ANCC AGACNP Certification Advanced Prep: Master
Critical Care & Acute Management Practice Questions &
Detailed Explanations
Subject: Adult-Gerontology Acute Care Nurse Practitioner (AGACNP) –
Hemodynamic Monitoring, Sepsis, and Cardiovascular Emergencies
Question 1: A 68-year-old patient with history of heart failure is admitted with acute respiratory
distress. Hemodynamic monitoring via pulmonary artery catheter reveals a Cardiac Index (CI) of
1.8 $L/min/m^2$, Pulmonary Artery Occlusion Pressure (PAOP) of 24 mmHg, and Systemic
Vascular Resistance (SVR) of 1800 $dynes/sec/cm^{-5}$. Which pharmacological strategy is
indicated?
A) Aggressive fluid resuscitation with 0.9% Normal Saline.
B) Initiation of a dobutamine infusion and cautious diuresis.
C) Immediate administration of a vasoconstrictor like norepinephrine.
D) Bolus administration of intravenous beta-blockers.
Correct Answer: B) Initiation of a dobutamine infusion and cautious diuresis.
Explanation: The patient’s profile (low CI, elevated PAOP, elevated SVR) is consistent with
cardiogenic shock. Dobutamine provides inotropic support to improve cardiac index, while
diuresis (cautiously) addresses the volume overload reflected by the elevated PAOP. Fluid
resuscitation (A) would exacerbate pulmonary congestion, and vasoconstrictors (C) would
increase afterload, worsening cardiac workload.
Question 2: A patient in the ICU develops sudden-onset hypotension, JVD, and muffled heart
sounds. The nurse practitioner suspects cardiac tamponade. Which ECG finding is most
pathognomonic for this condition?
A) ST-segment elevation in all leads.
B) Electrical alternans.
C) Development of a new bundle branch block.
D) Prolonged QT interval.
Correct Answer: B) Electrical alternans.
,Explanation: Electrical alternans—a beat-to-beat variation in QRS amplitude—occurs due to the
heart "swinging" within a fluid-filled pericardial sac. While ST elevation may occur in
pericarditis, electrical alternans is specifically associated with tamponade.
Question 3: During the management of septic shock, the Surviving Sepsis Campaign guidelines
emphasize the "One-Hour Bundle." Which of the following is NOT part of the initial one-hour
resuscitation bundle?
A) Measuring lactate levels.
B) Obtaining blood cultures prior to antibiotic administration.
C) Administering a 30 mL/kg crystalloid bolus for hypotension or lactate ≥ 4 mmol/L.
D) Starting hemodialysis for potential acute kidney injury.
Correct Answer: D) Starting hemodialysis for potential acute kidney injury.
Explanation: The one-hour bundle includes measuring lactate, obtaining blood cultures,
administering broad-spectrum antibiotics, fluid resuscitation (30 mL/kg), and applying
vasopressors if hypotensive during or after fluid resuscitation. Hemodialysis is not an initial
resuscitation intervention in the first hour.
Question 4: A patient is on mechanical ventilation with PEEP set at 15 $cmH_2O$. The patient
suddenly develops hypotension and decreased breath sounds on the right side. What is the most
likely cause and immediate intervention?
A) Pulmonary embolism; administer heparin.
B) Tension pneumothorax; perform needle decompression.
C) Bronchospasm; administer inhaled bronchodilators.
D) Mucus plug; perform endotracheal suctioning.
Correct Answer: B) Tension pneumothorax; perform needle decompression.
Explanation: High PEEP levels increase the risk of barotrauma and pneumothorax. Sudden
hypotension and asymmetric breath sounds indicate tension pneumothorax, a life-threatening
emergency necessitating immediate decompression.
Question 5: Which laboratory finding is most characteristic of disseminated intravascular
coagulation (DIC)?
A) Elevated fibrinogen and high platelet count.
, B) Low D-dimer and normal PT/PTT.
C) Elevated D-dimer, low fibrinogen, and prolonged PT/PTT.
D) Normal platelet count and elevated protein C levels.
Correct Answer: C) Elevated D-dimer, low fibrinogen, and prolonged PT/PTT.
Explanation: DIC involves systemic activation of coagulation followed by consumption of
clotting factors. This results in elevated fibrin degradation products (D-dimer), depletion of
fibrinogen, and prolonged clotting times due to factor consumption.
Question 6: A patient with acute pancreatitis develops severe abdominal pain and a drop in
hematocrit. The AGACNP suspects hemorrhage. Which nursing assessment finding is most
associated with retroperitoneal hemorrhage?
A) Cullen’s sign.
B) Grey Turner’s sign.
C) Kehr’s sign.
D) Murphy’s sign.
Correct Answer: B) Grey Turner’s sign.
Explanation: Grey Turner’s sign (ecchymosis of the flanks) is a classic indicator of
retroperitoneal hemorrhage often seen in severe acute pancreatitis. Cullen’s sign (periumbilical
ecchymosis) is also seen in hemorrhagic pancreatitis, but Grey Turner’s is the hallmark for
retroperitoneal bleed.
Question 7: An AGACNP is managing a patient with hyperosmolar hyperglycemic state (HHS).
Which of the following best differentiates HHS from diabetic ketoacidosis (DKA)?
A) HHS is characterized by significantly higher serum glucose levels and minimal to no ketosis.
B) HHS is characterized by lower serum glucose levels and severe metabolic acidosis.
C) DKA is associated with hyperosmolality, whereas HHS is not.
D) There is no clinical difference in management.
Correct Answer: A) HHS is characterized by significantly higher serum glucose levels and
minimal to no ketosis.
Critical Care & Acute Management Practice Questions &
Detailed Explanations
Subject: Adult-Gerontology Acute Care Nurse Practitioner (AGACNP) –
Hemodynamic Monitoring, Sepsis, and Cardiovascular Emergencies
Question 1: A 68-year-old patient with history of heart failure is admitted with acute respiratory
distress. Hemodynamic monitoring via pulmonary artery catheter reveals a Cardiac Index (CI) of
1.8 $L/min/m^2$, Pulmonary Artery Occlusion Pressure (PAOP) of 24 mmHg, and Systemic
Vascular Resistance (SVR) of 1800 $dynes/sec/cm^{-5}$. Which pharmacological strategy is
indicated?
A) Aggressive fluid resuscitation with 0.9% Normal Saline.
B) Initiation of a dobutamine infusion and cautious diuresis.
C) Immediate administration of a vasoconstrictor like norepinephrine.
D) Bolus administration of intravenous beta-blockers.
Correct Answer: B) Initiation of a dobutamine infusion and cautious diuresis.
Explanation: The patient’s profile (low CI, elevated PAOP, elevated SVR) is consistent with
cardiogenic shock. Dobutamine provides inotropic support to improve cardiac index, while
diuresis (cautiously) addresses the volume overload reflected by the elevated PAOP. Fluid
resuscitation (A) would exacerbate pulmonary congestion, and vasoconstrictors (C) would
increase afterload, worsening cardiac workload.
Question 2: A patient in the ICU develops sudden-onset hypotension, JVD, and muffled heart
sounds. The nurse practitioner suspects cardiac tamponade. Which ECG finding is most
pathognomonic for this condition?
A) ST-segment elevation in all leads.
B) Electrical alternans.
C) Development of a new bundle branch block.
D) Prolonged QT interval.
Correct Answer: B) Electrical alternans.
,Explanation: Electrical alternans—a beat-to-beat variation in QRS amplitude—occurs due to the
heart "swinging" within a fluid-filled pericardial sac. While ST elevation may occur in
pericarditis, electrical alternans is specifically associated with tamponade.
Question 3: During the management of septic shock, the Surviving Sepsis Campaign guidelines
emphasize the "One-Hour Bundle." Which of the following is NOT part of the initial one-hour
resuscitation bundle?
A) Measuring lactate levels.
B) Obtaining blood cultures prior to antibiotic administration.
C) Administering a 30 mL/kg crystalloid bolus for hypotension or lactate ≥ 4 mmol/L.
D) Starting hemodialysis for potential acute kidney injury.
Correct Answer: D) Starting hemodialysis for potential acute kidney injury.
Explanation: The one-hour bundle includes measuring lactate, obtaining blood cultures,
administering broad-spectrum antibiotics, fluid resuscitation (30 mL/kg), and applying
vasopressors if hypotensive during or after fluid resuscitation. Hemodialysis is not an initial
resuscitation intervention in the first hour.
Question 4: A patient is on mechanical ventilation with PEEP set at 15 $cmH_2O$. The patient
suddenly develops hypotension and decreased breath sounds on the right side. What is the most
likely cause and immediate intervention?
A) Pulmonary embolism; administer heparin.
B) Tension pneumothorax; perform needle decompression.
C) Bronchospasm; administer inhaled bronchodilators.
D) Mucus plug; perform endotracheal suctioning.
Correct Answer: B) Tension pneumothorax; perform needle decompression.
Explanation: High PEEP levels increase the risk of barotrauma and pneumothorax. Sudden
hypotension and asymmetric breath sounds indicate tension pneumothorax, a life-threatening
emergency necessitating immediate decompression.
Question 5: Which laboratory finding is most characteristic of disseminated intravascular
coagulation (DIC)?
A) Elevated fibrinogen and high platelet count.
, B) Low D-dimer and normal PT/PTT.
C) Elevated D-dimer, low fibrinogen, and prolonged PT/PTT.
D) Normal platelet count and elevated protein C levels.
Correct Answer: C) Elevated D-dimer, low fibrinogen, and prolonged PT/PTT.
Explanation: DIC involves systemic activation of coagulation followed by consumption of
clotting factors. This results in elevated fibrin degradation products (D-dimer), depletion of
fibrinogen, and prolonged clotting times due to factor consumption.
Question 6: A patient with acute pancreatitis develops severe abdominal pain and a drop in
hematocrit. The AGACNP suspects hemorrhage. Which nursing assessment finding is most
associated with retroperitoneal hemorrhage?
A) Cullen’s sign.
B) Grey Turner’s sign.
C) Kehr’s sign.
D) Murphy’s sign.
Correct Answer: B) Grey Turner’s sign.
Explanation: Grey Turner’s sign (ecchymosis of the flanks) is a classic indicator of
retroperitoneal hemorrhage often seen in severe acute pancreatitis. Cullen’s sign (periumbilical
ecchymosis) is also seen in hemorrhagic pancreatitis, but Grey Turner’s is the hallmark for
retroperitoneal bleed.
Question 7: An AGACNP is managing a patient with hyperosmolar hyperglycemic state (HHS).
Which of the following best differentiates HHS from diabetic ketoacidosis (DKA)?
A) HHS is characterized by significantly higher serum glucose levels and minimal to no ketosis.
B) HHS is characterized by lower serum glucose levels and severe metabolic acidosis.
C) DKA is associated with hyperosmolality, whereas HHS is not.
D) There is no clinical difference in management.
Correct Answer: A) HHS is characterized by significantly higher serum glucose levels and
minimal to no ketosis.
