AACN ACNPC-AG Certification Exam Actual
Exam 2026/2027 Complete Practice Questions
with Detailed Rationales – Pass Guaranteed –
A+ Graded
Section 1: Cardiovascular & Hemodynamic Management (25 questions)
Case Study 1: Post-operative CABG with Cardiogenic Shock
A 72-year-old male is 6 hours post-CABG x3. He was weaned from CPB with difficulty,
requiring epinephrine 0.05 mcg/kg/min. In the ICU, he remains intubated. BP 78/52, HR
110 sinus rhythm, CVP 18, PAOP 24, CI 1.8. He is cool and clammy. You are the
ACNP-AG rounding.
Q1: Which hemodynamic profile best describes this patient's presentation?
A. Hypovolemic shock
B. Cardiogenic shock [CORRECT]
C. Septic shock
D. Anaphylactic shock
Correct Answer: B
Rationale: The combination of low cardiac index (1.8), elevated filling pressures (CVP
18, PAOP 24), and cool extremities defines cardiogenic shock—pump failure with
congestion upstream and poor perfusion downstream. This is classic for
post-cardiotomy ventricular dysfunction.
Q2: The PA catheter waveform shows a prominent 'v' wave. What does this suggest?
A. Right ventricular failure
B. Tricuspid regurgitation
,C. Left ventricular failure or mitral regurgitation [CORRECT]
D. Pulmonary hypertension only
Correct Answer: C
Rationale: A prominent 'v' wave on the PAOP tracing reflects increased left atrial
pressure during ventricular systole, typically seen with mitral regurgitation or severe left
ventricular failure causing functional regurgitation—common post-CABG when the LV is
stunned.
Q3: Which vasoactive adjustment is most appropriate as the next step?
A. Increase epinephrine to max dose
B. Add vasopressin 0.03 units/min and consider dobutamine [CORRECT]
C. Start phenylephrine to increase afterload
D. Discontinue all inotropes and give fluid bolus
Correct Answer: B
Rationale: In post-cardiotomy cardiogenic shock with low CI and high filling pressures,
you need inodilation—dobutamine improves contractility while lowering afterload, and
vasopressin helps maintain renal perfusion pressure without the myocardial oxygen
demand of high-dose catecholamines.
Q4: Six hours later, CI remains 1.9 despite maximum medical therapy. BP 70/48. What is
the next best intervention?
A. Continue current management and wait 24 hours
B. Emergent initiation of VA-ECMO [CORRECT]
C. Immediate return to OR for re-exploration
D. Administer corticosteroids only
Correct Answer: B
Rationale: When post-cardiotomy shock persists despite optimal pharmacologic
support with CI <2.0 and escalating pressors, VA-ECMO provides temporary circulatory
support allowing the stunned myocardium to recover—this is the bridge to decision or
recovery.
Q5: On day 3, the patient is on VA-ECMO with flows 3.5 L/min. He becomes acutely
hypotensive with distended neck veins and muffled heart sounds. What is the
immediate concern?
A. ECMO cannula dislodgement
,B. Cardiac tamponade [CORRECT]
C. Massive pulmonary embolism
D. Acute aortic dissection
Correct Answer: B
Rationale: The triad of hypotension, elevated CVP with distended neck veins, and
muffled heart sounds in a post-CABG patient on anticoagulation screams cardiac
tamponade—likely from mediastinal bleeding causing compressive physiology despite
open sternotomy.
Q6: For the suspected tamponade, what is the immediate diagnostic and therapeutic
step?
A. STAT CT chest
B. Bedside transthoracic echo followed by emergency mediastinal exploration or
pericardiocentesis [CORRECT]
C. Increase ECMO flows to 5 L/min
D. Administer thrombolytics
Correct Answer: B
Rationale: Tamponade in the post-op cardiac patient is a clinical emergency confirmed
by echo showing right heart collapse; you don't wait for CT—open the chest or drain the
mediastinum immediately to relieve the compression and restore filling.
Q7: Following decompression, the patient stabilizes. ECMO flows are weaned to 2.0
L/min with MAP 65 on minimal support. What parameter best indicates myocardial
recovery and readiness for decannulation?
A. PAOP <12 mmHg
B. Cardiac Index >2.4 L/min/m² with minimal inotropic support and aortic opening on
echo [CORRECT]
C. CVP <8 mmHg
D. Mean arterial pressure >80 mmHg on high-dose vasopressors
Correct Answer: B
Rationale: To wean VA-ECMO, you need evidence the native heart can maintain systemic
perfusion—CI >2.4 with low-dose inotropes, coupled with echocardiographic evidence of
aortic valve opening and ejection, indicates the left ventricle is recovering sufficient
function.
, Q8: The patient successfully weans from ECMO but develops new atrial fibrillation with
RVR at 150 bpm. BP 98/62. What is the priority intervention?
A. Immediate electrical cardioversion
B. IV amiodarone 150 mg bolus and assess for anticoagulation [CORRECT]
C. IV diltiazem bolus
D. Immediate heparin drip only
Correct Answer: B
Rationale: In a post-cardiac surgery patient with new AF and marginal hemodynamics,
amiodarone is the drug of choice for rate and rhythm control without the negative
inotropy of calcium channel blockers; given the recent sternotomy and ECMO,
anticoagulation assessment is crucial to prevent thromboembolism.
Q9: You are reviewing a PA catheter tracing. The waveform shows a sharp upstroke, a
rounded peak during systole, and a gradual decline with a distinct 'a' wave and smaller
'v' wave. This represents:
A. Right atrial pressure tracing
B. Pulmonary artery wedge pressure (PAOP) [CORRECT]
C. Central venous pressure with tricuspid regurgitation
D. Pulmonary artery pressure tracing
Correct Answer: B
Rationale: The PAOP waveform reflects left atrial pressure transmitted through the
pulmonary vasculature—characterized by an 'a' wave from atrial contraction and a 'v'
wave from atrial filling against a closed mitral valve, distinct from the sharp systolic
peak of PA pressure.
Q10: A patient with acute RV infarction has a PA catheter placed. The tracing shows
elevated RA pressure with a prominent 'y' descent and equalization of RA and PAOP
during diastole. This hemodynamic pattern suggests:
A. Cardiac tamponade
B. Constrictive pericarditis
C. Right ventricular failure with volume overload [CORRECT]
D. Mitral stenosis
Correct Answer: C
Rationale: In RV failure, particularly from inferior MI, you see elevated right-sided
pressures with prominent 'y' descent as the stiff right ventricle fills rapidly in early
Exam 2026/2027 Complete Practice Questions
with Detailed Rationales – Pass Guaranteed –
A+ Graded
Section 1: Cardiovascular & Hemodynamic Management (25 questions)
Case Study 1: Post-operative CABG with Cardiogenic Shock
A 72-year-old male is 6 hours post-CABG x3. He was weaned from CPB with difficulty,
requiring epinephrine 0.05 mcg/kg/min. In the ICU, he remains intubated. BP 78/52, HR
110 sinus rhythm, CVP 18, PAOP 24, CI 1.8. He is cool and clammy. You are the
ACNP-AG rounding.
Q1: Which hemodynamic profile best describes this patient's presentation?
A. Hypovolemic shock
B. Cardiogenic shock [CORRECT]
C. Septic shock
D. Anaphylactic shock
Correct Answer: B
Rationale: The combination of low cardiac index (1.8), elevated filling pressures (CVP
18, PAOP 24), and cool extremities defines cardiogenic shock—pump failure with
congestion upstream and poor perfusion downstream. This is classic for
post-cardiotomy ventricular dysfunction.
Q2: The PA catheter waveform shows a prominent 'v' wave. What does this suggest?
A. Right ventricular failure
B. Tricuspid regurgitation
,C. Left ventricular failure or mitral regurgitation [CORRECT]
D. Pulmonary hypertension only
Correct Answer: C
Rationale: A prominent 'v' wave on the PAOP tracing reflects increased left atrial
pressure during ventricular systole, typically seen with mitral regurgitation or severe left
ventricular failure causing functional regurgitation—common post-CABG when the LV is
stunned.
Q3: Which vasoactive adjustment is most appropriate as the next step?
A. Increase epinephrine to max dose
B. Add vasopressin 0.03 units/min and consider dobutamine [CORRECT]
C. Start phenylephrine to increase afterload
D. Discontinue all inotropes and give fluid bolus
Correct Answer: B
Rationale: In post-cardiotomy cardiogenic shock with low CI and high filling pressures,
you need inodilation—dobutamine improves contractility while lowering afterload, and
vasopressin helps maintain renal perfusion pressure without the myocardial oxygen
demand of high-dose catecholamines.
Q4: Six hours later, CI remains 1.9 despite maximum medical therapy. BP 70/48. What is
the next best intervention?
A. Continue current management and wait 24 hours
B. Emergent initiation of VA-ECMO [CORRECT]
C. Immediate return to OR for re-exploration
D. Administer corticosteroids only
Correct Answer: B
Rationale: When post-cardiotomy shock persists despite optimal pharmacologic
support with CI <2.0 and escalating pressors, VA-ECMO provides temporary circulatory
support allowing the stunned myocardium to recover—this is the bridge to decision or
recovery.
Q5: On day 3, the patient is on VA-ECMO with flows 3.5 L/min. He becomes acutely
hypotensive with distended neck veins and muffled heart sounds. What is the
immediate concern?
A. ECMO cannula dislodgement
,B. Cardiac tamponade [CORRECT]
C. Massive pulmonary embolism
D. Acute aortic dissection
Correct Answer: B
Rationale: The triad of hypotension, elevated CVP with distended neck veins, and
muffled heart sounds in a post-CABG patient on anticoagulation screams cardiac
tamponade—likely from mediastinal bleeding causing compressive physiology despite
open sternotomy.
Q6: For the suspected tamponade, what is the immediate diagnostic and therapeutic
step?
A. STAT CT chest
B. Bedside transthoracic echo followed by emergency mediastinal exploration or
pericardiocentesis [CORRECT]
C. Increase ECMO flows to 5 L/min
D. Administer thrombolytics
Correct Answer: B
Rationale: Tamponade in the post-op cardiac patient is a clinical emergency confirmed
by echo showing right heart collapse; you don't wait for CT—open the chest or drain the
mediastinum immediately to relieve the compression and restore filling.
Q7: Following decompression, the patient stabilizes. ECMO flows are weaned to 2.0
L/min with MAP 65 on minimal support. What parameter best indicates myocardial
recovery and readiness for decannulation?
A. PAOP <12 mmHg
B. Cardiac Index >2.4 L/min/m² with minimal inotropic support and aortic opening on
echo [CORRECT]
C. CVP <8 mmHg
D. Mean arterial pressure >80 mmHg on high-dose vasopressors
Correct Answer: B
Rationale: To wean VA-ECMO, you need evidence the native heart can maintain systemic
perfusion—CI >2.4 with low-dose inotropes, coupled with echocardiographic evidence of
aortic valve opening and ejection, indicates the left ventricle is recovering sufficient
function.
, Q8: The patient successfully weans from ECMO but develops new atrial fibrillation with
RVR at 150 bpm. BP 98/62. What is the priority intervention?
A. Immediate electrical cardioversion
B. IV amiodarone 150 mg bolus and assess for anticoagulation [CORRECT]
C. IV diltiazem bolus
D. Immediate heparin drip only
Correct Answer: B
Rationale: In a post-cardiac surgery patient with new AF and marginal hemodynamics,
amiodarone is the drug of choice for rate and rhythm control without the negative
inotropy of calcium channel blockers; given the recent sternotomy and ECMO,
anticoagulation assessment is crucial to prevent thromboembolism.
Q9: You are reviewing a PA catheter tracing. The waveform shows a sharp upstroke, a
rounded peak during systole, and a gradual decline with a distinct 'a' wave and smaller
'v' wave. This represents:
A. Right atrial pressure tracing
B. Pulmonary artery wedge pressure (PAOP) [CORRECT]
C. Central venous pressure with tricuspid regurgitation
D. Pulmonary artery pressure tracing
Correct Answer: B
Rationale: The PAOP waveform reflects left atrial pressure transmitted through the
pulmonary vasculature—characterized by an 'a' wave from atrial contraction and a 'v'
wave from atrial filling against a closed mitral valve, distinct from the sharp systolic
peak of PA pressure.
Q10: A patient with acute RV infarction has a PA catheter placed. The tracing shows
elevated RA pressure with a prominent 'y' descent and equalization of RA and PAOP
during diastole. This hemodynamic pattern suggests:
A. Cardiac tamponade
B. Constrictive pericarditis
C. Right ventricular failure with volume overload [CORRECT]
D. Mitral stenosis
Correct Answer: C
Rationale: In RV failure, particularly from inferior MI, you see elevated right-sided
pressures with prominent 'y' descent as the stiff right ventricle fills rapidly in early
