CHPN Practice Exam

Noisy, congested respirations are very common during the dying process, and are sometimes referred to as a “death rattle”. Typically, they do not cause discomfort for the patient, but can be very distressing to family members. Elevating the head of the patient’s bed and 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.

Mary’s appearance and signs/symptoms are indicative of type A COPD (emphysema), and she may receive some benefit from a low level of oxygen such as 2L per nasal cannula (N/C) prn. Additional presenting signs and symptoms of a patient with type A COPD include muscle wasting, absence of central cyanosis, decreased ability to cough effectively, hyper-resonance on percussion and distant, diminished breath sounds. Type B COPD (chronic bronchitis) patients are often overweight with the presence of central cyanosis, minimal use of accessory muscles, resonance on percussion and adventitious breath sounds, which are typically wheezes. Pharmacologic treatment for COPD may include bronchodilators, corticosteroids, anticholinergics, nebulizer treatments, low level oxygen and antibiotic therapy to treat infections, if appropriate, as well as anxiolytics and low-dose morphine.

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.

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 Oxydose®), while maintaining the same dosing as currently ordered for breakthrough pain. Since most liquid forms are quite concentrated (Oxydose® concentration is 20 mg/ml), even patients who are unresponsive can tolerate such small volumes in the buccal space and typically maintain excellent pain control.

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.

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.

“Charges for hospitalizations related to the hospice admission diagnosis are billed to the hospice” is correct. Patients who enroll in the Hospice Medicare/Medicaid benefit remain enrolled in traditional Medicare/Medicaid for all other aspects of care that are not related to the hospice admitting diagnosis.

The hospice counselor is typically the member of the IDT who coordinates bereavement support transitioning for the patient’s family. Other members of the IDT may also participate in this support as appropriate.

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.

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.

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.

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.

Real-time documentation 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 real-time 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.

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.