2026 ANCC AGACNP Frances Guide Review – 400+
Practice Questions & Answers for Adult-Gerontology
Acute Care NP Board Exam
1. Clinical Practice & Core Competencies
1. A 72-year-old patient with a history of heart failure with reduced
ejection fraction (HFrEF) presents with acute respiratory distress. BP is
160/95 mmHg, HR 110 bpm, and SpO₂ 88% on 4L nasal cannula.
Jugular venous pressure is 12 cm H₂O, and crackles are heard
throughout the lung fields. Which of the following is the most
appropriate initial intervention?
A) Administer a fluid bolus of 500 mL normal saline.
B) Start a Dobutamine infusion to improve cardiac output.
C) Initiate BiPAP (non-invasive positive pressure ventilation) and
IV nitroglycerin.
D) Prepare for immediate endotracheal intubation.
CORRECT ANSWER. C) Initiate BiPAP (non-invasive positive
pressure ventilation) and IV nitroglycerin
Rationale: This patient is in acute decompensated heart failure with
respiratory failure and volume overload. BiPAP improves oxygenation
and reduces preload. IV nitroglycerin reduces preload and afterload,
improving hemodynamics. Fluid bolus would worsen volume overload.
Intubation should be considered if BiPAP fails.
,2.A 65-year-old patient presents with a Glasgow Coma Scale (GCS)
score of 11 (E3 V3 M5) after a mechanical fall. A non-contrast head CT
shows a 5 mm right-sided subdural hematoma. The patient takes
warfarin for atrial fibrillation. What is the most appropriate next step?
A) Observe in the emergency department for 6 hours.
B) Reverse warfarin with vitamin K only.
C) Administer 4-factor prothrombin complex concentrate (PCC)
and vitamin K.
D) Administer fresh frozen plasma (FFP) and vitamin K.
Answer: C) Administer 4-factor PCC and vitamin K.
Rationale: This patient has an acute subdural hematoma with GCS <13
and is taking warfarin, requiring urgent anticoagulation reversal. 4-factor
PCC is preferred over FFP because it provides rapid reversal. Vitamin K
should also be given to sustain the reversal. Observation without
reversing anticoagulation risks hematoma expansion.
3.A 55-year-old patient with septic shock is started on norepinephrine
and vasopressin. Which assessment finding is most concerning for
vasopressin therapy?
A) Heart rate of 110 bpm.
B) Mean arterial pressure (MAP) of 65 mmHg.
C) Development of cool, mottled extremities and abdominal pain.
D) Urine output of 30 mL/hr.
Answer: C) Development of cool, mottled extremities and abdominal
pain.
,Rationale: Vasopressin is a potent vasoconstrictor. While it is used for
septic shock, high doses or prolonged use can cause splanchnic and
peripheral ischemia. Cool, mottled extremities and abdominal pain could
indicate mesenteric ischemia, a serious complication requiring dose
reduction or discontinuation.
4.A 68-year-old patient with a history of COPD presents with worsening
dyspnea and a productive cough. ABG results on room air show: pH
7.30, PaCO₂ 58 mmHg, PaO₂ 55 mmHg, HCO₃ 30 mEq/L. What is the
most appropriate initial intervention?
A) Administer 100% oxygen via non-rebreather mask.
B) Initiate BiPAP.
C) Administer IV corticosteroids and nebulized bronchodilators.
D) Prepare for immediate intubation.
Answer: B) Initiate BiPAP.
Rationale: This patient is in acute hypercapnic respiratory failure.
BiPAP is the first-line therapy to support ventilation and reduce the
work of breathing. High-flow oxygen may suppress respiratory drive.
Corticosteroids and bronchodilators are important but do not address the
acute ventilatory failure.
5.A patient has a potassium level of 6.8 mEq/L with peaked T-waves on
ECG. Which of the following treatments for hyperkalemia works by
shifting potassium into the cells?
A) Calcium gluconate.
B) Insulin and dextrose.
C) Kayexalate (sodium polystyrene sulfonate).
D) Hemodialysis.
, Answer: B) Insulin and dextrose.
Rationale: Insulin increases Na⁺/K⁺-ATPase activity, shifting potassium
from the extracellular space into cells and producing a rapid but
temporary reduction in serum potassium. Calcium gluconate stabilizes
the cardiac membrane but does not lower serum potassium. Kayexalate
removes potassium through the GI tract, while hemodialysis removes
potassium from the blood.
Important clinical point: Because the patient has K⁺ 6.8 mEq/L plus
ECG changes, IV calcium is also indicated immediately for cardiac
membrane stabilization, followed by potassium-shifting and potassium-
removal therapies. The question specifically asks which treatment shifts
potassium into cells, making B correct.
6.A 62-year-old patient is 3 days post-hip repair surgery and suddenly
develops pleuritic chest pain and shortness of breath. HR 115, BP
145/90, SpO₂ 90%. What is the most appropriate next diagnostic step?
A) Chest X-ray.
B) 12-lead ECG.
C) CT pulmonary angiography (CTPA).
D) D-dimer.
Answer: C) CT pulmonary angiography (CTPA).
Rationale: This is a high-risk scenario for pulmonary embolism (PE).
In a hemodynamically stable patient with significant clinical suspicion,
CTPA is the preferred diagnostic imaging study. D-dimer is less useful
after surgery because postoperative elevations can produce false-positive
results.
Practice Questions & Answers for Adult-Gerontology
Acute Care NP Board Exam
1. Clinical Practice & Core Competencies
1. A 72-year-old patient with a history of heart failure with reduced
ejection fraction (HFrEF) presents with acute respiratory distress. BP is
160/95 mmHg, HR 110 bpm, and SpO₂ 88% on 4L nasal cannula.
Jugular venous pressure is 12 cm H₂O, and crackles are heard
throughout the lung fields. Which of the following is the most
appropriate initial intervention?
A) Administer a fluid bolus of 500 mL normal saline.
B) Start a Dobutamine infusion to improve cardiac output.
C) Initiate BiPAP (non-invasive positive pressure ventilation) and
IV nitroglycerin.
D) Prepare for immediate endotracheal intubation.
CORRECT ANSWER. C) Initiate BiPAP (non-invasive positive
pressure ventilation) and IV nitroglycerin
Rationale: This patient is in acute decompensated heart failure with
respiratory failure and volume overload. BiPAP improves oxygenation
and reduces preload. IV nitroglycerin reduces preload and afterload,
improving hemodynamics. Fluid bolus would worsen volume overload.
Intubation should be considered if BiPAP fails.
,2.A 65-year-old patient presents with a Glasgow Coma Scale (GCS)
score of 11 (E3 V3 M5) after a mechanical fall. A non-contrast head CT
shows a 5 mm right-sided subdural hematoma. The patient takes
warfarin for atrial fibrillation. What is the most appropriate next step?
A) Observe in the emergency department for 6 hours.
B) Reverse warfarin with vitamin K only.
C) Administer 4-factor prothrombin complex concentrate (PCC)
and vitamin K.
D) Administer fresh frozen plasma (FFP) and vitamin K.
Answer: C) Administer 4-factor PCC and vitamin K.
Rationale: This patient has an acute subdural hematoma with GCS <13
and is taking warfarin, requiring urgent anticoagulation reversal. 4-factor
PCC is preferred over FFP because it provides rapid reversal. Vitamin K
should also be given to sustain the reversal. Observation without
reversing anticoagulation risks hematoma expansion.
3.A 55-year-old patient with septic shock is started on norepinephrine
and vasopressin. Which assessment finding is most concerning for
vasopressin therapy?
A) Heart rate of 110 bpm.
B) Mean arterial pressure (MAP) of 65 mmHg.
C) Development of cool, mottled extremities and abdominal pain.
D) Urine output of 30 mL/hr.
Answer: C) Development of cool, mottled extremities and abdominal
pain.
,Rationale: Vasopressin is a potent vasoconstrictor. While it is used for
septic shock, high doses or prolonged use can cause splanchnic and
peripheral ischemia. Cool, mottled extremities and abdominal pain could
indicate mesenteric ischemia, a serious complication requiring dose
reduction or discontinuation.
4.A 68-year-old patient with a history of COPD presents with worsening
dyspnea and a productive cough. ABG results on room air show: pH
7.30, PaCO₂ 58 mmHg, PaO₂ 55 mmHg, HCO₃ 30 mEq/L. What is the
most appropriate initial intervention?
A) Administer 100% oxygen via non-rebreather mask.
B) Initiate BiPAP.
C) Administer IV corticosteroids and nebulized bronchodilators.
D) Prepare for immediate intubation.
Answer: B) Initiate BiPAP.
Rationale: This patient is in acute hypercapnic respiratory failure.
BiPAP is the first-line therapy to support ventilation and reduce the
work of breathing. High-flow oxygen may suppress respiratory drive.
Corticosteroids and bronchodilators are important but do not address the
acute ventilatory failure.
5.A patient has a potassium level of 6.8 mEq/L with peaked T-waves on
ECG. Which of the following treatments for hyperkalemia works by
shifting potassium into the cells?
A) Calcium gluconate.
B) Insulin and dextrose.
C) Kayexalate (sodium polystyrene sulfonate).
D) Hemodialysis.
, Answer: B) Insulin and dextrose.
Rationale: Insulin increases Na⁺/K⁺-ATPase activity, shifting potassium
from the extracellular space into cells and producing a rapid but
temporary reduction in serum potassium. Calcium gluconate stabilizes
the cardiac membrane but does not lower serum potassium. Kayexalate
removes potassium through the GI tract, while hemodialysis removes
potassium from the blood.
Important clinical point: Because the patient has K⁺ 6.8 mEq/L plus
ECG changes, IV calcium is also indicated immediately for cardiac
membrane stabilization, followed by potassium-shifting and potassium-
removal therapies. The question specifically asks which treatment shifts
potassium into cells, making B correct.
6.A 62-year-old patient is 3 days post-hip repair surgery and suddenly
develops pleuritic chest pain and shortness of breath. HR 115, BP
145/90, SpO₂ 90%. What is the most appropriate next diagnostic step?
A) Chest X-ray.
B) 12-lead ECG.
C) CT pulmonary angiography (CTPA).
D) D-dimer.
Answer: C) CT pulmonary angiography (CTPA).
Rationale: This is a high-risk scenario for pulmonary embolism (PE).
In a hemodynamically stable patient with significant clinical suspicion,
CTPA is the preferred diagnostic imaging study. D-dimer is less useful
after surgery because postoperative elevations can produce false-positive
results.
