ANCC AGACNP Frances Guide Review – 200 Practice Questions,
Answers and Detailed Informative Rationales -2026/2027
Update | Acute Care NP Board Exam Preparation
Question 1. A 68-year-old patient with a history of hypertension, diabetes
mellitus, and chronic kidney disease presents with acute dyspnea and
diaphoresis. Blood pressure is 86/54 mm Hg, heart rate is 118/min,
respiratory rate is 30/min, and oxygen saturation is 88% on room air. ECG
demonstrates ST-segment elevation in leads V1–V4. The patient has bilateral
crackles extending to the mid-lung fields. Which intervention should the
AGACNP prioritize?
A. Administer a 1-L normal saline bolus
B. Administer IV furosemide and initiate noninvasive positive-pressure
ventilation
C. Administer sublingual nitroglycerin
D. Administer oral metoprolol
Correct Answer: B. Administer IV furosemide and initiate noninvasive
positive-pressure ventilation
Rationale: The patient has an acute anterior STEMI complicated by
cardiogenic pulmonary edema and hypotension. Immediate management
should focus on improving oxygenation and reducing pulmonary congestion.
Noninvasive positive-pressure ventilation can improve oxygenation and
decrease the work of breathing, while IV loop diuretic therapy may help
reduce volume-related pulmonary congestion. Large-volume fluid
administration can worsen pulmonary edema, while nitrates are
contraindicated in significant hypotension. Beta-blocker therapy should also
be avoided during acute decompensated heart failure with hemodynamic
instability.
Question 2. A 74-year-old patient is admitted with fever, confusion,
hypotension, and suspected bacterial pneumonia. Laboratory results show
lactate 5.1 mmol/L, WBC 19,800/mm³, creatinine 2.4 mg/dL, and blood
pressure 78/46 mm Hg. Blood cultures have been obtained. After receiving an
appropriate crystalloid fluid bolus, the patient's blood pressure remains
82/48 mm Hg. Which medication should the AGACNP initiate first?
pg. 1
,A. Dopamine
B. Norepinephrine
C. Dobutamine
D. Phenylephrine
Correct Answer: B. Norepinephrine
Rationale: Persistent hypotension after adequate fluid resuscitation in septic
shock requires vasopressor therapy. Norepinephrine is the preferred first-line
vasopressor because it primarily produces α1-mediated vasoconstriction with
some β1 activity, improving vascular tone and maintaining organ perfusion.
Dopamine has a greater risk of tachyarrhythmias, dobutamine is primarily an
inotrope for low cardiac output states, and phenylephrine is generally not the
preferred initial vasopressor.
Question 3. A 59-year-old patient develops sudden aphasia and right-sided
weakness while hospitalized. The last-known-well time was 45 minutes ago.
Blood glucose is 102 mg/dL, blood pressure is 174/96 mm Hg, and the patient
is not taking anticoagulants. Which diagnostic study should the AGACNP
obtain immediately?
A. MRI of the brain with contrast
B. Noncontrast CT of the head
C. Carotid ultrasound
D. CT of the cervical spine
Correct Answer: B. Noncontrast CT of the head
Rationale: In a patient with sudden focal neurologic deficits suggestive of
acute ischemic stroke, a noncontrast head CT is obtained urgently to exclude
intracranial hemorrhage before thrombolytic therapy is considered. The study
is rapid and determines whether hemorrhage is present. MRI may provide
additional information but should not delay the initial emergency evaluation
when CT is readily available.
Question 4. A 67-year-old patient with atrial fibrillation suddenly develops
severe abdominal pain that appears disproportionate to the findings on
pg. 2
,physical examination. The abdomen is initially soft with minimal tenderness.
Lactate is 4.8 mmol/L. Which diagnosis should the AGACNP suspect?
A. Acute pancreatitis
B. Acute mesenteric ischemia
C. Small-bowel obstruction
D. Diverticulitis
Correct Answer: B. Acute mesenteric ischemia
Rationale: Severe abdominal pain that is disproportionate to the physical
examination is a classic presentation of acute mesenteric ischemia. Atrial
fibrillation increases the risk of arterial embolization, particularly to the
superior mesenteric artery. An elevated lactate supports the possibility of
tissue hypoperfusion, although a normal lactate does not exclude early
ischemia. Prompt vascular imaging and surgical or vascular consultation are
essential.
Question 5. A 71-year-old patient with COPD is admitted for an acute
exacerbation. Despite supplemental oxygen, the patient remains dyspneic.
ABG results are pH 7.27, PaCO₂ 68 mm Hg, and PaO₂ 58 mm Hg. The patient is
awake, cooperative, and protecting the airway. Which intervention is most
appropriate?
A. Immediate endotracheal intubation
B. Noninvasive positive-pressure ventilation
C. High-dose IV sodium bicarbonate
D. Oxygen therapy alone
Correct Answer: B. Noninvasive positive-pressure ventilation
Rationale: The patient has acute hypercapnic respiratory failure with
respiratory acidosis but remains awake and able to protect the airway.
Noninvasive positive-pressure ventilation, particularly bilevel ventilation, can
improve alveolar ventilation, decrease PaCO₂, reduce work of breathing, and
potentially prevent intubation. Intubation becomes necessary if the patient
deteriorates, cannot protect the airway, develops severe refractory
hypoxemia, or cannot tolerate noninvasive ventilation.
pg. 3
, Question 6. A 63-year-old patient receiving unfractionated heparin for acute
coronary syndrome develops a platelet count decrease from 220,000/mm³ to
92,000/mm³ on day 7 of therapy. The patient also develops a new lower-
extremity DVT. Which action should the AGACNP take?
A. Increase the heparin dose
B. Discontinue heparin and initiate a non-heparin anticoagulant
C. Administer platelet transfusion and continue heparin
D. Switch from unfractionated heparin to low-molecular-weight heparin
Correct Answer: B. Discontinue heparin and initiate a non-heparin
anticoagulant
Rationale: The substantial platelet decline occurring approximately 5–10
days after heparin exposure, combined with a new thrombosis, strongly
suggests heparin-induced thrombocytopenia (HIT). All heparin products
should be discontinued, and an alternative anticoagulant such as argatroban
or another appropriate non-heparin agent should be initiated when clinically
indicated. HIT is a prothrombotic disorder, so simply stopping anticoagulation
is insufficient.
Question 7. A 58-year-old patient with known heart failure presents with
worsening dyspnea, orthopnea, peripheral edema, and a 4-kg weight gain over
5 days. Blood pressure is 148/88 mm Hg. Examination reveals elevated
jugular venous pressure, bilateral crackles, and 3+ lower-extremity edema.
Which finding most strongly indicates that the patient is experiencing acute
decompensated heart failure with volume overload?
A. Elevated jugular venous pressure
B. Heart rate of 82/min
C. Mild fatigue
D. Sodium level of 138 mEq/L
Correct Answer: A. Elevated jugular venous pressure
Rationale: Elevated jugular venous pressure is a clinically important
indicator of increased right-sided filling pressure and systemic venous
pg. 4
Answers and Detailed Informative Rationales -2026/2027
Update | Acute Care NP Board Exam Preparation
Question 1. A 68-year-old patient with a history of hypertension, diabetes
mellitus, and chronic kidney disease presents with acute dyspnea and
diaphoresis. Blood pressure is 86/54 mm Hg, heart rate is 118/min,
respiratory rate is 30/min, and oxygen saturation is 88% on room air. ECG
demonstrates ST-segment elevation in leads V1–V4. The patient has bilateral
crackles extending to the mid-lung fields. Which intervention should the
AGACNP prioritize?
A. Administer a 1-L normal saline bolus
B. Administer IV furosemide and initiate noninvasive positive-pressure
ventilation
C. Administer sublingual nitroglycerin
D. Administer oral metoprolol
Correct Answer: B. Administer IV furosemide and initiate noninvasive
positive-pressure ventilation
Rationale: The patient has an acute anterior STEMI complicated by
cardiogenic pulmonary edema and hypotension. Immediate management
should focus on improving oxygenation and reducing pulmonary congestion.
Noninvasive positive-pressure ventilation can improve oxygenation and
decrease the work of breathing, while IV loop diuretic therapy may help
reduce volume-related pulmonary congestion. Large-volume fluid
administration can worsen pulmonary edema, while nitrates are
contraindicated in significant hypotension. Beta-blocker therapy should also
be avoided during acute decompensated heart failure with hemodynamic
instability.
Question 2. A 74-year-old patient is admitted with fever, confusion,
hypotension, and suspected bacterial pneumonia. Laboratory results show
lactate 5.1 mmol/L, WBC 19,800/mm³, creatinine 2.4 mg/dL, and blood
pressure 78/46 mm Hg. Blood cultures have been obtained. After receiving an
appropriate crystalloid fluid bolus, the patient's blood pressure remains
82/48 mm Hg. Which medication should the AGACNP initiate first?
pg. 1
,A. Dopamine
B. Norepinephrine
C. Dobutamine
D. Phenylephrine
Correct Answer: B. Norepinephrine
Rationale: Persistent hypotension after adequate fluid resuscitation in septic
shock requires vasopressor therapy. Norepinephrine is the preferred first-line
vasopressor because it primarily produces α1-mediated vasoconstriction with
some β1 activity, improving vascular tone and maintaining organ perfusion.
Dopamine has a greater risk of tachyarrhythmias, dobutamine is primarily an
inotrope for low cardiac output states, and phenylephrine is generally not the
preferred initial vasopressor.
Question 3. A 59-year-old patient develops sudden aphasia and right-sided
weakness while hospitalized. The last-known-well time was 45 minutes ago.
Blood glucose is 102 mg/dL, blood pressure is 174/96 mm Hg, and the patient
is not taking anticoagulants. Which diagnostic study should the AGACNP
obtain immediately?
A. MRI of the brain with contrast
B. Noncontrast CT of the head
C. Carotid ultrasound
D. CT of the cervical spine
Correct Answer: B. Noncontrast CT of the head
Rationale: In a patient with sudden focal neurologic deficits suggestive of
acute ischemic stroke, a noncontrast head CT is obtained urgently to exclude
intracranial hemorrhage before thrombolytic therapy is considered. The study
is rapid and determines whether hemorrhage is present. MRI may provide
additional information but should not delay the initial emergency evaluation
when CT is readily available.
Question 4. A 67-year-old patient with atrial fibrillation suddenly develops
severe abdominal pain that appears disproportionate to the findings on
pg. 2
,physical examination. The abdomen is initially soft with minimal tenderness.
Lactate is 4.8 mmol/L. Which diagnosis should the AGACNP suspect?
A. Acute pancreatitis
B. Acute mesenteric ischemia
C. Small-bowel obstruction
D. Diverticulitis
Correct Answer: B. Acute mesenteric ischemia
Rationale: Severe abdominal pain that is disproportionate to the physical
examination is a classic presentation of acute mesenteric ischemia. Atrial
fibrillation increases the risk of arterial embolization, particularly to the
superior mesenteric artery. An elevated lactate supports the possibility of
tissue hypoperfusion, although a normal lactate does not exclude early
ischemia. Prompt vascular imaging and surgical or vascular consultation are
essential.
Question 5. A 71-year-old patient with COPD is admitted for an acute
exacerbation. Despite supplemental oxygen, the patient remains dyspneic.
ABG results are pH 7.27, PaCO₂ 68 mm Hg, and PaO₂ 58 mm Hg. The patient is
awake, cooperative, and protecting the airway. Which intervention is most
appropriate?
A. Immediate endotracheal intubation
B. Noninvasive positive-pressure ventilation
C. High-dose IV sodium bicarbonate
D. Oxygen therapy alone
Correct Answer: B. Noninvasive positive-pressure ventilation
Rationale: The patient has acute hypercapnic respiratory failure with
respiratory acidosis but remains awake and able to protect the airway.
Noninvasive positive-pressure ventilation, particularly bilevel ventilation, can
improve alveolar ventilation, decrease PaCO₂, reduce work of breathing, and
potentially prevent intubation. Intubation becomes necessary if the patient
deteriorates, cannot protect the airway, develops severe refractory
hypoxemia, or cannot tolerate noninvasive ventilation.
pg. 3
, Question 6. A 63-year-old patient receiving unfractionated heparin for acute
coronary syndrome develops a platelet count decrease from 220,000/mm³ to
92,000/mm³ on day 7 of therapy. The patient also develops a new lower-
extremity DVT. Which action should the AGACNP take?
A. Increase the heparin dose
B. Discontinue heparin and initiate a non-heparin anticoagulant
C. Administer platelet transfusion and continue heparin
D. Switch from unfractionated heparin to low-molecular-weight heparin
Correct Answer: B. Discontinue heparin and initiate a non-heparin
anticoagulant
Rationale: The substantial platelet decline occurring approximately 5–10
days after heparin exposure, combined with a new thrombosis, strongly
suggests heparin-induced thrombocytopenia (HIT). All heparin products
should be discontinued, and an alternative anticoagulant such as argatroban
or another appropriate non-heparin agent should be initiated when clinically
indicated. HIT is a prothrombotic disorder, so simply stopping anticoagulation
is insufficient.
Question 7. A 58-year-old patient with known heart failure presents with
worsening dyspnea, orthopnea, peripheral edema, and a 4-kg weight gain over
5 days. Blood pressure is 148/88 mm Hg. Examination reveals elevated
jugular venous pressure, bilateral crackles, and 3+ lower-extremity edema.
Which finding most strongly indicates that the patient is experiencing acute
decompensated heart failure with volume overload?
A. Elevated jugular venous pressure
B. Heart rate of 82/min
C. Mild fatigue
D. Sodium level of 138 mEq/L
Correct Answer: A. Elevated jugular venous pressure
Rationale: Elevated jugular venous pressure is a clinically important
indicator of increased right-sided filling pressure and systemic venous
pg. 4
