ANCC AGACNP Certification Exam Newest Actual
Exam | Complete Real Exam Questions and
Correct Detailed Answers – Pass Guaranteed -
A+ Graded
SECTION 1: ASSESSMENT & DIAGNOSIS IN ACUTE CARE
Q1: A 78-year-old woman is transferred from a skilled nursing facility with confusion,
lethargy, and a temperature of 38.1°C. She has a history of hypertension and mild
cognitive impairment. Her vital signs are BP 98/62, HR 112, RR 24, SpO2 91% on room
air. She is minimally responsive to voice. Her WBC is 14,200 with 18% bands. Lactate is
3.8 mmol/L. What is the most appropriate immediate priority diagnosis?
A. Acute delirium from urinary tract infection
B. Sepsis with septic shock [CORRECT]
C. Community-acquired pneumonia
D. Acute stroke
Correct Answer: B
Rationale: The best answer is sepsis with septic shock. For ANCC AGACNP certification,
remember that altered mental status in an older adult with hypotension, tachycardia,
tachypnea, hypoxemia, leukocytosis with left shift, and elevated lactate is sepsis until
proven otherwise. Think about the most life-threatening condition first and your
ABCs—this presentation meets criteria for septic shock (lactate >2 with hypotension)
and needs immediate resuscitation, not just workup for a specific source.
Q2: A 64-year-old man presents to the ED with crushing substernal chest pain radiating
to his left jaw, onset 45 minutes ago. He is diaphoretic and nauseated. Vital signs: BP
156/94, HR 92, RR 18, SpO2 95% RA. ECG shows 2 mm ST-segment elevation in leads
V2-V4. Troponin is pending. What is the most appropriate immediate next step?
,A. Administer sublingual nitroglycerin and wait for troponin results
B. Activate the cardiac catheterization lab for primary PCI [CORRECT]
C. Start heparin drip and admit to telemetry
D. Obtain a chest CT to rule out aortic dissection
Correct Answer: B
Rationale: The best answer is activate the cath lab for primary PCI. This aligns with
current evidence-based guidelines (AHA/ACC) which state that STEMI with anterior ST
elevations requires emergent reperfusion within 90 minutes of first medical contact.
Door-to-balloon time is the priority—don't wait for biomarkers when the ECG tells the
story.
Q3: A 55-year-old man with a history of alcohol use disorder presents with hematemesis
and melena. He is pale, tachycardic at 118, and hypotensive at 88/56. His abdomen is
soft and non-tender. Hemoglobin is 6.8 g/dL (baseline 13.2). What is the most likely
source of bleeding?
A. Peptic ulcer disease or esophageal varices [CORRECT]
B. Diverticular bleed
C. Colon cancer
D. Mallory-Weiss tear
Correct Answer: A
Rationale: The best answer is peptic ulcer disease or esophageal varices. For ANCC
AGACNP certification, remember that hematemesis with melena in a patient with
alcohol history points to an upper GI source, with varices and ulcers being the most
common life-threatening causes. Think about the most life-threatening condition first
and your ABCs—this patient needs volume resuscitation and emergent endoscopy, not
just blood transfusion.
Q4: A 68-year-old woman with COPD presents with worsening dyspnea over 3 days. She
is using accessory muscles, speaking in short phrases, and has diffuse wheezing. ABG
on 2L NC shows pH 7.28, PaCO2 68, PaO2 58, HCO3 32. What is the primary acid-base
disturbance?
A. Acute respiratory acidosis
B. Chronic respiratory acidosis with acute-on-chronic exacerbation [CORRECT]
C. Metabolic alkalosis
D. Mixed respiratory and metabolic acidosis
,Correct Answer: B
Rationale: The best answer is chronic respiratory acidosis with acute-on-chronic
exacerbation. This aligns with ABG interpretation because the elevated HCO3 (32)
indicates renal compensation for chronic CO2 retention, while the pH of 7.28 shows an
acute decompensation from her COPD baseline. The elevated PaCO2 with partially
compensated metabolic response is classic for acute-on-chronic respiratory failure.
Q5: A 42-year-old man presents with sudden-onset severe headache, "worst headache
of my life," with nuchal rigidity. CT head is negative for hemorrhage. He is afebrile. What
is the most appropriate next diagnostic step?
A. Lumbar puncture to assess for xanthochromia [CORRECT]
B. Start empiric antibiotics for meningitis
C. MRI brain with contrast
D. Reassurance and discharge with primary care follow-up
Correct Answer: A
Rationale: The best answer is lumbar puncture for xanthochromia. For ANCC AGACNP
certification, remember that a thunderclap headache with negative CT still requires LP
to rule out subarachnoid hemorrhage, as CT can miss small bleeds after 6-12 hours.
Xanthochromia from RBC breakdown confirms SAH even when CT is negative.
Q6: A 72-year-old man with atrial fibrillation on warfarin presents with acute onset
right-sided weakness and aphasia. CT head shows no hemorrhage. Last known well
was 90 minutes ago. INR is 2.4. What is the most appropriate immediate intervention?
A. Administer IV tissue plasminogen activator (tPA) if no other contraindications
[CORRECT]
B. Wait for INR to normalize before thrombolysis
C. Start heparin drip immediately
D. Order MRI brain before any intervention
Correct Answer: A
Rationale: The best answer is administer IV tPA if no other contraindications. This
aligns with current stroke guidelines which state that an INR ≤2.4 does not exclude a
patient from IV thrombolysis for acute ischemic stroke within the window. Time is
brain—don't delay reperfusion waiting for the INR to drop further if it's already below 2.5.
, Q7: A 58-year-old woman post-op day 3 from laparoscopic cholecystectomy develops
sudden dyspnea, pleuritic chest pain, and tachycardia. SpO2 drops to 88% on room air.
CT pulmonary angiography shows a large saddle PE. BP is 82/58. What is the most
appropriate immediate management?
A. Start heparin drip and observe
B. Systemic thrombolysis or embolectomy [CORRECT]
C. Inferior vena cava filter placement
D. Start warfarin alone
Correct Answer: B
Rationale: The best answer is systemic thrombolysis or embolectomy. For ANCC
AGACNP certification, remember that a massive PE with hemodynamic compromise
(systolic BP <90) requires emergent reperfusion—thrombolysis if no contraindications,
or surgical/catheter embolectomy. Anticoagulation alone is insufficient when the patient
is in shock.
Q8: A 35-year-old man with type 1 diabetes presents with polyuria, polydipsia, nausea,
and abdominal pain. He stopped taking insulin 2 days ago. Vital signs: BP 96/62, HR
128, RR 32, temp 36.8°C. Labs: glucose 486 mg/dL, pH 7.12, PaCO2 18, HCO3 8, anion
gap 24, ketones positive. What is the primary acid-base disturbance?
A. Metabolic alkalosis
B. High anion gap metabolic acidosis with appropriate respiratory compensation
[CORRECT]
C. Respiratory acidosis
D. Normal anion gap metabolic acidosis
Correct Answer: B
Rationale: The best answer is high anion gap metabolic acidosis with respiratory
compensation. This aligns with DKA pathophysiology because insulin deficiency causes
ketone production (anion gap 24), and the low PaCO2 (18) shows the expected
compensatory hyperventilation. The pH of 7.12 confirms severe metabolic acidosis.
Q9: A 62-year-old man with a history of heart failure presents with progressive dyspnea,
orthopnea, and bilateral lower extremity edema. JVP is elevated at 8 cm. Lung exam
reveals bibasilar crackles. He is on furosemide 40 mg daily at home. BNP is 1,850
pg/mL. Chest X-ray shows pulmonary vascular congestion and cardiomegaly. What is
the most likely precipitating factor to assess for?
A. Acute pneumonia
Exam | Complete Real Exam Questions and
Correct Detailed Answers – Pass Guaranteed -
A+ Graded
SECTION 1: ASSESSMENT & DIAGNOSIS IN ACUTE CARE
Q1: A 78-year-old woman is transferred from a skilled nursing facility with confusion,
lethargy, and a temperature of 38.1°C. She has a history of hypertension and mild
cognitive impairment. Her vital signs are BP 98/62, HR 112, RR 24, SpO2 91% on room
air. She is minimally responsive to voice. Her WBC is 14,200 with 18% bands. Lactate is
3.8 mmol/L. What is the most appropriate immediate priority diagnosis?
A. Acute delirium from urinary tract infection
B. Sepsis with septic shock [CORRECT]
C. Community-acquired pneumonia
D. Acute stroke
Correct Answer: B
Rationale: The best answer is sepsis with septic shock. For ANCC AGACNP certification,
remember that altered mental status in an older adult with hypotension, tachycardia,
tachypnea, hypoxemia, leukocytosis with left shift, and elevated lactate is sepsis until
proven otherwise. Think about the most life-threatening condition first and your
ABCs—this presentation meets criteria for septic shock (lactate >2 with hypotension)
and needs immediate resuscitation, not just workup for a specific source.
Q2: A 64-year-old man presents to the ED with crushing substernal chest pain radiating
to his left jaw, onset 45 minutes ago. He is diaphoretic and nauseated. Vital signs: BP
156/94, HR 92, RR 18, SpO2 95% RA. ECG shows 2 mm ST-segment elevation in leads
V2-V4. Troponin is pending. What is the most appropriate immediate next step?
,A. Administer sublingual nitroglycerin and wait for troponin results
B. Activate the cardiac catheterization lab for primary PCI [CORRECT]
C. Start heparin drip and admit to telemetry
D. Obtain a chest CT to rule out aortic dissection
Correct Answer: B
Rationale: The best answer is activate the cath lab for primary PCI. This aligns with
current evidence-based guidelines (AHA/ACC) which state that STEMI with anterior ST
elevations requires emergent reperfusion within 90 minutes of first medical contact.
Door-to-balloon time is the priority—don't wait for biomarkers when the ECG tells the
story.
Q3: A 55-year-old man with a history of alcohol use disorder presents with hematemesis
and melena. He is pale, tachycardic at 118, and hypotensive at 88/56. His abdomen is
soft and non-tender. Hemoglobin is 6.8 g/dL (baseline 13.2). What is the most likely
source of bleeding?
A. Peptic ulcer disease or esophageal varices [CORRECT]
B. Diverticular bleed
C. Colon cancer
D. Mallory-Weiss tear
Correct Answer: A
Rationale: The best answer is peptic ulcer disease or esophageal varices. For ANCC
AGACNP certification, remember that hematemesis with melena in a patient with
alcohol history points to an upper GI source, with varices and ulcers being the most
common life-threatening causes. Think about the most life-threatening condition first
and your ABCs—this patient needs volume resuscitation and emergent endoscopy, not
just blood transfusion.
Q4: A 68-year-old woman with COPD presents with worsening dyspnea over 3 days. She
is using accessory muscles, speaking in short phrases, and has diffuse wheezing. ABG
on 2L NC shows pH 7.28, PaCO2 68, PaO2 58, HCO3 32. What is the primary acid-base
disturbance?
A. Acute respiratory acidosis
B. Chronic respiratory acidosis with acute-on-chronic exacerbation [CORRECT]
C. Metabolic alkalosis
D. Mixed respiratory and metabolic acidosis
,Correct Answer: B
Rationale: The best answer is chronic respiratory acidosis with acute-on-chronic
exacerbation. This aligns with ABG interpretation because the elevated HCO3 (32)
indicates renal compensation for chronic CO2 retention, while the pH of 7.28 shows an
acute decompensation from her COPD baseline. The elevated PaCO2 with partially
compensated metabolic response is classic for acute-on-chronic respiratory failure.
Q5: A 42-year-old man presents with sudden-onset severe headache, "worst headache
of my life," with nuchal rigidity. CT head is negative for hemorrhage. He is afebrile. What
is the most appropriate next diagnostic step?
A. Lumbar puncture to assess for xanthochromia [CORRECT]
B. Start empiric antibiotics for meningitis
C. MRI brain with contrast
D. Reassurance and discharge with primary care follow-up
Correct Answer: A
Rationale: The best answer is lumbar puncture for xanthochromia. For ANCC AGACNP
certification, remember that a thunderclap headache with negative CT still requires LP
to rule out subarachnoid hemorrhage, as CT can miss small bleeds after 6-12 hours.
Xanthochromia from RBC breakdown confirms SAH even when CT is negative.
Q6: A 72-year-old man with atrial fibrillation on warfarin presents with acute onset
right-sided weakness and aphasia. CT head shows no hemorrhage. Last known well
was 90 minutes ago. INR is 2.4. What is the most appropriate immediate intervention?
A. Administer IV tissue plasminogen activator (tPA) if no other contraindications
[CORRECT]
B. Wait for INR to normalize before thrombolysis
C. Start heparin drip immediately
D. Order MRI brain before any intervention
Correct Answer: A
Rationale: The best answer is administer IV tPA if no other contraindications. This
aligns with current stroke guidelines which state that an INR ≤2.4 does not exclude a
patient from IV thrombolysis for acute ischemic stroke within the window. Time is
brain—don't delay reperfusion waiting for the INR to drop further if it's already below 2.5.
, Q7: A 58-year-old woman post-op day 3 from laparoscopic cholecystectomy develops
sudden dyspnea, pleuritic chest pain, and tachycardia. SpO2 drops to 88% on room air.
CT pulmonary angiography shows a large saddle PE. BP is 82/58. What is the most
appropriate immediate management?
A. Start heparin drip and observe
B. Systemic thrombolysis or embolectomy [CORRECT]
C. Inferior vena cava filter placement
D. Start warfarin alone
Correct Answer: B
Rationale: The best answer is systemic thrombolysis or embolectomy. For ANCC
AGACNP certification, remember that a massive PE with hemodynamic compromise
(systolic BP <90) requires emergent reperfusion—thrombolysis if no contraindications,
or surgical/catheter embolectomy. Anticoagulation alone is insufficient when the patient
is in shock.
Q8: A 35-year-old man with type 1 diabetes presents with polyuria, polydipsia, nausea,
and abdominal pain. He stopped taking insulin 2 days ago. Vital signs: BP 96/62, HR
128, RR 32, temp 36.8°C. Labs: glucose 486 mg/dL, pH 7.12, PaCO2 18, HCO3 8, anion
gap 24, ketones positive. What is the primary acid-base disturbance?
A. Metabolic alkalosis
B. High anion gap metabolic acidosis with appropriate respiratory compensation
[CORRECT]
C. Respiratory acidosis
D. Normal anion gap metabolic acidosis
Correct Answer: B
Rationale: The best answer is high anion gap metabolic acidosis with respiratory
compensation. This aligns with DKA pathophysiology because insulin deficiency causes
ketone production (anion gap 24), and the low PaCO2 (18) shows the expected
compensatory hyperventilation. The pH of 7.12 confirms severe metabolic acidosis.
Q9: A 62-year-old man with a history of heart failure presents with progressive dyspnea,
orthopnea, and bilateral lower extremity edema. JVP is elevated at 8 cm. Lung exam
reveals bibasilar crackles. He is on furosemide 40 mg daily at home. BNP is 1,850
pg/mL. Chest X-ray shows pulmonary vascular congestion and cardiomegaly. What is
the most likely precipitating factor to assess for?
A. Acute pneumonia
