AGNP Certification Exam Prep 2026
Comprehensive Clinical Review Guide &
Practice Questions Detailed Rationales | Verified
Answers | Success Workbook
Section 1: Cardiovascular System
1. A 72-year-old male with a history of hypertension and type 2 diabetes
presents with exertional chest pressure that improves with rest. He describes
the pain as a "heavy sensation" in the center of his chest that sometimes
radiates to his left shoulder. His ECG shows no acute ischemic changes. What
is the most appropriate initial management for this patient?
A. Prescribe sublingual nitroglycerin and schedule a stress test.
B. Start the patient on a daily aspirin and order a lipid panel.
C. Refer the patient for immediate cardiac catheterization.
D. Reassure the patient and schedule a follow-up in 6 months.
Answer: B. Start the patient on a daily aspirin and order a lipid panel.
Rationale: This patient presents with stable angina, characterized by exertional
chest pressure relieved by rest. The initial management should include antiplatelet
therapy (aspirin) and risk factor modification. Ordering a lipid panel (B) will help
guide statin therapy. Option A (nitroglycerin) may be appropriate for symptom
relief but is not the most important initial step. Option C (immediate
catheterization) is reserved for unstable angina or acute MI. Option D
(reassurance) would be negligent given the clear anginal symptoms.
2. A 78-year-old female with a history of heart failure with preserved ejection
fraction (HFpEF) presents with progressive dyspnea on exertion, orthopnea,
and 2+ pitting edema in her lower extremities. Her blood pressure is 152/88
mmHg, heart rate is 92 bpm, and lungs are clear to auscultation. She is
currently on lisinopril 10 mg daily. What is the most appropriate next step in
managing her hypertension?
A. Increase lisinopril to 20 mg daily.
B. Add hydrochlorothiazide 12.5 mg daily.
,C. Add amlodipine 5 mg daily.
D. Add spironolactone 25 mg daily.
Answer: D. Add spironolactone 25 mg daily.
Rationale: In patients with HFpEF, the TOPCAT trial demonstrated benefit with
spironolactone in reducing heart failure hospitalizations. This patient has volume
overload (edema) and hypertension, making spironolactone an excellent choice.
Increasing lisinopril (A) may be insufficient for volume control.
Hydrochlorothiazide (B) may worsen electrolyte imbalances. Amlodipine (C) is a
calcium channel blocker that can exacerbate edema in heart failure patients.
3. A 65-year-old male presents with acute onset of severe, tearing chest pain
that radiates to his back. His blood pressure is 180/100 mmHg in the right
arm and 110/70 mmHg in the left arm. Which of the following is the most
appropriate next step in management?
A. Administer sublingual nitroglycerin.
B. Obtain an immediate CT angiography of the chest.
C. Start an IV infusion of labetalol.
D. Administer IV unfractionated heparin.
Answer: C. Start an IV infusion of labetalol.
Rationale: The patient's presentation is classic for an acute aortic dissection (Type
A). The priority is to reduce the rate of rise of left ventricular ejection
(contractility) and blood pressure to prevent propagation of the dissection.
Labetalol (a combined alpha and beta blocker) is the agent of choice. CT
angiography (B) is the diagnostic test of choice, but hemodynamic control is the
priority before or during imaging. Nitroglycerin (A) is a vasodilator but can cause
reflex tachycardia and worsen the dissection. Heparin (D) is not indicated.
4. A 72-year-old male with a history of atrial fibrillation is on warfarin
therapy. His INR is 5.2. He has no signs of bleeding. What is the most
appropriate management?
A. Hold warfarin and administer vitamin K 2.5 mg orally.
B. Hold warfarin and monitor INR.
C. Reduce the warfarin dose and recheck INR in 1 week.
D. Administer fresh frozen plasma.
Answer: A. Hold warfarin and administer vitamin K 2.5 mg orally.
Rationale: An INR > 5.0 without bleeding requires holding the warfarin and
administering a low dose of vitamin K (2.5 mg orally) to rapidly reduce the INR.
,Option B (hold and monitor) is appropriate for INR between 3.0 and 5.0. Option C
(reduce dose) is appropriate for INR between 3.0 and 5.0 without bleeding. Option
D (fresh frozen plasma) is indicated for life-threatening bleeding or when rapid
reversal is needed.
5. A 68-year-old female presents with palpitations, fatigue, and shortness of
breath. Her ECG shows atrial fibrillation with a ventricular rate of 130 bpm.
She is hemodynamically stable. Her CHA₂DS₂-VASc score is 4. What is the
most appropriate management?
A. Rate control with a beta-blocker and anticoagulation with warfarin.
B. Immediate synchronized cardioversion.
C. Rate control with a calcium channel blocker only.
D. Anticoagulation with aspirin only.
Answer: A. Rate control with a beta-blocker and anticoagulation with
warfarin.
Rationale: This patient has atrial fibrillation with a rapid ventricular response.
Rate control is indicated (beta-blocker or calcium channel blocker).
Anticoagulation is also indicated given her CHA₂DS₂-VASc score of 4 (high risk
for stroke). Warfarin or a direct oral anticoagulant (DOAC) is appropriate. Option
B (cardioversion) is for unstable patients or those who fail rate control. Option C
(rate control only) would miss the need for anticoagulation. Option D (aspirin) is
inadequate for stroke prevention in high-risk patients.
Section 2: Respiratory System
6. A 65-year-old male with a 40-pack-year smoking history presents with a
chronic cough, hemoptysis, and weight loss. A chest CT shows a 4-cm right
hilar mass with mediastinal lymphadenopathy. A biopsy reveals small cell
lung cancer (SCLC). Which of the following is the most appropriate initial
treatment?
A. Surgical resection
B. Radiation therapy alone
C. Chemotherapy and radiation therapy
D. Targeted therapy with a tyrosine kinase inhibitor
Answer: C. Chemotherapy and radiation therapy.
Rationale: Small cell lung cancer is typically not amenable to surgical resection
, due to early metastasis. The standard treatment for limited-stage SCLC is
concurrent chemotherapy and radiation therapy. In extensive-stage SCLC,
chemotherapy is the mainstay. Targeted therapy (D) is used for non-small cell lung
cancer with specific mutations (e.g., EGFR, ALK). Surgical resection (A) is not
indicated for SCLC.
7. A 58-year-old female with a history of asthma presents with severe
shortness of breath. She is unable to speak in full sentences. Her respiratory
rate is 28/min, heart rate is 110 bpm, and oxygen saturation is 88% on room
air. On exam, there is minimal wheezing and diminished breath sounds.
Which of the following is the most appropriate next step?
A. Administer inhaled albuterol and ipratropium.
B. Administer IV corticosteroids.
C. Prepare for intubation and mechanical ventilation.
D. Administer subcutaneous epinephrine.
Answer: C. Prepare for intubation and mechanical ventilation.
Rationale: The patient has signs of a severe asthma exacerbation with impending
respiratory failure. The absence of wheezing with diminished breath sounds
indicates severe airflow obstruction ("silent chest"). Intubation is indicated for
impending respiratory failure. While albuterol and corticosteroids (A, B) are
important, they are not sufficient, and intubation is the priority. Epinephrine (D) is
used in anaphylaxis or cardiac arrest, not as first-line treatment for asthma.
8. A 72-year-old male with a history of COPD presents with worsening
shortness of breath and a productive cough with purulent sputum. His
arterial blood gas shows: pH 7.30, PaCO2 65 mmHg, PaO2 55 mmHg, HCO3-
32 mEq/L. Which of the following is the most appropriate management?
A. Increase his home oxygen to 4 L/min.
B. Administer noninvasive positive pressure ventilation (NIPPV).
C. Initiate mechanical ventilation.
D. Administer IV antibiotics and corticosteroids.
Answer: B. Administer noninvasive positive pressure ventilation (NIPPV).
Rationale: The patient has an acute exacerbation of COPD with hypercapnic
respiratory failure (pH < 7.35, PaCO2 > 45). NIPPV is the first-line treatment for
respiratory failure in COPD patients who are alert and cooperative. It can reduce
the need for intubation and improve outcomes. Mechanical ventilation (C) is
reserved for patients who fail NIPPV or are unable to protect their airway.
Comprehensive Clinical Review Guide &
Practice Questions Detailed Rationales | Verified
Answers | Success Workbook
Section 1: Cardiovascular System
1. A 72-year-old male with a history of hypertension and type 2 diabetes
presents with exertional chest pressure that improves with rest. He describes
the pain as a "heavy sensation" in the center of his chest that sometimes
radiates to his left shoulder. His ECG shows no acute ischemic changes. What
is the most appropriate initial management for this patient?
A. Prescribe sublingual nitroglycerin and schedule a stress test.
B. Start the patient on a daily aspirin and order a lipid panel.
C. Refer the patient for immediate cardiac catheterization.
D. Reassure the patient and schedule a follow-up in 6 months.
Answer: B. Start the patient on a daily aspirin and order a lipid panel.
Rationale: This patient presents with stable angina, characterized by exertional
chest pressure relieved by rest. The initial management should include antiplatelet
therapy (aspirin) and risk factor modification. Ordering a lipid panel (B) will help
guide statin therapy. Option A (nitroglycerin) may be appropriate for symptom
relief but is not the most important initial step. Option C (immediate
catheterization) is reserved for unstable angina or acute MI. Option D
(reassurance) would be negligent given the clear anginal symptoms.
2. A 78-year-old female with a history of heart failure with preserved ejection
fraction (HFpEF) presents with progressive dyspnea on exertion, orthopnea,
and 2+ pitting edema in her lower extremities. Her blood pressure is 152/88
mmHg, heart rate is 92 bpm, and lungs are clear to auscultation. She is
currently on lisinopril 10 mg daily. What is the most appropriate next step in
managing her hypertension?
A. Increase lisinopril to 20 mg daily.
B. Add hydrochlorothiazide 12.5 mg daily.
,C. Add amlodipine 5 mg daily.
D. Add spironolactone 25 mg daily.
Answer: D. Add spironolactone 25 mg daily.
Rationale: In patients with HFpEF, the TOPCAT trial demonstrated benefit with
spironolactone in reducing heart failure hospitalizations. This patient has volume
overload (edema) and hypertension, making spironolactone an excellent choice.
Increasing lisinopril (A) may be insufficient for volume control.
Hydrochlorothiazide (B) may worsen electrolyte imbalances. Amlodipine (C) is a
calcium channel blocker that can exacerbate edema in heart failure patients.
3. A 65-year-old male presents with acute onset of severe, tearing chest pain
that radiates to his back. His blood pressure is 180/100 mmHg in the right
arm and 110/70 mmHg in the left arm. Which of the following is the most
appropriate next step in management?
A. Administer sublingual nitroglycerin.
B. Obtain an immediate CT angiography of the chest.
C. Start an IV infusion of labetalol.
D. Administer IV unfractionated heparin.
Answer: C. Start an IV infusion of labetalol.
Rationale: The patient's presentation is classic for an acute aortic dissection (Type
A). The priority is to reduce the rate of rise of left ventricular ejection
(contractility) and blood pressure to prevent propagation of the dissection.
Labetalol (a combined alpha and beta blocker) is the agent of choice. CT
angiography (B) is the diagnostic test of choice, but hemodynamic control is the
priority before or during imaging. Nitroglycerin (A) is a vasodilator but can cause
reflex tachycardia and worsen the dissection. Heparin (D) is not indicated.
4. A 72-year-old male with a history of atrial fibrillation is on warfarin
therapy. His INR is 5.2. He has no signs of bleeding. What is the most
appropriate management?
A. Hold warfarin and administer vitamin K 2.5 mg orally.
B. Hold warfarin and monitor INR.
C. Reduce the warfarin dose and recheck INR in 1 week.
D. Administer fresh frozen plasma.
Answer: A. Hold warfarin and administer vitamin K 2.5 mg orally.
Rationale: An INR > 5.0 without bleeding requires holding the warfarin and
administering a low dose of vitamin K (2.5 mg orally) to rapidly reduce the INR.
,Option B (hold and monitor) is appropriate for INR between 3.0 and 5.0. Option C
(reduce dose) is appropriate for INR between 3.0 and 5.0 without bleeding. Option
D (fresh frozen plasma) is indicated for life-threatening bleeding or when rapid
reversal is needed.
5. A 68-year-old female presents with palpitations, fatigue, and shortness of
breath. Her ECG shows atrial fibrillation with a ventricular rate of 130 bpm.
She is hemodynamically stable. Her CHA₂DS₂-VASc score is 4. What is the
most appropriate management?
A. Rate control with a beta-blocker and anticoagulation with warfarin.
B. Immediate synchronized cardioversion.
C. Rate control with a calcium channel blocker only.
D. Anticoagulation with aspirin only.
Answer: A. Rate control with a beta-blocker and anticoagulation with
warfarin.
Rationale: This patient has atrial fibrillation with a rapid ventricular response.
Rate control is indicated (beta-blocker or calcium channel blocker).
Anticoagulation is also indicated given her CHA₂DS₂-VASc score of 4 (high risk
for stroke). Warfarin or a direct oral anticoagulant (DOAC) is appropriate. Option
B (cardioversion) is for unstable patients or those who fail rate control. Option C
(rate control only) would miss the need for anticoagulation. Option D (aspirin) is
inadequate for stroke prevention in high-risk patients.
Section 2: Respiratory System
6. A 65-year-old male with a 40-pack-year smoking history presents with a
chronic cough, hemoptysis, and weight loss. A chest CT shows a 4-cm right
hilar mass with mediastinal lymphadenopathy. A biopsy reveals small cell
lung cancer (SCLC). Which of the following is the most appropriate initial
treatment?
A. Surgical resection
B. Radiation therapy alone
C. Chemotherapy and radiation therapy
D. Targeted therapy with a tyrosine kinase inhibitor
Answer: C. Chemotherapy and radiation therapy.
Rationale: Small cell lung cancer is typically not amenable to surgical resection
, due to early metastasis. The standard treatment for limited-stage SCLC is
concurrent chemotherapy and radiation therapy. In extensive-stage SCLC,
chemotherapy is the mainstay. Targeted therapy (D) is used for non-small cell lung
cancer with specific mutations (e.g., EGFR, ALK). Surgical resection (A) is not
indicated for SCLC.
7. A 58-year-old female with a history of asthma presents with severe
shortness of breath. She is unable to speak in full sentences. Her respiratory
rate is 28/min, heart rate is 110 bpm, and oxygen saturation is 88% on room
air. On exam, there is minimal wheezing and diminished breath sounds.
Which of the following is the most appropriate next step?
A. Administer inhaled albuterol and ipratropium.
B. Administer IV corticosteroids.
C. Prepare for intubation and mechanical ventilation.
D. Administer subcutaneous epinephrine.
Answer: C. Prepare for intubation and mechanical ventilation.
Rationale: The patient has signs of a severe asthma exacerbation with impending
respiratory failure. The absence of wheezing with diminished breath sounds
indicates severe airflow obstruction ("silent chest"). Intubation is indicated for
impending respiratory failure. While albuterol and corticosteroids (A, B) are
important, they are not sufficient, and intubation is the priority. Epinephrine (D) is
used in anaphylaxis or cardiac arrest, not as first-line treatment for asthma.
8. A 72-year-old male with a history of COPD presents with worsening
shortness of breath and a productive cough with purulent sputum. His
arterial blood gas shows: pH 7.30, PaCO2 65 mmHg, PaO2 55 mmHg, HCO3-
32 mEq/L. Which of the following is the most appropriate management?
A. Increase his home oxygen to 4 L/min.
B. Administer noninvasive positive pressure ventilation (NIPPV).
C. Initiate mechanical ventilation.
D. Administer IV antibiotics and corticosteroids.
Answer: B. Administer noninvasive positive pressure ventilation (NIPPV).
Rationale: The patient has an acute exacerbation of COPD with hypercapnic
respiratory failure (pH < 7.35, PaCO2 > 45). NIPPV is the first-line treatment for
respiratory failure in COPD patients who are alert and cooperative. It can reduce
the need for intubation and improve outcomes. Mechanical ventilation (C) is
reserved for patients who fail NIPPV or are unable to protect their airway.
