VERIFIED QUESTIONS & CORRECT ANSWERS - A+ GRADED - 2026/2027 EDITION
ADULT-GERONTOLOGY ACUTE CARE
NURSE PRACTITIONER CERTIFICATION
(AGACNP-BC®) EXAMINATION
Aligned with the ANCC AGACNP-BC Examination Blueprint, AACN ACNPC-AG Competencies, and
Advanced Practice Nursing Standards (2026/2027 Edition)
150 Questions - Multiple Choice (A-D) - 80% Scenario-Based / 20% Direct Knowledge
Cognitive Levels: 15% Recall - 45% Application - 40% Analysis
Section 1: Clinical Judgment & Diagnostic Reasoning
Questions 1-25 (25 questions)
Q1: Which of the following correctly describes the calculation and normal range of the serum anion gap?
A. Anion gap = Sodium - (Chloride + Bicarbonate); normal range 8-12 mEq/L [CORRECT]
B. Anion gap = Sodium + (Chloride + Bicarbonate); normal range 8-12 mEq/L
C. Anion gap = (Sodium + Chloride) - Bicarbonate; normal range 14-18 mEq/L
D. Anion gap = Chloride - (Sodium + Bicarbonate); normal range 10-16 mEq/L
Correct Answer: A
Rationale: The anion gap is calculated as serum sodium minus the sum of serum chloride and bicarbonate, with a
normal reference range of approximately 8-12 mEq/L. It reflects unmeasured anions such as albumin, phosphate,
and organic acids, and an elevated gap points toward high anion gap metabolic acidosis (methanol, uremia, DKA,
propylene glycol, isoniazid, lactate, ethylene glycol, salicylates). Options B, C, and D reverse or misarrange the
formula components, and their stated ranges are inconsistent with standard reference values. Accurate calculation
and interpretation of the anion gap is a core AGACNP diagnostic reasoning competency in the ANCC test content
outline.
1
,AGACNP-BC Certification Examination - Verified Questions & Correct Answers - 2026/2027 Edition
Q2: A 68-year-old man is admitted with pneumonia and sepsis. ABG on 2 L nasal cannula: pH 7.28,
PaCO2 28 mmHg, HCO3 14 mEq/L, PaO2 68 mmHg; serum lactate is 4.2 mmol/L. Which interpretation
is correct?
A. Primary respiratory alkalosis with metabolic acidosis of renal origin
B. High anion gap metabolic acidosis with appropriate respiratory compensation [CORRECT]
C. Chronic respiratory acidosis with metabolic compensation
D. Normal acid-base status with an elevated lactate of no clinical significance
Correct Answer: B
Rationale: The patient has a high anion gap metabolic acidosis (calculated gap of approximately 18 mEq/L)
driven by lactic acidosis from septic hypoperfusion. Winter's formula predicts an expected PaCO2 of 1.5 x 14 + 8
= 29 +/- 2 mmHg, and the measured PaCO2 of 28 mmHg falls within that range, confirming appropriate
respiratory compensation rather than a second primary disorder. Option A misidentifies the primary process,
option C is unsupported because the pH is acidemic with a low PaCO2, and option D is dangerously wrong
because a lactate of 4.2 mmol/L defines occult hypoperfusion with prognostic weight. Serum lactate measurement
and interpretation are explicit Surviving Sepsis Campaign (2021) hour-1 bundle elements.
Q3: A 72-year-old woman with severe COPD presents with 3 days of worsening dyspnea. ABG on room
air: pH 7.34, PaCO2 62 mmHg, HCO3 34 mEq/L, PaO2 55 mmHg. Which acid-base interpretation
guides the safest oxygen titration strategy?
A. Acute respiratory acidosis; correct hypoxemia aggressively to an SpO2 of 94-98%
B. Metabolic alkalosis with compensatory hypoventilation
C. Mixed metabolic and respiratory acidosis
D. Chronic respiratory acidosis with renal metabolic compensation; titrate oxygen to an SpO2 of
88-92% [CORRECT]
Correct Answer: D
Rationale: The elevated bicarbonate of 34 mEq/L indicates chronic renal compensation, confirming chronic
(acute-on-chronic) respiratory acidosis rather than a purely acute process. In CO2-retaining patients, oxygen
should be titrated to a target saturation of 88-92% because excessive supplemental oxygen can suppress hypoxic
ventilatory drive and worsen hypercapnia. Option A risks CO2 narcosis, option B is wrong because the primary
derangement is ventilatory (elevated PaCO2) rather than metabolic, and option C is incorrect because the pH is
acidemic without a primary metabolic acidosis. This oxygenation target reflects GOLD and British Thoracic
Society guidance for acute COPD exacerbations.
2
,AGACNP-BC Certification Examination - Verified Questions & Correct Answers - 2026/2027 Edition
Q4: A 58-year-old man with ESRD missed two hemodialysis sessions. Serum potassium is 6.9 mEq/L and
the ECG shows tall, peaked T waves with QRS widening. As the AGACNP, what is your FIRST
intervention?
A. IV calcium gluconate [CORRECT]
B. Oral sodium zirconium cyclosilicate
C. IV insulin 10 units with dextrose 50%
D. Nebulized albuterol
Correct Answer: A
Rationale: Peaked T waves with QRS widening signal impending cardiac conduction failure, so immediate
myocardial membrane stabilization with IV calcium gluconate is the first priority; calcium does not lower serum
potassium but protects the myocardium for 30-60 minutes. Insulin with glucose and nebulized albuterol shift
potassium intracellularly over 15-30 minutes but will not reverse established conduction changes fast enough to be
first. Sodium zirconium cyclosilicate eliminates potassium through the gut over hours and is inappropriate as an
emergency measure. After stabilization, definitive removal in anuric ESRD requires urgent dialysis - a
pharmacology and prioritization crossover topic heavily weighted on the ANCC examination.
Q5: An 82-year-old woman is brought from home with new confusion and fatigue. She reports no chest
pain. ECG shows a new left bundle branch block, and troponin returns at 2.1 ng/mL with a confirmed
serial rise. Vital signs are stable. What is the most appropriate interpretation and action?
A. Delirium workup only; troponin elevation reflects assay artifact in the elderly
B. Acute ischemic stroke pathway; the LBBB is a secondary finding
C. Atypical acute coronary syndrome; manage as a non-ST-elevation ACS with early cardiology
consultation [CORRECT]
D. Stable angina; obtain an outpatient stress test within two weeks
Correct Answer: C
Rationale: Elderly patients, women, and patients with diabetes frequently present with atypical acute coronary
syndrome symptoms such as confusion, fatigue, dyspnea, or syncope instead of chest pain. A new left bundle
branch block with a rising troponin is diagnostic of acute myocardial injury and warrants management as a
non-ST-elevation acute coronary syndrome with early cardiology involvement. Option A incorrectly dismisses a
rising troponin, option B misattributes the presentation to stroke without neurologic localization, and option D is
unsafe because rising biomarkers define an acute event rather than stable disease. Recognition of atypical geriatric
presentations is a named ANCC blueprint content area and an AACN ACNPC-AG gerontologic competency.
3
, AGACNP-BC Certification Examination - Verified Questions & Correct Answers - 2026/2027 Edition
Q6: A 24-year-old man with type 1 diabetes presents with 2 days of polyuria, vomiting, and Kussmaul
respirations. Glucose is 540 mg/dL, pH 7.12, PaCO2 21 mmHg, HCO3 8 mEq/L, anion gap 26 mEq/L,
serum ketones positive. Which statement is correct?
A. A primary respiratory acidosis is present because the PaCO2 is below 30 mmHg
B. The low PaCO2 represents appropriate respiratory compensation for the metabolic acidosis
[CORRECT]
C. The anion gap is normal, indicating a hyperchloremic metabolic acidosis
D. IV bicarbonate is indicated immediately because the pH is below 7.2
Correct Answer: B
Rationale: Winter's formula predicts an expected PaCO2 of 1.5 x 8 + 8 = 20 +/- 2 mmHg, and the measured
PaCO2 of 21 mmHg confirms appropriate compensatory hyperventilation (Kussmaul respirations) rather than a
primary respiratory disorder. The anion gap of 26 mEq/L is frankly elevated, consistent with ketoacidosis, so
option C is incorrect. IV bicarbonate is not recommended by ADA guidance unless the pH falls below 6.9, so
option D is wrong despite the significant acidemia. DKA interpretation and staged management (fluids, then
insulin, then potassium) are ANCC endocrine blueprint staples.
Q7: Which single laboratory index most reliably distinguishes prerenal acute kidney injury from acute
tubular necrosis?
A. Serum blood urea nitrogen concentration
B. Urine specific gravity
C. Serum creatinine concentration
D. Fractional excretion of sodium (FENa) [CORRECT]
Correct Answer: D
Rationale: A FENa below 1% indicates avid tubular sodium reabsorption typical of prerenal azotemia, whereas a
FENa above 2% reflects tubular damage with impaired reabsorption in acute tubular necrosis. BUN and creatinine
rise in both conditions, so neither independently discriminates them, and the BUN-to-creatinine ratio is suggestive
but less reliable than FENa. Urine specific gravity can support prerenal physiology (concentrated urine) but is
confounded by diuretics and contrast administration. FENa interpretation - with the caveat that diuretics raise it,
favoring a fractional excretion of urea in that setting - is standard AGACNP diagnostic content aligned with
KDIGO 2012 AKI concepts.
4
ADULT-GERONTOLOGY ACUTE CARE
NURSE PRACTITIONER CERTIFICATION
(AGACNP-BC®) EXAMINATION
Aligned with the ANCC AGACNP-BC Examination Blueprint, AACN ACNPC-AG Competencies, and
Advanced Practice Nursing Standards (2026/2027 Edition)
150 Questions - Multiple Choice (A-D) - 80% Scenario-Based / 20% Direct Knowledge
Cognitive Levels: 15% Recall - 45% Application - 40% Analysis
Section 1: Clinical Judgment & Diagnostic Reasoning
Questions 1-25 (25 questions)
Q1: Which of the following correctly describes the calculation and normal range of the serum anion gap?
A. Anion gap = Sodium - (Chloride + Bicarbonate); normal range 8-12 mEq/L [CORRECT]
B. Anion gap = Sodium + (Chloride + Bicarbonate); normal range 8-12 mEq/L
C. Anion gap = (Sodium + Chloride) - Bicarbonate; normal range 14-18 mEq/L
D. Anion gap = Chloride - (Sodium + Bicarbonate); normal range 10-16 mEq/L
Correct Answer: A
Rationale: The anion gap is calculated as serum sodium minus the sum of serum chloride and bicarbonate, with a
normal reference range of approximately 8-12 mEq/L. It reflects unmeasured anions such as albumin, phosphate,
and organic acids, and an elevated gap points toward high anion gap metabolic acidosis (methanol, uremia, DKA,
propylene glycol, isoniazid, lactate, ethylene glycol, salicylates). Options B, C, and D reverse or misarrange the
formula components, and their stated ranges are inconsistent with standard reference values. Accurate calculation
and interpretation of the anion gap is a core AGACNP diagnostic reasoning competency in the ANCC test content
outline.
1
,AGACNP-BC Certification Examination - Verified Questions & Correct Answers - 2026/2027 Edition
Q2: A 68-year-old man is admitted with pneumonia and sepsis. ABG on 2 L nasal cannula: pH 7.28,
PaCO2 28 mmHg, HCO3 14 mEq/L, PaO2 68 mmHg; serum lactate is 4.2 mmol/L. Which interpretation
is correct?
A. Primary respiratory alkalosis with metabolic acidosis of renal origin
B. High anion gap metabolic acidosis with appropriate respiratory compensation [CORRECT]
C. Chronic respiratory acidosis with metabolic compensation
D. Normal acid-base status with an elevated lactate of no clinical significance
Correct Answer: B
Rationale: The patient has a high anion gap metabolic acidosis (calculated gap of approximately 18 mEq/L)
driven by lactic acidosis from septic hypoperfusion. Winter's formula predicts an expected PaCO2 of 1.5 x 14 + 8
= 29 +/- 2 mmHg, and the measured PaCO2 of 28 mmHg falls within that range, confirming appropriate
respiratory compensation rather than a second primary disorder. Option A misidentifies the primary process,
option C is unsupported because the pH is acidemic with a low PaCO2, and option D is dangerously wrong
because a lactate of 4.2 mmol/L defines occult hypoperfusion with prognostic weight. Serum lactate measurement
and interpretation are explicit Surviving Sepsis Campaign (2021) hour-1 bundle elements.
Q3: A 72-year-old woman with severe COPD presents with 3 days of worsening dyspnea. ABG on room
air: pH 7.34, PaCO2 62 mmHg, HCO3 34 mEq/L, PaO2 55 mmHg. Which acid-base interpretation
guides the safest oxygen titration strategy?
A. Acute respiratory acidosis; correct hypoxemia aggressively to an SpO2 of 94-98%
B. Metabolic alkalosis with compensatory hypoventilation
C. Mixed metabolic and respiratory acidosis
D. Chronic respiratory acidosis with renal metabolic compensation; titrate oxygen to an SpO2 of
88-92% [CORRECT]
Correct Answer: D
Rationale: The elevated bicarbonate of 34 mEq/L indicates chronic renal compensation, confirming chronic
(acute-on-chronic) respiratory acidosis rather than a purely acute process. In CO2-retaining patients, oxygen
should be titrated to a target saturation of 88-92% because excessive supplemental oxygen can suppress hypoxic
ventilatory drive and worsen hypercapnia. Option A risks CO2 narcosis, option B is wrong because the primary
derangement is ventilatory (elevated PaCO2) rather than metabolic, and option C is incorrect because the pH is
acidemic without a primary metabolic acidosis. This oxygenation target reflects GOLD and British Thoracic
Society guidance for acute COPD exacerbations.
2
,AGACNP-BC Certification Examination - Verified Questions & Correct Answers - 2026/2027 Edition
Q4: A 58-year-old man with ESRD missed two hemodialysis sessions. Serum potassium is 6.9 mEq/L and
the ECG shows tall, peaked T waves with QRS widening. As the AGACNP, what is your FIRST
intervention?
A. IV calcium gluconate [CORRECT]
B. Oral sodium zirconium cyclosilicate
C. IV insulin 10 units with dextrose 50%
D. Nebulized albuterol
Correct Answer: A
Rationale: Peaked T waves with QRS widening signal impending cardiac conduction failure, so immediate
myocardial membrane stabilization with IV calcium gluconate is the first priority; calcium does not lower serum
potassium but protects the myocardium for 30-60 minutes. Insulin with glucose and nebulized albuterol shift
potassium intracellularly over 15-30 minutes but will not reverse established conduction changes fast enough to be
first. Sodium zirconium cyclosilicate eliminates potassium through the gut over hours and is inappropriate as an
emergency measure. After stabilization, definitive removal in anuric ESRD requires urgent dialysis - a
pharmacology and prioritization crossover topic heavily weighted on the ANCC examination.
Q5: An 82-year-old woman is brought from home with new confusion and fatigue. She reports no chest
pain. ECG shows a new left bundle branch block, and troponin returns at 2.1 ng/mL with a confirmed
serial rise. Vital signs are stable. What is the most appropriate interpretation and action?
A. Delirium workup only; troponin elevation reflects assay artifact in the elderly
B. Acute ischemic stroke pathway; the LBBB is a secondary finding
C. Atypical acute coronary syndrome; manage as a non-ST-elevation ACS with early cardiology
consultation [CORRECT]
D. Stable angina; obtain an outpatient stress test within two weeks
Correct Answer: C
Rationale: Elderly patients, women, and patients with diabetes frequently present with atypical acute coronary
syndrome symptoms such as confusion, fatigue, dyspnea, or syncope instead of chest pain. A new left bundle
branch block with a rising troponin is diagnostic of acute myocardial injury and warrants management as a
non-ST-elevation acute coronary syndrome with early cardiology involvement. Option A incorrectly dismisses a
rising troponin, option B misattributes the presentation to stroke without neurologic localization, and option D is
unsafe because rising biomarkers define an acute event rather than stable disease. Recognition of atypical geriatric
presentations is a named ANCC blueprint content area and an AACN ACNPC-AG gerontologic competency.
3
, AGACNP-BC Certification Examination - Verified Questions & Correct Answers - 2026/2027 Edition
Q6: A 24-year-old man with type 1 diabetes presents with 2 days of polyuria, vomiting, and Kussmaul
respirations. Glucose is 540 mg/dL, pH 7.12, PaCO2 21 mmHg, HCO3 8 mEq/L, anion gap 26 mEq/L,
serum ketones positive. Which statement is correct?
A. A primary respiratory acidosis is present because the PaCO2 is below 30 mmHg
B. The low PaCO2 represents appropriate respiratory compensation for the metabolic acidosis
[CORRECT]
C. The anion gap is normal, indicating a hyperchloremic metabolic acidosis
D. IV bicarbonate is indicated immediately because the pH is below 7.2
Correct Answer: B
Rationale: Winter's formula predicts an expected PaCO2 of 1.5 x 8 + 8 = 20 +/- 2 mmHg, and the measured
PaCO2 of 21 mmHg confirms appropriate compensatory hyperventilation (Kussmaul respirations) rather than a
primary respiratory disorder. The anion gap of 26 mEq/L is frankly elevated, consistent with ketoacidosis, so
option C is incorrect. IV bicarbonate is not recommended by ADA guidance unless the pH falls below 6.9, so
option D is wrong despite the significant acidemia. DKA interpretation and staged management (fluids, then
insulin, then potassium) are ANCC endocrine blueprint staples.
Q7: Which single laboratory index most reliably distinguishes prerenal acute kidney injury from acute
tubular necrosis?
A. Serum blood urea nitrogen concentration
B. Urine specific gravity
C. Serum creatinine concentration
D. Fractional excretion of sodium (FENa) [CORRECT]
Correct Answer: D
Rationale: A FENa below 1% indicates avid tubular sodium reabsorption typical of prerenal azotemia, whereas a
FENa above 2% reflects tubular damage with impaired reabsorption in acute tubular necrosis. BUN and creatinine
rise in both conditions, so neither independently discriminates them, and the BUN-to-creatinine ratio is suggestive
but less reliable than FENa. Urine specific gravity can support prerenal physiology (concentrated urine) but is
confounded by diuretics and contrast administration. FENa interpretation - with the caveat that diuretics raise it,
favoring a fractional excretion of urea in that setting - is standard AGACNP diagnostic content aligned with
KDIGO 2012 AKI concepts.
4
