1
Santa Clara County Ambulatory
Care Nurse Examination Version
2.0 — Advanced Clinical
Reasoning & Complex Case
Management a well detailed one
written and graded
A+ upgraded
Examination Overview
Total Questions: 150 scored items (plus 25 pretest questions in actual examination)
Time Allowed: 3 hours
Difficulty Level: Advanced/Hard — Designed for experienced ambulatory care nurses preparing
for board certification
Content Distribution: Based on ANCC Ambulatory Care Nursing (AMB-BC™) Test Content
Outline
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Domain Percentage Questions
Assess and Evaluate (Clinical Practice) 40% 60
Plan and Implement (Care Management) 18% 27
Professional Role 22% 33
Education 19% 30
Total 100% 150
SECTION I: ASSESS AND EVALUATE — Clinical Assessment, Triage, and Diagnostic Reasoning
Questions 1–60
1. A 62-year-old male with a 45-pack-year smoking history presents with new-onset
hoarseness, unilateral throat pain, and a sensation of a "lump" in his throat for the past 6
weeks. He reports a 15-pound unintentional weight loss over 3 months. What is the nurse's
PRIORITY action?
A) Schedule a follow-up appointment in 2 weeks to reassess symptoms
B) Prescribe a course of antibiotics for suspected laryngitis
C) Notify the provider immediately and facilitate urgent otolaryngology referral
D) Recommend voice rest and over-the-counter throat lozenges
-detailed answer 100% correct :- C
Rationale: The combination of persistent hoarseness (>3 weeks), unilateral throat pain, weight
loss, and significant smoking history is highly suspicious for laryngeal or oropharyngeal
malignancy. Urgent referral for visualization (laryngoscopy) and biopsy is essential. Delaying
evaluation (A) or treating symptomatically (B, D) would delay cancer diagnosis.
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2. A 45-year-old female with no significant medical history presents with 3 days of progressive
bilateral hand weakness, tingling, and difficulty gripping objects. She reports these symptoms
started after a recent upper respiratory infection. On examination, you note diminished deep
tendon reflexes in both upper extremities. What is the nurse's priority concern?
A) Carpal tunnel syndrome
B) Guillain-Barré syndrome
C) Rheumatoid arthritis
D) Cervical radiculopathy
-detailed answer 100% correct :- B
Rationale: The acute onset of bilateral, symmetric ascending weakness following a viral illness,
with diminished reflexes, is classic for Guillain-Barré syndrome (GBS). GBS is a medical
emergency that can progress to respiratory failure. The nurse must notify the provider
immediately for urgent neurologic evaluation and possible hospitalization. Carpal tunnel (A)
typically affects the median nerve distribution unilaterally; rheumatoid arthritis (C) presents
with joint pain and swelling; cervical radiculopathy (D) typically causes unilateral symptoms.
3. A 72-year-old patient with heart failure (HFrEF, ejection fraction 28%) is in the clinic for a
routine visit. Current medications include carvedilol 25 mg BID, lisinopril 20 mg daily,
furosemide 40 mg daily, and spironolactone 25 mg daily. Laboratory results show potassium
5.8 mEq/L, creatinine 1.9 mg/dL (baseline 1.2), and BUN 42 mg/dL. Which medication
combination is MOST likely responsible for this laboratory profile?
A) Carvedilol and lisinopril
B) Lisinopril and spironolactone
C) Furosemide and spironolactone
D) Carvedilol and furosemide
-detailed answer 100% correct :- B
Rationale: The combination of an ACE inhibitor (lisinopril) and a potassium-sparing diuretic
(spironolactone) significantly increases the risk of hyperkalemia, particularly in patients with
underlying renal impairment. The rising creatinine suggests acute kidney injury, likely from the
combination of ACE inhibition and diuresis in a patient with low ejection fraction. This requires
immediate provider notification and likely medication adjustment.
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4. A 28-year-old G1P0 female at 34 weeks gestation presents with a blood pressure of
158/102 mmHg, 3+ proteinuria on dipstick, and complaints of a severe frontal headache and
"flashing lights" in her vision. She reports epigastric pain that she describes as "heartburn."
What is the nurse's IMMEDIATE action?
A) Administer a proton pump inhibitor for the epigastric pain
B) Place the patient in a dark, quiet room and reassess in 30 minutes
C) Notify the provider and prepare for possible emergent delivery
D) Schedule a 24-hour urine collection for protein quantification
-detailed answer 100% correct :- C
Rationale: The patient has severe preeclampsia with neurologic symptoms (headache, visual
changes) and epigastric pain—the latter may indicate hepatic involvement or HELLP syndrome.
This is a life-threatening emergency requiring immediate provider notification and preparation
for possible delivery. Delaying care (A, B, D) puts both mother and fetus at risk for eclampsia,
stroke, or hepatic rupture.
5. A 55-year-old patient with type 2 diabetes (HbA1c 8.2%) is on metformin 1000 mg BID and
glipizide 10 mg BID. The patient reports waking up with severe headaches and night sweats. A
fasting blood glucose drawn at 6 AM is 52 mg/dL. What is the MOST appropriate nursing
intervention?
A) Increase the glipizide dose to control morning hyperglycemia
B) Add a bedtime snack and consider reducing the glipizide dose
C) Switch glipizide to a once-daily formulation
D) Recommend a continuous glucose monitor
-detailed answer 100% correct :- B
Rationale: The patient is experiencing nocturnal hypoglycemia with rebound morning
hyperglycemia (Somogyi effect). The 6 AM glucose of 52 mg/dL confirms hypoglycemia. Adding
a bedtime snack and reducing the glipizide dose addresses the underlying cause. Increasing the
glipizide dose (A) would worsen hypoglycemia. A CGM (D) may be helpful but is not the
immediate intervention.
6. A 38-year-old male with a history of intravenous drug use presents with fever, malaise, and
a new heart murmur. Blood cultures are pending. The nurse notes splinter hemorrhages on
Santa Clara County Ambulatory
Care Nurse Examination Version
2.0 — Advanced Clinical
Reasoning & Complex Case
Management a well detailed one
written and graded
A+ upgraded
Examination Overview
Total Questions: 150 scored items (plus 25 pretest questions in actual examination)
Time Allowed: 3 hours
Difficulty Level: Advanced/Hard — Designed for experienced ambulatory care nurses preparing
for board certification
Content Distribution: Based on ANCC Ambulatory Care Nursing (AMB-BC™) Test Content
Outline
, 2
Domain Percentage Questions
Assess and Evaluate (Clinical Practice) 40% 60
Plan and Implement (Care Management) 18% 27
Professional Role 22% 33
Education 19% 30
Total 100% 150
SECTION I: ASSESS AND EVALUATE — Clinical Assessment, Triage, and Diagnostic Reasoning
Questions 1–60
1. A 62-year-old male with a 45-pack-year smoking history presents with new-onset
hoarseness, unilateral throat pain, and a sensation of a "lump" in his throat for the past 6
weeks. He reports a 15-pound unintentional weight loss over 3 months. What is the nurse's
PRIORITY action?
A) Schedule a follow-up appointment in 2 weeks to reassess symptoms
B) Prescribe a course of antibiotics for suspected laryngitis
C) Notify the provider immediately and facilitate urgent otolaryngology referral
D) Recommend voice rest and over-the-counter throat lozenges
-detailed answer 100% correct :- C
Rationale: The combination of persistent hoarseness (>3 weeks), unilateral throat pain, weight
loss, and significant smoking history is highly suspicious for laryngeal or oropharyngeal
malignancy. Urgent referral for visualization (laryngoscopy) and biopsy is essential. Delaying
evaluation (A) or treating symptomatically (B, D) would delay cancer diagnosis.
, 3
2. A 45-year-old female with no significant medical history presents with 3 days of progressive
bilateral hand weakness, tingling, and difficulty gripping objects. She reports these symptoms
started after a recent upper respiratory infection. On examination, you note diminished deep
tendon reflexes in both upper extremities. What is the nurse's priority concern?
A) Carpal tunnel syndrome
B) Guillain-Barré syndrome
C) Rheumatoid arthritis
D) Cervical radiculopathy
-detailed answer 100% correct :- B
Rationale: The acute onset of bilateral, symmetric ascending weakness following a viral illness,
with diminished reflexes, is classic for Guillain-Barré syndrome (GBS). GBS is a medical
emergency that can progress to respiratory failure. The nurse must notify the provider
immediately for urgent neurologic evaluation and possible hospitalization. Carpal tunnel (A)
typically affects the median nerve distribution unilaterally; rheumatoid arthritis (C) presents
with joint pain and swelling; cervical radiculopathy (D) typically causes unilateral symptoms.
3. A 72-year-old patient with heart failure (HFrEF, ejection fraction 28%) is in the clinic for a
routine visit. Current medications include carvedilol 25 mg BID, lisinopril 20 mg daily,
furosemide 40 mg daily, and spironolactone 25 mg daily. Laboratory results show potassium
5.8 mEq/L, creatinine 1.9 mg/dL (baseline 1.2), and BUN 42 mg/dL. Which medication
combination is MOST likely responsible for this laboratory profile?
A) Carvedilol and lisinopril
B) Lisinopril and spironolactone
C) Furosemide and spironolactone
D) Carvedilol and furosemide
-detailed answer 100% correct :- B
Rationale: The combination of an ACE inhibitor (lisinopril) and a potassium-sparing diuretic
(spironolactone) significantly increases the risk of hyperkalemia, particularly in patients with
underlying renal impairment. The rising creatinine suggests acute kidney injury, likely from the
combination of ACE inhibition and diuresis in a patient with low ejection fraction. This requires
immediate provider notification and likely medication adjustment.
, 4
4. A 28-year-old G1P0 female at 34 weeks gestation presents with a blood pressure of
158/102 mmHg, 3+ proteinuria on dipstick, and complaints of a severe frontal headache and
"flashing lights" in her vision. She reports epigastric pain that she describes as "heartburn."
What is the nurse's IMMEDIATE action?
A) Administer a proton pump inhibitor for the epigastric pain
B) Place the patient in a dark, quiet room and reassess in 30 minutes
C) Notify the provider and prepare for possible emergent delivery
D) Schedule a 24-hour urine collection for protein quantification
-detailed answer 100% correct :- C
Rationale: The patient has severe preeclampsia with neurologic symptoms (headache, visual
changes) and epigastric pain—the latter may indicate hepatic involvement or HELLP syndrome.
This is a life-threatening emergency requiring immediate provider notification and preparation
for possible delivery. Delaying care (A, B, D) puts both mother and fetus at risk for eclampsia,
stroke, or hepatic rupture.
5. A 55-year-old patient with type 2 diabetes (HbA1c 8.2%) is on metformin 1000 mg BID and
glipizide 10 mg BID. The patient reports waking up with severe headaches and night sweats. A
fasting blood glucose drawn at 6 AM is 52 mg/dL. What is the MOST appropriate nursing
intervention?
A) Increase the glipizide dose to control morning hyperglycemia
B) Add a bedtime snack and consider reducing the glipizide dose
C) Switch glipizide to a once-daily formulation
D) Recommend a continuous glucose monitor
-detailed answer 100% correct :- B
Rationale: The patient is experiencing nocturnal hypoglycemia with rebound morning
hyperglycemia (Somogyi effect). The 6 AM glucose of 52 mg/dL confirms hypoglycemia. Adding
a bedtime snack and reducing the glipizide dose addresses the underlying cause. Increasing the
glipizide dose (A) would worsen hypoglycemia. A CGM (D) may be helpful but is not the
immediate intervention.
6. A 38-year-old male with a history of intravenous drug use presents with fever, malaise, and
a new heart murmur. Blood cultures are pending. The nurse notes splinter hemorrhages on
