ANCC & AACN ALIGNED | CERTIF ICATION
EXAMINATION
AGACNP Board
Certification
175 board-style examination questions with verified
answers and comprehensive APRN-level rationales,
mapped to the 2026/2027 ANCC and AACN AGACNP
test content outlines across ten clinical and
professional practice domains.
Adult-Gerontology Acute Care Nurse Practitioner
2026/2027 Edition — Exam Questions with
Verified Answers & Rationales
1 75 Q U E STI O N S | V E RI F I E D A N SW E RS & RATI O N A L E S |
ANCC & AACN DUAL ALIGNMENT
,AGACNP BOARD CERTIFICATION EXAMINATION | 2026-2027 EDITION 175 QUESTIONS
SECTION 1
Clinical Assessment and Diagnostic Reasoning
Questions 1-25
Comprehensive History and Physical Exam, Diagnostic Test Selection, and Clinical Decision-Making
Q1. An 86-year-old man from a skilled nursing facility is brought to the emergency department for 12 hours
of increasing confusion and lethargy. He is afebrile at 36.4 C, heart rate 102/min, blood pressure 94/58 mm
Hg, respiratory rate 20/min, and SpO2 94 percent on room air. The white blood cell count is 7,400 cells per
microliter, and the physical examination is nonfocal. Which of the following is the BEST initial diagnostic
action?
A. Draw two sets of blood cultures and obtain a serum lactate level [CORRECT]
B. Obtain a non-contrast head CT first to evaluate the new confusion
C. Obtain urinalysis and chest radiograph, then reassess the patient in 4 hours
D. Begin intravenous broad-spectrum antibiotics immediately and draw blood cultures after the first
dose
Correct Answer: A
Rationale: Very old adults often have a blunted febrile response and may show a normal white cell count during
sepsis because of immunosenescence, so acute confusion or functional decline is frequently the presenting sign
rather than fever. The priority diagnostics are blood cultures drawn before antimicrobials whenever feasible and a
serum lactate, since a lactate of 2 mmol/L or greater signals occult hypoperfusion and identifies a septic phenotype
even without fever or leukocytosis. Non-contrast head CT as a first step delays recognition of a treatable infection,
because new confusion in this context is expected rather than an indication to image first. Waiting several hours to
reassess wastes the critical early treatment window. Antibiotics given before cultures reduce the yield of pathogen
identification and undermine de-escalation, although therapy must never be withheld if the patient deteriorates.
His hypotension with a systolic pressure in the 90s plus altered mentation already suggests possible septic shock
and demands the urgent sepsis bundle.
Q2. A new rapid diagnostic assay for pulmonary embolism has a sensitivity of 91 percent and a specificity of
88 percent, giving a positive likelihood ratio of about 7.6. A patient has a moderate pretest probability of
pulmonary embolism of about 30 percent. Which of the following statements BEST describes the application
of these test characteristics to interpreting a positive result?
A. A negative result excludes pulmonary embolism regardless of pretest probability
B. A positive result means that 91 percent of patients with a positive test have the disease
C. The pretest odds of 0.43 multiplied by the positive likelihood ratio of 7.6 yield post-test odds near
3.3, a post-test probability of about 76 percent [CORRECT]
D. Likelihood ratios are informative only when the pretest probability is below 10 percent
Correct Answer: C
Rationale: A 30 percent pretest probability corresponds to pretest odds of 0.43, and multiplying by a positive
likelihood ratio of 7.6 gives post-test odds of about 3.3, which converts to a post-test probability near 76 percent,
so a positive result moves this patient from an indeterminate zone into a range that justifies treatment or definitive
imaging. Equating the 91 percent sensitivity with the probability of disease after a positive test is a classic error,
Adult-Gerontology Acute Care Nurse Practitioner | ANCC & AACN Aligned 1
,AGACNP BOARD CERTIFICATION EXAMINATION | 2026-2027 EDITION 175 QUESTIONS
because that describes positive predictive value, which depends on pretest probability. The negative likelihood
ratio here is about 0.10, which lowers the probability substantially at moderate pretest odds but does not exclude
disease. Likelihood ratios are most useful precisely at intermediate probabilities, where the result changes
management, and they are independent of disease prevalence in the tested population.
Q3. A 52-year-old woman presents to the emergency department with 2 days of pleuritic chest pain and
dyspnea. Heart rate is sustained at 104/min, respiratory rate 22/min, and SpO2 93 percent on room air. There
is no unilateral leg swelling, hemoptysis, malignancy, recent surgery, or immobilization, and pulmonary
embolism is not judged the most likely diagnosis (Wells score 1.5). The D-dimer returns elevated at 890
ng/mL FEU. What is the MOST appropriate next step?
A. Reassure the patient and discharge home because the Wells score is low
B. Proceed with CT pulmonary angiography [CORRECT]
C. Start empiric therapeutic apixaban without imaging
D. Repeat the D-dimer in 24 hours before deciding
Correct Answer: B
Rationale: The Wells score of 1.5 places her in the low-probability category, so a negative D-dimer would have
excluded pulmonary embolism without imaging. Because the D-dimer is elevated, imaging is required, and CT
pulmonary angiography is the standard next test in a patient with normal renal function and no contrast allergy.
Discharging a patient with an elevated D-dimer and compatible symptoms risks missing a fatal embolism. Empiric
anticoagulation without an established diagnosis exposes her to bleeding risk while alternative diagnoses such as
pneumonia or musculoskeletal pain remain possible. Repeat D-dimer testing adds delay and never excludes disease
once the value is elevated. Ventilation-perfusion scanning is reserved for renal failure, pregnancy, or contrast
allergy because it is less definitive.
Q4. A 27-year-old man with diabetic ketoacidosis has a glucose of 520 mg/dL and Kussmaul respirations. A
venous blood gas shows pH 7.14, pCO2 28 mm Hg, bicarbonate 9 mEq/L, and lactate 3.4 mmol/L; he is alert
with SpO2 98 percent on room air. Which of the following findings would MOST strongly justify obtaining
an arterial blood gas rather than relying solely on the venous specimen?
A. Venous pH of 7.14 with bicarbonate of 9 mEq/L
B. Venous lactate of 3.4 mmol/L
C. Serum potassium of 5.2 mEq/L on the chemistry panel
D. Oxygen saturation of 88 percent on room air with increased work of breathing [CORRECT]
Correct Answer: D
Rationale: Venous blood gases correlate well with arterial pH and bicarbonate and are entirely adequate for
tracking the acid-base correction of diabetic ketoacidosis, sparing repeated arterial punctures. Venous lactate is
also a validated substitute for arterial lactate in most settings, and potassium comes from the chemistry panel
rather than the gas. The listed venous pH, bicarbonate, and lactate values can all be managed using venous
measurements with awareness of expected venous-arterial differences. Oxygenation is the one domain a venous
gas cannot assess, because a venous pO2 does not reflect arterial oxygenation and does not permit calculation of
the alveolar-arterial gradient. New hypoxemia or worsening work of breathing therefore mandates an arterial
blood gas to quantify gas exchange.
Adult-Gerontology Acute Care Nurse Practitioner | ANCC & AACN Aligned 2
, AGACNP BOARD CERTIFICATION EXAMINATION | 2026-2027 EDITION 175 QUESTIONS
Q5. A hypotensive patient in the cardiac intensive care unit has the following pulmonary artery catheter data:
CVP 3 mm Hg, pulmonary artery occlusion pressure 7 mm Hg, cardiac index 4.6 L/min/m2, systemic
vascular resistance 480 dynes-sec/cm5, and mixed venous oxygen saturation 78 percent. Which of the
following BEST matches these hemodynamic data with the correct shock classification?
A. Distributive (septic) shock: low filling pressures, high cardiac index, low systemic vascular
resistance [CORRECT]
B. Hypovolemic shock: low filling pressures, low cardiac index, high systemic vascular resistance
C. Cardiogenic shock: high filling pressures, low cardiac index, high systemic vascular resistance
D. Obstructive shock: high CVP with low cardiac index and high systemic vascular resistance
Correct Answer: A
Rationale: Filling pressures are low, the cardiac index is high, and the systemic vascular resistance is markedly
reduced, which is the distributive profile produced by sepsis through vasodilation and capillary leak. Hypovolemic
shock shows low filling pressures but a low cardiac index with compensatory vasoconstriction and high systemic
vascular resistance. Cardiogenic shock combines high filling pressures with a low cardiac index and high systemic
vascular resistance. Obstructive shock typically shows elevated CVP with a low cardiac index and high systemic
vascular resistance, as in massive pulmonary embolism or tamponade. Recognizing the profile quickly directs
therapy toward volume plus vasopressors rather than inotropes or drainage.
Q6. A 66-year-old man slipped on ice and struck his head, with a witnessed loss of consciousness of about 20
seconds. In the emergency department his Glasgow Coma Scale score is 15, there is no retrograde amnesia
beyond 30 minutes, no vomiting, no anticoagulant use, and no signs of skull fracture, and the neurologic
examination is normal. According to the Canadian CT Head Rule, which of the following is the MOST
appropriate management?
A. Discharge home with written head injury precautions and a responsible adult
B. Observe for 4 to 6 hours with serial Glasgow Coma Scale checks before deciding
C. Perform a non-contrast CT of the head now [CORRECT]
D. Obtain a contrast-enhanced CT of the head to improve sensitivity
Correct Answer: C
Rationale: The Canadian CT Head Rule applies to patients with witnessed loss of consciousness, amnesia, or
confusion after blunt head injury and a Glasgow Coma Scale score of 13 to 15, and it mandates imaging when any
high-risk criterion is present. Age of 65 years or older is itself a high-risk criterion, so this patient meets the rule
despite a normal examination. Observation with serial checks is the approach reserved for medium-risk criteria
only, such as dangerous mechanism or vomiting. Discharging without imaging in a patient 66 years old risks
missing a lesion requiring neurosurgical intervention. Acute traumatic intracranial blood is detected best on
non-contrast CT, and contrast administration adds nothing for trauma evaluation.
Adult-Gerontology Acute Care Nurse Practitioner | ANCC & AACN Aligned 3
EXAMINATION
AGACNP Board
Certification
175 board-style examination questions with verified
answers and comprehensive APRN-level rationales,
mapped to the 2026/2027 ANCC and AACN AGACNP
test content outlines across ten clinical and
professional practice domains.
Adult-Gerontology Acute Care Nurse Practitioner
2026/2027 Edition — Exam Questions with
Verified Answers & Rationales
1 75 Q U E STI O N S | V E RI F I E D A N SW E RS & RATI O N A L E S |
ANCC & AACN DUAL ALIGNMENT
,AGACNP BOARD CERTIFICATION EXAMINATION | 2026-2027 EDITION 175 QUESTIONS
SECTION 1
Clinical Assessment and Diagnostic Reasoning
Questions 1-25
Comprehensive History and Physical Exam, Diagnostic Test Selection, and Clinical Decision-Making
Q1. An 86-year-old man from a skilled nursing facility is brought to the emergency department for 12 hours
of increasing confusion and lethargy. He is afebrile at 36.4 C, heart rate 102/min, blood pressure 94/58 mm
Hg, respiratory rate 20/min, and SpO2 94 percent on room air. The white blood cell count is 7,400 cells per
microliter, and the physical examination is nonfocal. Which of the following is the BEST initial diagnostic
action?
A. Draw two sets of blood cultures and obtain a serum lactate level [CORRECT]
B. Obtain a non-contrast head CT first to evaluate the new confusion
C. Obtain urinalysis and chest radiograph, then reassess the patient in 4 hours
D. Begin intravenous broad-spectrum antibiotics immediately and draw blood cultures after the first
dose
Correct Answer: A
Rationale: Very old adults often have a blunted febrile response and may show a normal white cell count during
sepsis because of immunosenescence, so acute confusion or functional decline is frequently the presenting sign
rather than fever. The priority diagnostics are blood cultures drawn before antimicrobials whenever feasible and a
serum lactate, since a lactate of 2 mmol/L or greater signals occult hypoperfusion and identifies a septic phenotype
even without fever or leukocytosis. Non-contrast head CT as a first step delays recognition of a treatable infection,
because new confusion in this context is expected rather than an indication to image first. Waiting several hours to
reassess wastes the critical early treatment window. Antibiotics given before cultures reduce the yield of pathogen
identification and undermine de-escalation, although therapy must never be withheld if the patient deteriorates.
His hypotension with a systolic pressure in the 90s plus altered mentation already suggests possible septic shock
and demands the urgent sepsis bundle.
Q2. A new rapid diagnostic assay for pulmonary embolism has a sensitivity of 91 percent and a specificity of
88 percent, giving a positive likelihood ratio of about 7.6. A patient has a moderate pretest probability of
pulmonary embolism of about 30 percent. Which of the following statements BEST describes the application
of these test characteristics to interpreting a positive result?
A. A negative result excludes pulmonary embolism regardless of pretest probability
B. A positive result means that 91 percent of patients with a positive test have the disease
C. The pretest odds of 0.43 multiplied by the positive likelihood ratio of 7.6 yield post-test odds near
3.3, a post-test probability of about 76 percent [CORRECT]
D. Likelihood ratios are informative only when the pretest probability is below 10 percent
Correct Answer: C
Rationale: A 30 percent pretest probability corresponds to pretest odds of 0.43, and multiplying by a positive
likelihood ratio of 7.6 gives post-test odds of about 3.3, which converts to a post-test probability near 76 percent,
so a positive result moves this patient from an indeterminate zone into a range that justifies treatment or definitive
imaging. Equating the 91 percent sensitivity with the probability of disease after a positive test is a classic error,
Adult-Gerontology Acute Care Nurse Practitioner | ANCC & AACN Aligned 1
,AGACNP BOARD CERTIFICATION EXAMINATION | 2026-2027 EDITION 175 QUESTIONS
because that describes positive predictive value, which depends on pretest probability. The negative likelihood
ratio here is about 0.10, which lowers the probability substantially at moderate pretest odds but does not exclude
disease. Likelihood ratios are most useful precisely at intermediate probabilities, where the result changes
management, and they are independent of disease prevalence in the tested population.
Q3. A 52-year-old woman presents to the emergency department with 2 days of pleuritic chest pain and
dyspnea. Heart rate is sustained at 104/min, respiratory rate 22/min, and SpO2 93 percent on room air. There
is no unilateral leg swelling, hemoptysis, malignancy, recent surgery, or immobilization, and pulmonary
embolism is not judged the most likely diagnosis (Wells score 1.5). The D-dimer returns elevated at 890
ng/mL FEU. What is the MOST appropriate next step?
A. Reassure the patient and discharge home because the Wells score is low
B. Proceed with CT pulmonary angiography [CORRECT]
C. Start empiric therapeutic apixaban without imaging
D. Repeat the D-dimer in 24 hours before deciding
Correct Answer: B
Rationale: The Wells score of 1.5 places her in the low-probability category, so a negative D-dimer would have
excluded pulmonary embolism without imaging. Because the D-dimer is elevated, imaging is required, and CT
pulmonary angiography is the standard next test in a patient with normal renal function and no contrast allergy.
Discharging a patient with an elevated D-dimer and compatible symptoms risks missing a fatal embolism. Empiric
anticoagulation without an established diagnosis exposes her to bleeding risk while alternative diagnoses such as
pneumonia or musculoskeletal pain remain possible. Repeat D-dimer testing adds delay and never excludes disease
once the value is elevated. Ventilation-perfusion scanning is reserved for renal failure, pregnancy, or contrast
allergy because it is less definitive.
Q4. A 27-year-old man with diabetic ketoacidosis has a glucose of 520 mg/dL and Kussmaul respirations. A
venous blood gas shows pH 7.14, pCO2 28 mm Hg, bicarbonate 9 mEq/L, and lactate 3.4 mmol/L; he is alert
with SpO2 98 percent on room air. Which of the following findings would MOST strongly justify obtaining
an arterial blood gas rather than relying solely on the venous specimen?
A. Venous pH of 7.14 with bicarbonate of 9 mEq/L
B. Venous lactate of 3.4 mmol/L
C. Serum potassium of 5.2 mEq/L on the chemistry panel
D. Oxygen saturation of 88 percent on room air with increased work of breathing [CORRECT]
Correct Answer: D
Rationale: Venous blood gases correlate well with arterial pH and bicarbonate and are entirely adequate for
tracking the acid-base correction of diabetic ketoacidosis, sparing repeated arterial punctures. Venous lactate is
also a validated substitute for arterial lactate in most settings, and potassium comes from the chemistry panel
rather than the gas. The listed venous pH, bicarbonate, and lactate values can all be managed using venous
measurements with awareness of expected venous-arterial differences. Oxygenation is the one domain a venous
gas cannot assess, because a venous pO2 does not reflect arterial oxygenation and does not permit calculation of
the alveolar-arterial gradient. New hypoxemia or worsening work of breathing therefore mandates an arterial
blood gas to quantify gas exchange.
Adult-Gerontology Acute Care Nurse Practitioner | ANCC & AACN Aligned 2
, AGACNP BOARD CERTIFICATION EXAMINATION | 2026-2027 EDITION 175 QUESTIONS
Q5. A hypotensive patient in the cardiac intensive care unit has the following pulmonary artery catheter data:
CVP 3 mm Hg, pulmonary artery occlusion pressure 7 mm Hg, cardiac index 4.6 L/min/m2, systemic
vascular resistance 480 dynes-sec/cm5, and mixed venous oxygen saturation 78 percent. Which of the
following BEST matches these hemodynamic data with the correct shock classification?
A. Distributive (septic) shock: low filling pressures, high cardiac index, low systemic vascular
resistance [CORRECT]
B. Hypovolemic shock: low filling pressures, low cardiac index, high systemic vascular resistance
C. Cardiogenic shock: high filling pressures, low cardiac index, high systemic vascular resistance
D. Obstructive shock: high CVP with low cardiac index and high systemic vascular resistance
Correct Answer: A
Rationale: Filling pressures are low, the cardiac index is high, and the systemic vascular resistance is markedly
reduced, which is the distributive profile produced by sepsis through vasodilation and capillary leak. Hypovolemic
shock shows low filling pressures but a low cardiac index with compensatory vasoconstriction and high systemic
vascular resistance. Cardiogenic shock combines high filling pressures with a low cardiac index and high systemic
vascular resistance. Obstructive shock typically shows elevated CVP with a low cardiac index and high systemic
vascular resistance, as in massive pulmonary embolism or tamponade. Recognizing the profile quickly directs
therapy toward volume plus vasopressors rather than inotropes or drainage.
Q6. A 66-year-old man slipped on ice and struck his head, with a witnessed loss of consciousness of about 20
seconds. In the emergency department his Glasgow Coma Scale score is 15, there is no retrograde amnesia
beyond 30 minutes, no vomiting, no anticoagulant use, and no signs of skull fracture, and the neurologic
examination is normal. According to the Canadian CT Head Rule, which of the following is the MOST
appropriate management?
A. Discharge home with written head injury precautions and a responsible adult
B. Observe for 4 to 6 hours with serial Glasgow Coma Scale checks before deciding
C. Perform a non-contrast CT of the head now [CORRECT]
D. Obtain a contrast-enhanced CT of the head to improve sensitivity
Correct Answer: C
Rationale: The Canadian CT Head Rule applies to patients with witnessed loss of consciousness, amnesia, or
confusion after blunt head injury and a Glasgow Coma Scale score of 13 to 15, and it mandates imaging when any
high-risk criterion is present. Age of 65 years or older is itself a high-risk criterion, so this patient meets the rule
despite a normal examination. Observation with serial checks is the approach reserved for medium-risk criteria
only, such as dangerous mechanism or vomiting. Discharging without imaging in a patient 66 years old risks
missing a lesion requiring neurosurgical intervention. Acute traumatic intracranial blood is detected best on
non-contrast CT, and contrast administration adds nothing for trauma evaluation.
Adult-Gerontology Acute Care Nurse Practitioner | ANCC & AACN Aligned 3
