THE ULTIMATE AGACNP BOARD
EXAM CRAM SESSION: HIGH-YIELD
QUESTIONS WITH RATIONALES A
COMPREHENSIVE, SYSTEM-BASED
REVIEW FOR THE ANCC AND AACN
CERTIFICATION EXAMS
1. A 65-year-old patient with a history of hypertension presents with
sudden onset of severe, "worst headache of my life" and nuchal
rigidity. What is the most appropriate next step?
A. Stat CT head without contrast
B. Lumbar puncture
C. MRI of the brain
D. Administration of IV tPA
Answer: A. Stat CT head without contrast
Rationale: This presentation is classic for subarachnoid hemorrhage. A
non-contrast CT head is the initial diagnostic test of choice due to its high
sensitivity for acute blood in the subarachnoid space. A lumbar puncture is
performed if the CT is negative but clinical suspicion remains high to check
for xanthochromia or red blood cells. MRI is not the initial study, and tPA is
contraindicated in hemorrhagic stroke.
,2. A 72-year-old patient is in the ICU with severe sepsis. Which of the
following is an early goal-directed therapy target for the first 6 hours
of resuscitation?
A. Central venous pressure (CVP) of 4-6 mmHg
B. Mean arterial pressure (MAP) ≥ 65 mmHg
C. Urine output of < 0.5 mL/kg/hr
D. Mixed venous oxygen saturation (SvO2) < 50%
Answer: B. Mean arterial pressure (MAP) ≥ 65 mmHg
Rationale: The Surviving Sepsis Campaign guidelines recommend a MAP
target of ≥ 65 mmHg during initial resuscitation. This is achieved with fluid
resuscitation and vasopressors to ensure adequate organ perfusion. A CVP
target (often 8-12 mmHg) is no longer a strict requirement in all protocols.
Urine output should be > 0.5 mL/kg/hr, and a low SvO2 indicates
inadequate oxygen delivery, not a target.
3. A patient is being treated for acute respiratory distress syndrome
(ARDS) on a ventilator. The plateau pressure is measured at 32 cm
H₂O. What is the most appropriate intervention?
A. Increase the tidal volume
B. Decrease the tidal volume
C. Increase the PEEP
D. Change to Pressure Support Ventilation
Answer: B. Decrease the tidal volume
Rationale: In ARDS, lung-protective ventilation strategies are critical to
prevent ventilator-induced lung injury (barotrauma). A plateau pressure >
30 cm H₂O indicates increased risk . The primary intervention is to decrease
tidal volume (to 6 mL/kg of predicted body weight) to keep plateau
pressures ≤ 30 cm H₂O .
,4. Which of the following ECG findings is most characteristic of
hyperkalemia?
A. Prolonged QT interval
B. Peaked T-waves
C. ST-segment elevation
D. U-waves
Answer: B. Peaked T-waves
Rationale: Peaked, narrow, and symmetrical T-waves are one of the earliest
and most characteristic ECG changes seen in hyperkalemia . As potassium
levels rise further, changes can progress to a widened QRS complex, loss of
P waves, and a sine-wave pattern. Hypokalemia is associated with U-waves,
prolonged QT can be caused by medications or electrolyte disturbances,
and ST elevation is seen in myocardial infarction.
5. A 68-year-old patient is admitted with a diagnosis of alcohol
withdrawal. Which of the following is the cornerstone of
pharmacological management?
A. Haloperidol
B. Lorazepam
C. Thiamine
D. Phenytoin
Answer: B. Lorazepam
Rationale: Benzodiazepines (such as lorazepam, chlordiazepoxide, or
diazepam) are the mainstay of treatment for alcohol withdrawal. They work
by potentiating GABA, thus reducing the autonomic hyperactivity and risk
of seizures and delirium tremens [citation:5, 12]. Haloperidol can be used
for severe agitation but is not the primary treatment. Thiamine is given to
prevent Wernicke's encephalopathy, but benzodiazepines are the
cornerstone for managing withdrawal symptoms.
, 6. A 78-year-old with a history of heart failure and CKD is found to
have a potassium level of 6.8 mEq/L with peaked T-waves on ECG.
Which of the following is the most appropriate immediate
intervention to shift potassium into the cells?
A. IV Calcium gluconate
B. IV Insulin with Dextrose
C. IV Sodium bicarbonate
D. Oral Sodium polystyrene sulfonate (Kayexalate)
Answer: B. IV Insulin with Dextrose
Rationale: In acute hyperkalemia with ECG changes, the priority is to
stabilize the cardiac membrane (with IV calcium) and shift potassium
intracellularly. IV insulin with dextrose is the most rapid and reliable agent
for shifting potassium into cells. Sodium bicarbonate is also used but is less
predictable in patients with renal failure. Kayexalate removes potassium
from the body but works too slowly for acute, life-threatening hyperkalemia
with ECG changes.
7. A patient presents with a one-hour history of sudden, severe right-
sided chest pain and dyspnea. Vitals: HR 115, BP 88/60, RR 28, O2 sat
88% on room air. The patient is obese and was recently immobile after
knee surgery. What is the most likely diagnosis and best immediate
diagnostic test?
A. Myocardial Infarction; EKG and troponin
B. Pulmonary Embolism; CT Pulmonary Angiography
C. Pneumothorax; Chest X-Ray
D. Pericarditis; Echocardiogram
Answer: B. Pulmonary Embolism; CT Pulmonary Angiography
Rationale: This patient has a high risk for pulmonary embolism (obesity,
recent immobility) and presents with the classic triad of pleuritic chest pain,
dyspnea, and hypoxia, with hemodynamic instability (tachycardia,
EXAM CRAM SESSION: HIGH-YIELD
QUESTIONS WITH RATIONALES A
COMPREHENSIVE, SYSTEM-BASED
REVIEW FOR THE ANCC AND AACN
CERTIFICATION EXAMS
1. A 65-year-old patient with a history of hypertension presents with
sudden onset of severe, "worst headache of my life" and nuchal
rigidity. What is the most appropriate next step?
A. Stat CT head without contrast
B. Lumbar puncture
C. MRI of the brain
D. Administration of IV tPA
Answer: A. Stat CT head without contrast
Rationale: This presentation is classic for subarachnoid hemorrhage. A
non-contrast CT head is the initial diagnostic test of choice due to its high
sensitivity for acute blood in the subarachnoid space. A lumbar puncture is
performed if the CT is negative but clinical suspicion remains high to check
for xanthochromia or red blood cells. MRI is not the initial study, and tPA is
contraindicated in hemorrhagic stroke.
,2. A 72-year-old patient is in the ICU with severe sepsis. Which of the
following is an early goal-directed therapy target for the first 6 hours
of resuscitation?
A. Central venous pressure (CVP) of 4-6 mmHg
B. Mean arterial pressure (MAP) ≥ 65 mmHg
C. Urine output of < 0.5 mL/kg/hr
D. Mixed venous oxygen saturation (SvO2) < 50%
Answer: B. Mean arterial pressure (MAP) ≥ 65 mmHg
Rationale: The Surviving Sepsis Campaign guidelines recommend a MAP
target of ≥ 65 mmHg during initial resuscitation. This is achieved with fluid
resuscitation and vasopressors to ensure adequate organ perfusion. A CVP
target (often 8-12 mmHg) is no longer a strict requirement in all protocols.
Urine output should be > 0.5 mL/kg/hr, and a low SvO2 indicates
inadequate oxygen delivery, not a target.
3. A patient is being treated for acute respiratory distress syndrome
(ARDS) on a ventilator. The plateau pressure is measured at 32 cm
H₂O. What is the most appropriate intervention?
A. Increase the tidal volume
B. Decrease the tidal volume
C. Increase the PEEP
D. Change to Pressure Support Ventilation
Answer: B. Decrease the tidal volume
Rationale: In ARDS, lung-protective ventilation strategies are critical to
prevent ventilator-induced lung injury (barotrauma). A plateau pressure >
30 cm H₂O indicates increased risk . The primary intervention is to decrease
tidal volume (to 6 mL/kg of predicted body weight) to keep plateau
pressures ≤ 30 cm H₂O .
,4. Which of the following ECG findings is most characteristic of
hyperkalemia?
A. Prolonged QT interval
B. Peaked T-waves
C. ST-segment elevation
D. U-waves
Answer: B. Peaked T-waves
Rationale: Peaked, narrow, and symmetrical T-waves are one of the earliest
and most characteristic ECG changes seen in hyperkalemia . As potassium
levels rise further, changes can progress to a widened QRS complex, loss of
P waves, and a sine-wave pattern. Hypokalemia is associated with U-waves,
prolonged QT can be caused by medications or electrolyte disturbances,
and ST elevation is seen in myocardial infarction.
5. A 68-year-old patient is admitted with a diagnosis of alcohol
withdrawal. Which of the following is the cornerstone of
pharmacological management?
A. Haloperidol
B. Lorazepam
C. Thiamine
D. Phenytoin
Answer: B. Lorazepam
Rationale: Benzodiazepines (such as lorazepam, chlordiazepoxide, or
diazepam) are the mainstay of treatment for alcohol withdrawal. They work
by potentiating GABA, thus reducing the autonomic hyperactivity and risk
of seizures and delirium tremens [citation:5, 12]. Haloperidol can be used
for severe agitation but is not the primary treatment. Thiamine is given to
prevent Wernicke's encephalopathy, but benzodiazepines are the
cornerstone for managing withdrawal symptoms.
, 6. A 78-year-old with a history of heart failure and CKD is found to
have a potassium level of 6.8 mEq/L with peaked T-waves on ECG.
Which of the following is the most appropriate immediate
intervention to shift potassium into the cells?
A. IV Calcium gluconate
B. IV Insulin with Dextrose
C. IV Sodium bicarbonate
D. Oral Sodium polystyrene sulfonate (Kayexalate)
Answer: B. IV Insulin with Dextrose
Rationale: In acute hyperkalemia with ECG changes, the priority is to
stabilize the cardiac membrane (with IV calcium) and shift potassium
intracellularly. IV insulin with dextrose is the most rapid and reliable agent
for shifting potassium into cells. Sodium bicarbonate is also used but is less
predictable in patients with renal failure. Kayexalate removes potassium
from the body but works too slowly for acute, life-threatening hyperkalemia
with ECG changes.
7. A patient presents with a one-hour history of sudden, severe right-
sided chest pain and dyspnea. Vitals: HR 115, BP 88/60, RR 28, O2 sat
88% on room air. The patient is obese and was recently immobile after
knee surgery. What is the most likely diagnosis and best immediate
diagnostic test?
A. Myocardial Infarction; EKG and troponin
B. Pulmonary Embolism; CT Pulmonary Angiography
C. Pneumothorax; Chest X-Ray
D. Pericarditis; Echocardiogram
Answer: B. Pulmonary Embolism; CT Pulmonary Angiography
Rationale: This patient has a high risk for pulmonary embolism (obesity,
recent immobility) and presents with the classic triad of pleuritic chest pain,
dyspnea, and hypoxia, with hemodynamic instability (tachycardia,
