibits no symptoms of discomfort. How should the nurse respond?
		a. "Incontinence will qualify them for continuous home care."
		b. "This benefit is only covered for brief periods of crisis."
		c. "You should discuss placement at a skilled nursing facility."
		d. "Medicare will not pay for continuous home care."
Medicare will pay for continuous home care for patients only if they meet criteria and only for brief periods of time. This benefit is for periods of crisis. Continuous home care is the second of four levels of hospice care. Incontinence is expected with dementia and would not be covered. Placement at a skilled nursing facility does not address the question and would not be covered under this benefit. Incorrect answer. Please choose another answer.

47.	The hospice nurse is entering the house of a new patient. A person from the house next door comes to greet the nurse, introducing themselves as a close friend of the patient. They tell the nurse they are happy the patient has finally elected hospice to get the extra help. What will guide the nurse's response?
		a. Prognosis of the patient
		b. Relation to the patient
		c. Privacy of the patient
		d. Familiarity with the patient
HIPAA guidelines prohibit the nurse from divulging any information about the patient without their consent. Without knowing the wishes of the patient, the nurse would not be able to share any information regardless of relation. The patient's decision to elect hospice services is protected under HIPAA. Incorrect answer. Please choose another answer.

48.	The nurse is discharging a well-liked patient from hospice services so the patient may enroll in a clinical trial. The nurse understands which of the following would violate professional boundaries?
		a. Providing education about the nature of clinical trials.
		b. Giving the nurse's home phone number to keep in contact.
		c. Talking to the family about readmission policies for the hospice agency.
		d. Accepting a small, handmade gift from the patient.
Sharing personal contact information with the patient or family is a violation of professional boundaries. If the patient wishes to stay in contact, they can go through the hospice agency. If it is within the hospice agency's policies, a small gift can be appropriate if it is not high in value. Education on clinical trials may be warranted if there seems to be deficits in understanding. Discussing readmission policies would be recommended in this scenario. Incorrect answer. Please choose another answer.

49.	A patient with gastrointestinal cancer is being assessed for hospice services. The patient has had their stomach and most of their intestines surgically removed. Total parenteral nutrition (TPN) is needed for all their nutritional needs. After a lengthy discussion with the hospice nurse, the patient remains adamant that they continue TPN but still wishes to be on hospice services. How does the nurse proceed?
		a. Explain that their goals are not compatible with hospice philosophy.
		b. Discuss TPN coverage options with contracted pharmacy.
		c. Inform that TPN is not covered under the hospice benefit.
		d. Call provider to get orders for NG tube placement.
Total parenteral nutrition (TPN) is considered a life-prolonging measure and not covered under the hospice benefit. TPN is also not considered a comfort measure. Since this patient is reliant on TPN, an NG tube is not likely to provide meaningful nutrition. The pharmacy would not be able to help with coverage of TPN. The patient's goals may or may not be in line with hospice, though their views on nutrition are not. Incorrect answer. Please choose another answer.

50.	The hospice nurse is contacted by a hospice volunteer. The volunteer reports that their patient has copious amounts of blood coming from an unknown area underneath the patient. After informing the volunteer that help is coming, what is the nurse's instruction?
		a. "Turn the patient to see where the blood is coming from."
		b. "Stay with the patient and provide a calming presence."
		c. "Call the family to inform them of this change."
		d. "Do not touch the patient until I can get there."
The volunteer should stay with the patient to provide comfort if they are able. It is inappropriate for the nurse to delegate any assessment to a volunteer. Similarly, the volunteer should not be the one to educate the family on any change of status. The volunteer is allowed to touch the patient. Incorrect answer. Please choose another answer.

Quality starts with who wrote the material.

Our practice exam writer

Melissa Robinson, Ph.D., RN, CHPN

, is an associate professor of nursing at Linfield College and on staff at the Providence Hospice in Oregon, where she works in long term care facilities, as well as in hospital and home settings. Melissa has been a CHPN for over thirteen years. She is widely published on the subject of distance learning and earned her doctorate in nursing education from Capella University.

Laurl Matey, MSN, RN, CHPN

, is an Oncology Nursing Specialist with the Oncology Nursing Society (ONS) and an adjunct professor at Grand Canyon University in the College of Nursing and Healthcare. She is a peer content reviewer for the Journal of Hospice and Palliative Nursing and for the Asian Pacific Journal of Oncology Nursing. Laurl earned her Master of Science in Nursing degree from the University of Pittsburgh.

Mary Spicketts, RN, CHPN, MSN

, is the Director of Education and Research at the Hospice of Michigan. She has been a CHPN and CHPPN for over 10 years. Mary has helped develop MSN level course curriculum for Western Governors University and has participated in two exam writing workshops with the Hospice and Palliative Nurses Association.

Sue Montgomery, RN, CHPN

, is a registered nurse and professional medical writer with over 28 years of nursing experience. She worked for 14 years as a CHPN at one of the nation's largest hospices in Florida. Sue has been published in the National Hospice and Palliative Care Organization’s national magazine, Insights.

The actual CHPN exam consists of 150 multiple choice questions over seven domains of practice for the care of adult patients and families.

Patient Care: Assessment and Planning
Patient Care: Pain Management
Patient Care: Symptom Management
Support, Education and Advocacy
Practice Issues

Only 135 questions are scored. Fifteen of the questions are trial items being considered for future exams. Three hours are given to complete the exam.

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