ASAP PACE Certification 2026/2027 Questions & Answers with
Detailed Rationales | Complete Exam-Style Questions | Graded A+
Pass Guaranteed
Section 1: Pain Assessment & Evaluation
Question 1
A 68-year-old patient with chronic low back pain and no history of opioid use presents
for initial evaluation. The nurse practitioner plans to initiate opioid therapy if non-opioid
treatments fail. According to current CDC guidelines, which assessment should be
completed before starting opioids?
A. Comprehensive pain assessment including pain intensity, functional goals, and risk
assessment
B. Urine drug screening only
C. Pain intensity rating using a 0-10 scale only
D. Review of the PDMP only
Correct Answer: A. Comprehensive pain assessment including pain intensity, functional
goals, and risk assessment
Rationale: The 2022 CDC Guideline for Prescribing Opioids for Pain requires a
comprehensive biopsychosocial assessment before initiating opioids, including pain
history, functional goals, risk assessment for opioid use disorder, and evaluation of
nonpharmacological and non-opioid options. Relying solely on urine drug screening (B),
a pain scale (C), or PDMP review (D) is insufficient and does not meet the standard of
care for safe opioid prescribing.
Question 2
,A patient is taking oral morphine 15 mg every 4 hours for cancer pain. The provider
plans to rotate to oral oxycodone due to intolerable side effects. Using standard
equianalgesic dosing, what is the approximate equivalent dose of oral oxycodone for
each administration?
A. 5 mg
B. 10 mg
C. 15 mg
D. 20 mg
Correct Answer: B. 10 mg
Rationale: The standard oral equianalgesic ratio is approximately 30 mg oral morphine
to 20 mg oral oxycodone (a 1.5:1 ratio). Therefore, 15 mg oral morphine is equivalent to
approximately 10 mg oral oxycodone. When rotating opioids, a 25-50% dose reduction
for incomplete cross-tolerance should be applied, but this question asks for the pure
equianalgesic equivalent before reduction.
Question 3
A patient with metastatic lung cancer is taking extended-release morphine 60 mg every
12 hours with good baseline pain control. The patient reports 3 to 4 episodes daily of
severe, sudden pain that lasts 15 to 20 minutes. Which is the most appropriate
management of breakthrough pain?
A. Increase the extended-release morphine to 90 mg every 12 hours
B. Add immediate-release morphine at 10% to 20% of the total daily extended-release
dose
C. Switch to transdermal fentanyl patch
D. Add adjuvant gabapentin 300 mg three times daily
Correct Answer: B. Add immediate-release morphine at 10% to 20% of the total daily
extended-release dose
,Rationale: Breakthrough cancer pain is best managed with an immediate-release opioid
dosed at 10-20% of the total daily long-acting opioid dose. The patient's total daily
morphine dose is 120 mg, so an appropriate breakthrough dose is 10-20 mg of
immediate-release morphine. Increasing the baseline dose (A) is inappropriate for
episodic breakthrough pain. Switching to fentanyl (C) does not address breakthrough
episodes. Gabapentin (D) is an adjuvant for neuropathic pain, not episodic breakthrough
pain.
Question 4
A patient on chronic oxycodone therapy reports constipation unresponsive to increased
fluids, fiber, and exercise. Which medication should be added first according to current
guidelines for opioid-induced constipation?
A. Docusate sodium 100 mg twice daily
B. Senna 8.6 mg daily
C. Methylnaltrexone 12 mg subcutaneously every other day
D. Loperamide 4 mg initially, then 2 mg after each loose stool
Correct Answer: B. Senna 8.6 mg daily
Rationale: First-line treatment for opioid-induced constipation includes a stimulant
laxative such as senna or bisacodyl, often combined with an osmotic laxative like
polyethylene glycol. Docusate (A) is a stool softener with insufficient evidence as
monotherapy for OIC. Methylnaltrexone (C) is a peripheral opioid antagonist reserved
for refractory OIC. Loperamide (D) is an antidiarrheal and is contraindicated for
constipation.
Question 5
A patient prescribed oxycodone presents with a urine drug screen positive for morphine
and codeine but negative for oxycodone. The patient denies taking other medications.
Which is the most appropriate interpretation?
, A. The patient is non-adherent with oxycodone and likely diverting the medication
B. The patient is using heroin, which metabolizes to morphine and codeine
C. Oxycodone metabolizes to morphine and codeine, which is an expected finding
D. The immunoassay may lack specificity and confirmatory testing is needed before
making conclusions
Correct Answer: D. The immunoassay may lack specificity and confirmatory testing is
needed before making conclusions
Rationale: Oxycodone does not metabolize to morphine or codeine; it metabolizes to
oxymorphone and noroxycodone. However, immunoassay urine drug screens can yield
false positives due to cross-reactivity. Before making conclusions about non-adherence
or illicit use, definitive testing via LC-MS/MS (liquid chromatography-tandem mass
spectrometry) is required to accurately identify specific drugs and metabolites.
Question 6
A patient with moderate opioid use disorder is being inducted onto
buprenorphine/naloxone. The patient last used heroin 10 hours ago and is in moderate
withdrawal with a COWS score of 14. Which is the appropriate initial dose?
A. 16 mg/4 mg buprenorphine/naloxone
B. 8 mg/2 mg buprenorphine/naloxone
C. 2 mg/0.5 mg buprenorphine/naloxone
D. 24 mg/6 mg buprenorphine/naloxone
Correct Answer: C. 2 mg/0.5 mg buprenorphine/naloxone
Rationale: Buprenorphine induction should begin with a low dose (2-4 mg) when the
patient is in moderate to severe withdrawal (COWS ≥12) to minimize the risk of
precipitated withdrawal. Starting with high doses (A, B, D) while the patient still has full
agonist opioids on board can displace the agonist and precipitate severe withdrawal.
The dose is titrated upward in 2-4 mg increments based on response.
Question 7
Detailed Rationales | Complete Exam-Style Questions | Graded A+
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Section 1: Pain Assessment & Evaluation
Question 1
A 68-year-old patient with chronic low back pain and no history of opioid use presents
for initial evaluation. The nurse practitioner plans to initiate opioid therapy if non-opioid
treatments fail. According to current CDC guidelines, which assessment should be
completed before starting opioids?
A. Comprehensive pain assessment including pain intensity, functional goals, and risk
assessment
B. Urine drug screening only
C. Pain intensity rating using a 0-10 scale only
D. Review of the PDMP only
Correct Answer: A. Comprehensive pain assessment including pain intensity, functional
goals, and risk assessment
Rationale: The 2022 CDC Guideline for Prescribing Opioids for Pain requires a
comprehensive biopsychosocial assessment before initiating opioids, including pain
history, functional goals, risk assessment for opioid use disorder, and evaluation of
nonpharmacological and non-opioid options. Relying solely on urine drug screening (B),
a pain scale (C), or PDMP review (D) is insufficient and does not meet the standard of
care for safe opioid prescribing.
Question 2
,A patient is taking oral morphine 15 mg every 4 hours for cancer pain. The provider
plans to rotate to oral oxycodone due to intolerable side effects. Using standard
equianalgesic dosing, what is the approximate equivalent dose of oral oxycodone for
each administration?
A. 5 mg
B. 10 mg
C. 15 mg
D. 20 mg
Correct Answer: B. 10 mg
Rationale: The standard oral equianalgesic ratio is approximately 30 mg oral morphine
to 20 mg oral oxycodone (a 1.5:1 ratio). Therefore, 15 mg oral morphine is equivalent to
approximately 10 mg oral oxycodone. When rotating opioids, a 25-50% dose reduction
for incomplete cross-tolerance should be applied, but this question asks for the pure
equianalgesic equivalent before reduction.
Question 3
A patient with metastatic lung cancer is taking extended-release morphine 60 mg every
12 hours with good baseline pain control. The patient reports 3 to 4 episodes daily of
severe, sudden pain that lasts 15 to 20 minutes. Which is the most appropriate
management of breakthrough pain?
A. Increase the extended-release morphine to 90 mg every 12 hours
B. Add immediate-release morphine at 10% to 20% of the total daily extended-release
dose
C. Switch to transdermal fentanyl patch
D. Add adjuvant gabapentin 300 mg three times daily
Correct Answer: B. Add immediate-release morphine at 10% to 20% of the total daily
extended-release dose
,Rationale: Breakthrough cancer pain is best managed with an immediate-release opioid
dosed at 10-20% of the total daily long-acting opioid dose. The patient's total daily
morphine dose is 120 mg, so an appropriate breakthrough dose is 10-20 mg of
immediate-release morphine. Increasing the baseline dose (A) is inappropriate for
episodic breakthrough pain. Switching to fentanyl (C) does not address breakthrough
episodes. Gabapentin (D) is an adjuvant for neuropathic pain, not episodic breakthrough
pain.
Question 4
A patient on chronic oxycodone therapy reports constipation unresponsive to increased
fluids, fiber, and exercise. Which medication should be added first according to current
guidelines for opioid-induced constipation?
A. Docusate sodium 100 mg twice daily
B. Senna 8.6 mg daily
C. Methylnaltrexone 12 mg subcutaneously every other day
D. Loperamide 4 mg initially, then 2 mg after each loose stool
Correct Answer: B. Senna 8.6 mg daily
Rationale: First-line treatment for opioid-induced constipation includes a stimulant
laxative such as senna or bisacodyl, often combined with an osmotic laxative like
polyethylene glycol. Docusate (A) is a stool softener with insufficient evidence as
monotherapy for OIC. Methylnaltrexone (C) is a peripheral opioid antagonist reserved
for refractory OIC. Loperamide (D) is an antidiarrheal and is contraindicated for
constipation.
Question 5
A patient prescribed oxycodone presents with a urine drug screen positive for morphine
and codeine but negative for oxycodone. The patient denies taking other medications.
Which is the most appropriate interpretation?
, A. The patient is non-adherent with oxycodone and likely diverting the medication
B. The patient is using heroin, which metabolizes to morphine and codeine
C. Oxycodone metabolizes to morphine and codeine, which is an expected finding
D. The immunoassay may lack specificity and confirmatory testing is needed before
making conclusions
Correct Answer: D. The immunoassay may lack specificity and confirmatory testing is
needed before making conclusions
Rationale: Oxycodone does not metabolize to morphine or codeine; it metabolizes to
oxymorphone and noroxycodone. However, immunoassay urine drug screens can yield
false positives due to cross-reactivity. Before making conclusions about non-adherence
or illicit use, definitive testing via LC-MS/MS (liquid chromatography-tandem mass
spectrometry) is required to accurately identify specific drugs and metabolites.
Question 6
A patient with moderate opioid use disorder is being inducted onto
buprenorphine/naloxone. The patient last used heroin 10 hours ago and is in moderate
withdrawal with a COWS score of 14. Which is the appropriate initial dose?
A. 16 mg/4 mg buprenorphine/naloxone
B. 8 mg/2 mg buprenorphine/naloxone
C. 2 mg/0.5 mg buprenorphine/naloxone
D. 24 mg/6 mg buprenorphine/naloxone
Correct Answer: C. 2 mg/0.5 mg buprenorphine/naloxone
Rationale: Buprenorphine induction should begin with a low dose (2-4 mg) when the
patient is in moderate to severe withdrawal (COWS ≥12) to minimize the risk of
precipitated withdrawal. Starting with high doses (A, B, D) while the patient still has full
agonist opioids on board can displace the agonist and precipitate severe withdrawal.
The dose is titrated upward in 2-4 mg increments based on response.
Question 7
