End-of-life topics appear across multiple domains, including Holistic Patient Care, which makes up 15% of your 125 scored items. You must know how to manage refractory symptoms, navigate advance directives, and handle post-mortem regulatory guidelines. Test your readiness with our CMSRN practice test covering these specific clinical scenarios.
Question 1
An 82-year-old with advanced dementia hospitalized for dehydration has a valid DPOA-HC designating a niece as agent. The niece requests a feeding tube, but the patient's living will states "no artificial nutrition." The care team notes the niece recently gained inheritance rights. How should the nurse proceed?
- A) A) Advocate for the niece's decision since she holds legal authority as DPOA-HC.
- B) B) Refuse the feeding tube based on the living will's explicit instructions.
- C) C) Clarify the niece's rationale and report concerns of potential conflict of interest.✓
- D) D) Defer to the physician's judgment regarding clinical appropriateness of the tube.
Show rationale
While DPOA-HC agents must follow known patient wishes, the niece's inheritance and contradictory request raise red flags. The nurse must investigate inconsistencies per ethical obligations (B is incorrect without due process). Reporting safeguards against undue influence without usurping legal authority (A ignores the conflict). Clinical decisions (D) are secondary to establishing valid consent. The nurse should collaborate with ethics/social work to ensure the agent acts in the patient’s best interests.
Question 2
A conscious patient with pleural mesothelioma has refractory dyspnea despite maximal opioids. Chest X-ray shows large right pleural effusion. The patient declines thoracentesis due to prior discomfort. Which alternative intervention is indicated?
- A) A) Administer high-dose corticosteroids orally
- B) B) Apply cold compresses to the patient's chest
- C) C) Initiate therapeutic indwelling pleural catheter✓
- D) D) Provide handheld fan with directed airflow
Show rationale
Indwelling catheters allow repeated drainage with minimal discomfort, aligning with patient's refusal of thoracentesis and effusion evidence. Steroids (A) lack evidence for malignant effusions and cause side effects. Cold compresses (B) have no proven dyspnea benefit. Fans (D) provide minimal relief for mechanical compression. Catheter placement directly addresses the physiological barrier (effusion) while respecting autonomy through a less invasive option.
Question 3
After pronouncing death, a nurse discovers the deceased has an implanted radioactive seed for prostate cancer. Which action follows regulatory guidelines?
- A) A) Placing a radiation warning tag on the body bag before morgue transfer✓
- B) B) Notifying nuclear medicine to retrieve the device prior to funeral home release
- C) C) Documenting the implant only in the nursing notes for coroner review
- D) D) Asking family to sign a radiation exposure waiver for visitation
Show rationale
NRC regulations require radiation hazard labeling for bodies with radioactive implants. Option A ensures safe handling. Option B is incorrect; seeds aren't retrieved as they pose minimal risk. Option C is insufficient; hazard documentation must accompany the body. Option D is unnecessary; visitation is safe with proper labeling. The implant type determines protocol, requiring clear hazard communication.
Question 4
A 58-year-old patient with a massive intracerebral hemorrhage is declared brain dead. The family asks the nurse, "Could his organs help someone else?" while tearfully discussing his undocumented wish to be a donor. Which action aligns with the Organ Procurement Organization (OPO) protocol?
- A) A) Provide brochures about donation and ask if they'd like to speak to the OPO coordinator✓
- B) B) Contact the OPO immediately since brain death confirms donation eligibility
- C) C) Explain that the patient's undocumented wishes cannot be honored without family consent
- D) D) Consult the hospital ethics committee before initiating donation discussions
Show rationale
OPO protocols require trained coordinators to handle donation discussions. The nurse's role is to provide basic information and facilitate OPO contact without coercion. Option B oversteps by initiating contact without family readiness. Option C inaccurately implies undocumented wishes are irrelevant; families can still consent. Option D delays time-sensitive processes unnecessarily. Brain death establishes medical eligibility, but family emotional readiness (tearfulness) necessitates a non-coercive approach per United Network for Organ Sharing guidelines.
Question 5
A 72-year-old with end-stage heart failure (ejection fraction 25%) and anemia (Hb 9.0 g/dL) reports profound fatigue limiting self-care. Oxygen saturation is 94% on room air. The nurse notes the patient tires after 5 minutes of activity. Which intervention addresses fatigue most effectively?
- A) A) Initiate a supervised aerobic exercise program three times weekly
- B) B) Administer prescribed intravenous iron sucrose infusion promptly
- C) C) Teach energy conservation techniques with activity pacing✓
- D) D) Increase dietary protein intake to 1.5 g/kg/day immediately
Show rationale
Energy conservation is foundational for fatigue in advanced illness. Exercise (A) risks overexertion with severe heart failure. IV iron (B) corrects anemia but takes weeks for effect. Protein increase (D) may help cachexia but doesn't address acute fatigue. Cues: extreme deconditioning (tiring in 5 minutes) and stable oxygen saturation prioritize non-pharmacologic management per palliative care standards.
Question 6
A 70-year-old with peritoneal carcinomatosis reports constant nausea and fatigue. Exam shows ascites and dry mucous membranes. The nurse should anticipate which combination therapy?
- A) A) Scheduled scopolamine patch and IV fluid bolus
- B) B) PRN lorazepam and salt-restricted diet
- C) C) Scheduled octreotide and therapeutic paracentesis✓
- D) D) PRN promethazine and high-carbohydrate meals
Show rationale
Octreotide reduces secretion-related nausea in carcinomatosis; paracentesis alleviates ascites-induced fatigue. Scopolamine (A) may worsen dry mouth. Lorazepam (B) targets anxiety nausea, not ascites. Promethazine (D) is sedating, exacerbating fatigue. Cues: ascites and dehydration signs indicate mechanical contributors requiring dual symptom control per NCCN guidelines.
Question 7
A hospice nurse notes a terminally ill patient has new onset of loud, gurgling respirations. The patient is comatose with absent corneal reflexes and irregular pulse (48/min). Which intervention is both effective for symptom management and consistent with imminent death care priorities?
- A) A) Administer IV atropine to reduce secretions
- B) B) Initiate nasopharyngeal suctioning every 30 minutes
- C) C) Position laterally with slight head elevation✓
- D) D) Start high-flow oxygen via non-rebreather mask
Show rationale
Lateral positioning promotes drainage of oropharyngeal secretions, reducing "death rattle" without invasive measures. Option A is suboptimal as IV access is often discontinued in active dying; subcutaneous glycopyrrolate is preferred. Option B causes discomfort without clearing deep secretions. Option D increases dryness without benefit when hypoxemia is expected. CMSRN guidelines prioritize non-invasive comfort measures for respiratory secretions in unconscious patients near death.
Question 8
After a 45-year-old donor's organs are recovered in the OR, the spouse tells the nurse, "I need to see him without all those tubes now." Which response prioritizes both bereavement care and tissue donation integrity?
- A) A) Prepare the body by removing medical devices and covering surgical sites per OPO instructions✓
- B) B) Escort the family to the OR immediately to view the body before transport
- C) C) Explain that surgical incisions make viewing inappropriate to preserve dignity
- D) D) Delay viewing until the funeral home prepares the body to avoid family distress
Show rationale
OPO protocols include post-recovery body preparation to facilitate viewing while maintaining dignity. Immediate OR viewing (B) risks exposing the family to traumatic sights and disrupts sterile processes. Denying viewing (C) disregards bereavement needs; covering incisions allows respectful closure. Delaying to funeral homes (D) may prolong grief without cause; nurses can prepare bodies per OPO standards. Covering surgical sites balances emotional needs with ethical obligations.
Question 9
A 70-year-old with advanced heart failure (NYHA Class IV) has frequent hospitalizations. The cardiologist estimates a prognosis of 8 months. The patient wishes to avoid future hospitalizations but continue diuretics and cardiac medications. Which care model prioritizes symptom control without requiring treatment discontinuation?
- A) A) Hospice care with home nursing for comfort measures
- B) B) Palliative care coordinating home-based support✓
- C) C) Skilled nursing facility for 24-hour clinical oversight
- D) D) Cardiac rehabilitation for exercise optimization
Show rationale
Palliative care manages symptoms and aligns care with goals (avoiding hospitalizations) while allowing ongoing disease-directed treatments (diuretics). Hospice (A) typically requires ≤6-month prognosis and focuses solely on comfort. Skilled nursing (C) provides acute care, not symptom-focused support. Rehabilitation (D) is inappropriate for end-stage functional decline. Prognosis exceeding 6 months and desire for continued treatment are key cues per CMS guidelines.
Question 10
A patient with metastatic cancer becomes agitated, plucking at bed linens and moaning. Vital signs show BP 90/60, temp 38.5°C (101.3°F), and irregular pulse. Which assessment finding most reliably differentiates terminal restlessness from delirium requiring medical intervention?
- A) A) Diaphoresis with mottled extremities✓
- B) B) Disorientation to time and place
- C) C) Elevated temperature with dry mucous membranes
- D) D) Visual hallucinations reporting deceased relatives
Show rationale
Diaphoresis + mottling confirm terminal physiological decline, making restlessness an imminent death sign. Option B/C/D suggest reversible delirium: disorientation may indicate infection/medication toxicity, fever requires evaluation for sepsis, and hallucinations could stem from electrolyte imbalances. Per CMSRN protocols, concurrent signs of multisystem failure (mottling, hypotension) differentiate terminal agitation from treatable delirium.
Question 11
A hospice nurse visits a home and finds a terminal lung cancer patient deceased. The spouse reports the patient fell the previous night but refused hospital care. An untreated 5-cm hematoma is visible on the occiput. Which action aligns with coroner protocols?
- A) A) Advise the spouse to call funeral home directly for body removal
- B) B) Document the injury and notify the hospice physician for pronouncement
- C) C) Contact the coroner due to unexplained trauma before death✓
- D) D) Provide grief support and complete routine post-mortem care
Show rationale
Unexplained trauma (hematoma cue) in non-hospitalized patients requires coroner notification per statutory guidelines. Option C addresses this. Option A ignores potential forensic evidence. Option B is insufficient; coroners override hospice protocols for traumatic deaths. Option D neglects legal obligations despite palliative context.
Question 12
A 72-year-old patient with metastatic lung cancer admitted for pneumonia has a living will specifying no intubation. During a sudden respiratory arrest, the spouse insists the patient "would want everything done." The patient is unresponsive. What is the nurse's priority action?
- A) A) Initiate CPR immediately while clarifying the spouse's statements
- B) B) Honor the living will by withholding resuscitation measures✓
- C) C) Contact the hospital ethics committee for emergency guidance
- D) D) Defer to the spouse's request as the legal next of kin
Show rationale
The living will is a legally binding document reflecting the patient's autonomous wishes, which take precedence over family requests in emergencies. Option B aligns with ethical principles of autonomy and legal requirements for advance directives. Option A violates the patient's explicit directive. Option C delays time-sensitive care and isn't feasible during arrest. Option D disregards the legal standing of the living will. Nurses must act on valid advance directives per the Patient Self-Determination Act, even with family objections.
Question 13
An alert lung cancer patient with dyspnea during conversation reports panic with activity. Palliative Performance Scale is 50%. Which non-pharmacological intervention demonstrates the strongest evidence for dyspnea relief?
- A) A) Instruct pursed-lip breathing techniques
- B) B) Provide mindfulness meditation recording
- C) C) Apply cool cloth to the forehead
- D) D) Use a handheld fan directed toward face✓
Show rationale
Fan therapy stimulates trigeminal nerve receptors, reducing dyspnea perception with immediate effect, supported by Cochrane reviews. Pursed-lip breathing (A) benefits COPD but not restrictive malignancies. Meditation (B) requires practice time inconsistent with acute panic. Cool cloths (C) offer comfort but lack dyspnea-specific evidence. The fan's rapid response aligns best with activity-triggered panic and preserved cognition.
Question 14
An alert 65-year-old with end-stage heart failure requests DNR status, but her daughter insists on "full code" during a family meeting. The patient tells the nurse privately, "I'm ready to go peacefully." What is the nurse's priority action?
- A) A) Advocate for the patient's stated wishes with the healthcare team and daughter✓
- B) B) Defer to the daughter's preference since family consensus is required
- C) C) Suggest a psychiatric consult to assess the patient's decision-making capacity
- D) D) Delay documentation until the ethics committee resolves the conflict
Show rationale
Option A prioritizes the alert patient's autonomy (cue 1) and private disclosure (cue 2). Competent patients have legal authority over code decisions, requiring nurse advocacy per palliative care standards. Option B disregards self-determination. Option C is unwarranted without evidence of incapacity. Option D delays fulfilling ethical obligations. Nurses must champion patient preferences even during family disagreements, as per AMSN advocacy principles.
Question 15
During end-of-life care, a family declines organ donation due to religious concerns but asks about tissue donation. How should the nurse proceed?
- A) A) Honor the refusal since both processes are linked ethically
- B) B) Explain tissue donation remains possible and contact the OPO✓
- C) C) Suggest corneal donation only to align with religious views
- D) D) Document refusal without further discussion per autonomy
Show rationale
Organ and tissue donation are separate consents; declining one doesn't preclude the other. Option A misrepresents regulations. Option C assumes religious compatibility without assessment; OPOs handle nuanced discussions. Option D neglects therapeutic communication; nurses should clarify options without pressure. Religious objections often vary by donation type, warranting OPO consultation for culturally sensitive education.
