Free AGACNP Practice Test: 40 Questions

Answer: B. Perform synchronized cardioversion

He's hemodynamically unstable—hypotension plus new confusion—and the abrupt jump from 88 to 186 with a regular, narrow QRS makes the rhythm the likely cause of his instability. The earlier hemoglobin does not rule out a new bleed or another contributor. For unstable narrow-complex tachycardia, the 2025 AHA guideline gives synchronized cardioversion a Class 1 recommendation. If time and his condition allow, procedural sedation may be appropriate first.

Why not the others

• A. Adenosine can terminate regular narrow-complex tachycardia and may be considered while preparing treatment, but it must not delay prompt synchronized cardioversion for this severe instability.
• C. Diltiazem can convert a stable, regular narrow-complex tachycardia, but hypotension is a common side effect. At 76/48, that's the wrong direction.
• D. Unsynchronized shocks are for pulseless VT/VF and polymorphic VT. Synchronizing to the QRS avoids delivering the shock during the vulnerable T wave.

Takeaway: Decide stable or unstable first, then ask whether the rhythm is causing it. In this unstable narrow-complex tachycardia, prioritize synchronized cardioversion.

Sources: AHA 2025 Guidelines, Part 9: Adult Advanced Life Support, Regular Narrow-Complex Tachycardia, recommendations 1–3 and 5, and synopsis; Polymorphic VT supportive text; AHA 2025 Adult Tachyarrhythmia With a Pulse Algorithm, p. 1: tachyarrhythmia-caused instability and synchronized cardioversion branch.

Answer: C. Use a qualified medical interpreter from the hospital's phone or video service

Under the federal Section 1557 rule, a covered health program must offer a qualified interpreter when interpretation is needed—free, accurate, timely, and in a way that protects the patient's privacy and independent decision-making. A remote interpreter qualifies when the connection meets the rule's quality standards.

Why not the others

• A. The rule restricts relying on an accompanying adult who is not a qualified interpreter, with limited exceptions. This is not an emergency, and the patient has not requested her son under the rule's private, documented request process.
• B. Staff who aren't qualified interpreters or qualified bilingual staff can't be relied on to communicate with a patient with limited English proficiency.
• D. This repeats the same prohibited shortcut and adds weak evidence of consent. A nod through an unqualified interpreter doesn't show she understood the procedure.

Takeaway: Fluency alone doesn't establish interpreter qualifications. Use qualified language assistance here; the patient's choice, privacy, and independent decision-making matter.

Source: 45 CFR 92.201, Meaningful access for individuals with limited English proficiency (eCFR), § 92.201(b), (c)(1), (e)(2), (e)(4), (f), (h).

Answer: D. Give IV potassium and hold insulin until potassium is above 3.5 mmol/L

Insulin drives potassium into cells. Starting it with a potassium of 3.0 can push the level lower and trigger arrhythmias. The 2024 consensus says that when potassium is below 3.5 mmol/L at presentation, replacement starts first and insulin waits until potassium is above 3.5.

Why not the others

• A. Right drug, wrong moment. Insulin waits for potassium.
• B. The consensus doesn't recommend routine bicarbonate; it's considered only in severe acidosis with a pH below 7.0. Hers is 7.18.
• C. The 2024 report allows subcutaneous rapid-acting insulin for uncomplicated mild or moderate DKA, but any insulin still has to wait for potassium.

Version note: This question uses the 2024 consensus threshold: delay insulin when potassium is below 3.5 mmol/L until it rises above 3.5.

Takeaway: In DKA, check potassium before insulin. Below 3.5, potassium comes first.

Source: Hyperglycaemic crises in adults with diabetes: a consensus report (2024), Section 4, Potassium, Bicarbonate, and Insulin.

Answer: A. 420 mL

The 2026 Surviving Sepsis Campaign guideline strongly recommends a low tidal volume of 6 mL/kg over more than 10 mL/kg in sepsis-associated ARDS, with an upper plateau pressure goal of 30 cm H2O. Tidal volume is based on predicted body weight, not actual weight: 6 × 70 kg = 420 mL.

Why not the others

• B. That's 6 mL/kg of actual weight (6 × 96 = 576). It delivers about 37% more volume than intended.
• C. That's 10 mL/kg of predicted weight, above the recommended initial target of 6 mL/kg. It is not the initial lung-protective setting asked for here.
• D. That's 10 mL/kg of actual weight.

Takeaway: Set tidal volume from predicted body weight, then check the plateau pressure.

Sources: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Mechanical ventilation: low tidal volume and plateau-pressure recommendations; ATS/ESICM/SCCM: Mechanical Ventilation in Adult Patients with ARDS (2017), Low Tidal Volume Ventilation; implementation considerations, printed p. 1256.

Answer: B. Stop heparin and start an argatroban infusion at therapeutic intensity

ASH recommends the 4Ts score over clinical gestalt, and hers is high: a platelet fall of more than 50% (88 is 36% of 245), a drop that began on day 6 of heparin, a new thrombosis, and no other cause. For high-probability HIT, ASH recommends stopping heparin and starting a non-heparin anticoagulant at therapeutic intensity without waiting for the lab result. Argatroban, bivalirudin, fondaparinux, or a DOAC are options; argatroban is cleared by the liver, so her normal liver function matters.

Why not the others

• A. HIT is a profoundly hypercoagulable state. Waiting leaves it untreated.
• C. ASH recommends against starting a vitamin K antagonist until the platelet count recovers to at least 150,000/mm³; early warfarin has been linked to venous limb gangrene and skin necrosis.
• D. ASH suggests against routine platelet transfusion in HIT for patients at average bleeding risk.

Takeaway: In HIT, thrombocytopenia does not protect against thrombosis. Treat the clotting risk while assessing bleeding risk.

Source: ASH: Diagnosis and Management of Heparin-Induced Thrombocytopenia — pocket guide, PDF pp. 2–4: 4Ts table, high-probability algorithm, anticoagulant selection, VKA timing, and platelet transfusion.

Answer: D. Decide whether to start antibiotics by clinical evaluation; when the right duration is unclear after adequate source control, use procalcitonin plus clinical evaluation to decide when to stop

The guideline suggests clinical evaluation alone, rather than adding procalcitonin, to decide whether to start antimicrobials. For stopping, it flips: when a patient has adequate source control and the best duration is unclear, it suggests procalcitonin and clinical evaluation together. Both are conditional recommendations, and the guideline adds that sepsis shouldn't be ruled in or out with a single biomarker.

Why not the others

• A. It uses procalcitonin where the guideline suggests against it (starting) and drops it where the guideline suggests it helps (stopping).
• B. No single biomarker rules sepsis in or out, and the stopping recommendation pairs procalcitonin with clinical evaluation.
• C. That discards the one use the guideline supports: helping decide when to discontinue therapy.

Takeaway: Use clinical evaluation to decide whether to start antibiotics. After adequate source control, procalcitonin can help alongside clinical evaluation when the stopping point is unclear.

Source: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Antibiotic initiation and antimicrobial therapy recommendations; biomarker good practice statement.

Answer: C. 2.5 mg twice daily

For nonvalvular atrial fibrillation, the label lowers the dose to 2.5 mg twice daily when a patient has at least two of three characteristics: age 80 or older, weight 60 kg or less, or serum creatinine 1.5 mg/dL or higher. She meets two (age 82, weight 58 kg). Her creatinine doesn't need to qualify.

Why not the others

• A. That's the usual atrial fibrillation dose for patients with fewer than two of the three characteristics.
• B. That's the regimen for treating DVT or PE, not stroke prevention in atrial fibrillation.
• D. The label's atrial fibrillation doses are both twice daily; once daily isn't one of them.

Takeaway: For atrial fibrillation, count the three criteria. Any two lower the dose.

Source: Apixaban U.S. prescribing information, revised August 2026, Sections 2.1 and 7: NVAF dose criteria; indication-specific dosing.

Answer: A. Add vasopressin

The 2026 Surviving Sepsis Campaign guideline suggests adding vasopressin for adults with septic shock on escalating doses of norepinephrine. His MAP is below the recommended initial target of 65 mm Hg, and norepinephrine alone isn't getting him there.

Why not the others

• B. The guideline strongly recommends norepinephrine over dopamine as the first-line agent. Switching moves backward.
• C. Inotropes are suggested for septic shock with cardiac dysfunction and persistent hypoperfusion. His echo shows normal function.
• D. The guideline found insufficient evidence to recommend it as rescue therapy.

Version note: For patients 65 and older, the 2026 guideline suggests an initial MAP range of 60 to 65 mm Hg. At 54, his recommended initial target is 65 mm Hg.

Takeaway: Rising norepinephrine? Add vasopressin—don't swap to dopamine.

Source: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Vasopressor, inotrope, and mean arterial pressure recommendations.

Answer: D. Look for other causes of his delirium and observe him closely instead of treating the bacteriuria

IDSA's 2019 guideline makes a strong recommendation for this exact situation: an older patient with cognitive or functional impairment, bacteriuria, and delirium—but no urinary symptoms and no systemic signs such as fever or hemodynamic instability—should be assessed for other causes and observed carefully rather than treated with antibiotics. The same recommendation covers bacteriuria found after a fall.

Why not the others

• A. That treats a lab result, not a syndrome. The guideline recommends against it here.
• B. A second positive culture wouldn't change the plan. Bacteriuria alone doesn't explain his delirium.
• C. Adding a bladder scan doesn't make antibiotics appropriate. The workup should look for the real cause of his delirium.

Takeaway: Delirium plus bacteriuria, with no urinary or systemic signs, calls for a search for the real cause—not antibiotics.

Source: IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria, Section V, recommendations 1–2 and remarks: older cognitively impaired patients with bacteriuria and no local/systemic infection signs.

Answer: B. Write a time-limited order that can be renewed for up to 4 hours at a time, and make sure he's seen face-to-face within 1 hour

Federal rules say restraint orders must never be written as standing or as-needed (PRN) orders. For violent or self-destructive behavior, each order for an adult can be renewed in increments of up to 4 hours, for up to 24 hours total; after that, a physician or other licensed practitioner must see and assess the patient before writing a new order. The patient must also be seen face-to-face within 1 hour of starting restraints by a physician, other licensed practitioner, or appropriately trained RN. When an RN performs that evaluation, the attending physician or other responsible licensed practitioner must be consulted as soon as possible. Restraints must end at the earliest possible time, even before the order expires.

Why not the others

• A. PRN restraint orders are prohibited outright.
• C. The 24-hour mark is a ceiling on renewals, not the length of a single order, and it ends with an in-person assessment.
• D. Restraint must follow an order from the physician or other licensed practitioner responsible for the patient's care, as hospital policy and state law allow.

Takeaway: No PRN restraints. For adult violent or self-destructive behavior: up to 4 hours per order and a face-to-face evaluation within 1 hour. Stop restraints as soon as possible; a time limit is not a required duration. States can be stricter.

Source: 42 CFR 482.13, Condition of participation: Patient's rights (eCFR), 42 CFR 482.13(e)(5)–(9), (12)–(14): violent restraint orders, earliest discontinuation, and face-to-face evaluation.

Answer: C. Give IV lorazepam

In the American Epilepsy Society guideline, the initial-therapy phase begins at 5 minutes of seizure activity, and a benzodiazepine—IM midazolam, IV lorazepam, or IV diazepam—is the initial therapy of choice. With an IV already in place, IV lorazepam fits.

Why not the others

• A. It's a second-therapy option for seizures that continue after a benzodiazepine, not the first drug.
• B. Also a second-therapy option.
• D. The initial-therapy phase starts at 5 minutes. The guideline also found that second therapy is often less effective than initial therapy, so the first drug matters.

Takeaway: Past 5 minutes, a benzodiazepine goes first.

Source: American Epilepsy Society: guideline and treatment algorithm for convulsive status epilepticus, Stabilization, initial therapy, and second therapy phases.

Answer: A. The National Early Warning Score (NEWS)

The guideline strongly recommends NEWS, NEWS2, MEWS, or SIRS over qSOFA as a single tool to screen acutely ill hospital patients for sepsis. It also recommends running screening inside a hospital performance-improvement program.

Why not the others

• B. It's the one tool the guideline specifically recommends against using alone for screening.
• C. The guideline says sepsis shouldn't be ruled in or out with a single biomarker.
• D. Lactate is worth measuring once sepsis is suspected, but it's a single biomarker, not a screening tool.

Takeaway: For screening, NEWS, MEWS, or SIRS beat qSOFA. For diagnosis, no single lab rules sepsis in or out.

Source: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Performance improvement, screening, biomarker, and blood lactate statements.

Answer: B. An immediate unsynchronized shock (defibrillation)

AHA's 2025 guideline gives a Class 1 recommendation for an immediate unsynchronized shock in sustained polymorphic VT, and treats every form of polymorphic VT as unstable. After the shock, IV magnesium may be considered to prevent recurrences, because this looks like torsades de pointes with a long QT.

Why not the others

• A. The defibrillator can't reliably synchronize to a QRS that changes from beat to beat, so polymorphic VT needs a high-energy unsynchronized shock.
• C. Amiodarone can prolong the QT further and promote torsades in this long-QT setting. It does not replace the immediate shock.
• D. AHA lists adenosine as harmful in unstable, irregular, or polymorphic wide-complex tachycardia.

Takeaway: Polymorphic VT gets an unsynchronized shock. For long-QT recurrences, think magnesium.

Source: AHA 2025 Guidelines, Part 9: Adult Advanced Life Support, Polymorphic Ventricular Tachycardia, recommendations 1–2 and supportive text; Wide-Complex Tachycardia, recommendation 6.

Answer: D. Give hydrocortisone 100 mg IV now and start prompt IV fluid resuscitation

This is a suspected adrenal crisis. The Endocrine Society recommends an immediate parenteral injection of hydrocortisone 100 mg for adults, with prompt appropriate fluid resuscitation, and says treatment should begin before diagnostic results are available.

Why not the others

• A. Confirmatory testing waits until her condition allows; treatment comes first.
• B. She can't keep pills down. The guideline calls for a parenteral dose.
• C. Fluids matter, but withholding hydrocortisone until after a 2 L reassessment delays essential treatment. Give parenteral hydrocortisone promptly and resuscitate with IV fluid.

Takeaway: Suspected adrenal crisis: hydrocortisone 100 mg IV promptly, plus IV fluid resuscitation. Don't wait for labs.

Source: Endocrine Society: Diagnosis and Treatment of Primary Adrenal Insufficiency (2016), Recommendations 1.3 and 4.1: treatment before results; immediate parenteral hydrocortisone and fluid resuscitation.

Answer: C. Help her decide based on what he would have chosen, using his documented wishes and values

When a patient's preferences are known, AMA Opinion 2.1.2 tells clinicians to help the surrogate decide by substituted judgment: what the patient would choose, based on his advance directive, documented preferences, and values. His documents speak directly to this decision.

Why not the others

• A. She's the right person to decide, but she decides as his voice. The opinion calls for an ethics consult if a surrogate's decision is clearly not what the patient would have chosen.
• B. The best-interest standard is for when the patient's wishes aren't known and can't reasonably be inferred. Here they're documented.
• D. A vote isn't an ethical standard, and it sidelines both his wishes and his designated agent.

Takeaway: A surrogate speaks for the patient. When his wishes are known, they guide the decision.

Source: AMA Code of Medical Ethics, Opinion 2.1.2: Decisions for Adult Patients Who Lack Capacity, Opinion 2.1.2, items (a)–(f).

Answer: A. High-flow nasal cannula

For sepsis with acute hypoxemic respiratory failure and a PaO2/FiO2 ratio below 200, the 2026 Surviving Sepsis Campaign guideline suggests high-flow nasal cannula over conventional oxygen, and as the initial therapy over noninvasive positive pressure ventilation.

Why not the others

• B. For this hypoxemic, non-hypercapnic picture, the guideline suggests HFNC first.
• C. He has acute hypoxemic respiratory failure despite substantial conventional oxygen support. The guideline favors HFNC, with prompt reassessment rather than waiting 4 hours.
• D. No immediate intubation indication is supplied. A monitored HFNC trial is reasonable here, but worsening oxygenation, work of breathing, mental status, or airway protection should prompt escalation without delaying needed intubation.

Takeaway: In selected sepsis-related acute hypoxemic respiratory failure, use a closely monitored HFNC trial; do not let it delay needed intubation.

Source: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Respiratory support recommendations for acute hypoxemic respiratory failure.

Answer: D. Rifampin lowers apixaban exposure, raising stroke and clot risk; avoid the combination and plan an alternative with the team

The label says to avoid using apixaban with drugs that are combined P-gp and strong CYP3A4 inducers, and it names rifampin. Those drugs lower apixaban exposure, which raises the risk of stroke and other thromboembolic events.

Why not the others

• A. For patients taking 5 or 10 mg twice daily, the label reduces apixaban by 50% with certain combined P-gp and strong CYP3A4 inhibitors; it avoids those combinations when the patient is already on 2.5 mg twice daily. Rifampin is an inducer and does the opposite.
• B. The label lists this interaction specifically.
• C. The label says to avoid using them together; spacing the doses isn't offered as a workaround.

Takeaway: Too little anticoagulant is a safety problem, too. Strong inducers such as rifampin: avoid with apixaban.

Source: Apixaban U.S. prescribing information, revised August 2026, Sections 7.1–7.2: combined P-gp/strong CYP3A4 inhibitors and inducers.

Answer: B. “I want to make sure I explained this clearly. Can you tell me, in your own words, how you'll take your medicines at home?”

That's teach-back: asking the patient to explain, in his own words, what he needs to know or do. AHRQ describes it as the way to confirm that you explained things clearly and that he understands.

Why not the others

• A. Inviting questions is good practice, but it doesn't show what he understood.
• C. AHRQ notes that patients often say yes to this when they don't understand, either because they think they do or because they're embarrassed.
• D. Written instructions reinforce the message, but they don't check understanding.

Takeaway: Ask for it back in the patient's words, and frame it as checking your explanation, not testing the patient.

Source: AHRQ TeamSTEPPS Tool: Teach-Back, Tool description and examples.

Answer: C. Epinephrine 0.5 mg (500 micrograms) IM, using the 1 mg/mL concentration

Resuscitation Council UK's 2025 guidelines call for IM adrenaline (epinephrine) 500 micrograms of the 1 mg/mL concentration at the first suspicion of anaphylaxis, repeated after 5 minutes if there's no improvement, along with an early IV crystalloid bolus.

Why not the others

• A. It isn't the guideline's first drug, and it shouldn't delay IM epinephrine.
• B. Also not the first drug, and it shouldn't delay IM epinephrine.
• D. That's the cardiac arrest dose of epinephrine. This patient has a pulse.

Takeaway: Anaphylaxis: IM epinephrine first, repeat in 5 minutes if needed, and give IV fluid early.

Sources: Resuscitation Council UK 2025 Guidelines: Special circumstances, Management and prevention of cardiac arrest due to anaphylaxis; AHA 2025 Guidelines, Part 9: Adult Advanced Life Support, Vasopressor Medications in Adult Cardiac Arrest, recommendation 2.

Answer: A. Not yet conclusive: PaCO2 rose only 18 mm Hg, and it must also be at least 20 mm Hg above baseline

Under the 2023 AAN/AAP/CNS/SCCM criteria, the apnea test supports brain death when there are no spontaneous respirations, pH is below 7.30, and PaCO2 is at least 60 mm Hg and at least 20 mm Hg above the patient's baseline. His PaCO2 went from 44 to 62—a rise of 18. Because he remains stable, the protocol can continue the apnea test with repeat blood gases until criteria are met; this result alone does not establish brain death. Ancillary testing is reserved for the guideline-defined situations in which the clinical evaluation or apnea test cannot be completed or interpreted.

Why not the others

• B. Crossing 60 isn't enough on its own; both PaCO2 thresholds must be met.
• C. The pH criterion is below 7.30, and his is 7.27.
• D. There's no 80 mm Hg requirement.

Takeaway: Apnea test: PaCO2 at least 60 and at least 20 above baseline, pH below 7.30, and no breathing effort. Check both CO2 numbers.

Source: 2023 AAN/AAP/CNS/SCCM brain death consensus guideline — supplemental eTables, eTable 5, PDF pp. 11–12: prerequisites, oxygenation, CO2/pH endpoints, and repeat testing when stable.

Answer: A. Epinephrine 1 mg IV

PEA is a nonshockable rhythm. AHA's 2025 guideline says it's reasonable to give epinephrine as soon as feasible in nonshockable arrest, and to repeat 1 mg every 3 to 5 minutes.

Why not the others

• B. Amiodarone may be considered for VF or pulseless VT that doesn't respond to defibrillation. PEA is neither.
• C. Routine calcium isn't recommended in cardiac arrest. AHA addresses it only in special circumstances such as hyperkalemia or certain poisonings.
• D. PEA isn't a shockable rhythm, so there's no reason to delay epinephrine for shocks.

Takeaway: Nonshockable arrest: epinephrine early. Shockable arrest: shock first.

Source: AHA 2025 Guidelines, Part 9: Adult Advanced Life Support, Vasopressor Medications, recommendations 2–4; Nonvasopressor Medications, recommendations 1 and 4.

Answer: C. Remove the catheter and provide continence care

CDC lists using an indwelling catheter as a substitute for nursing care of a patient with incontinence as an inappropriate use. For surgical patients, it recommends removing the catheter as soon as possible, preferably within 24 hours, unless there's an appropriate indication for continued use. She has none.

Why not the others

• A. CDC recommends against changing catheters at routine, fixed intervals.
• B. CDC recommends against routine systemic antibiotics to prevent CAUTI.
• D. Helping an existing open sacral or perineal wound heal in an incontinent patient is an appropriate indication, but she has no wound, and CDC makes no recommendation for catheters to prevent skin breakdown.

Takeaway: Every catheter day needs a reason. Incontinence alone isn't one.

Source: CDC Guideline for Prevention of CAUTI: Summary of Recommendations, I.A, I.A.2, I.A.4 and Table 2; III.E–III.F: appropriate indications, removal, fixed intervals, and prophylactic antibiotics.

Answer: D. Hyperglycemic hyperosmolar state (HHS)

The 2024 criteria for HHS are glucose of 600 mg/dL or higher, effective osmolality above 300 mOsm/kg (or total above 320), beta-hydroxybutyrate below 3.0 mmol/L, and pH 7.3 or higher with bicarbonate 15 mmol/L or higher. She meets all four. Her stupor fits the picture, but altered mental status is not one of the four 2024 diagnostic criteria.

Why not the others

• A. DKA requires ketosis (beta-hydroxybutyrate 3.0 mmol/L or higher) and acidosis (pH below 7.3, bicarbonate below 18, or both). She has neither.
• B. Euglycemic DKA still requires ketosis and acidosis, and her glucose is far from normal.
• C. Mixed features mean hyperosmolality with significant ketonemia or acidosis. Her ketones and pH don't reach those thresholds.

Takeaway: HHS versus DKA comes down to ketones and acid–base status, not glucose alone.

Source: Hyperglycaemic crises in adults with diabetes: a consensus report (2024), Section 3 and Figure 2: all four HHS diagnostic criteria; ketosis and acidosis thresholds.

Answer: B. Do a passive leg raise and measure the change in stroke volume before deciding

The 2026 Surviving Sepsis Campaign guideline suggests using dynamic measures—such as the stroke volume response to a passive leg raise or a fluid bolus—to guide fluids, rather than physical exam or static measures alone. CVP is a static number.

Why not the others

• A. A single static pressure doesn't tell you whether more fluid will raise his stroke volume.
• C. The guideline says to individualize fluids after the initial bolus rather than continuing until lactate normalizes.
• D. Capillary refill is suggested as an adjunct to other perfusion measures, not the sole guide.

Takeaway: Test whether the heart will respond to fluid instead of guessing from a static number.

Source: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Resuscitation, serial lactate, and capillary refill recommendations.

Answer: D. “I'm requesting that you come to the bedside now. Can we confirm the immediate plan?”

SBAR ends with a Recommendation or Request: what's needed and when, followed by a repeat-back of the response to make sure it's accurate. The call already covers the situation, background, and assessment. What's missing is a specific ask.

Why not the others

• A. Open-ended. It leaves the next step to chance.
• B. It postpones the request while the patient is unstable.
• C. Sharing data helps, but it isn't a request for action.

Takeaway: Finish SBAR with a specific request and a time frame, then confirm with a repeat-back.

Source: AHRQ TeamSTEPPS Tool: SBAR, Tool description; Repeat-Back Recommendations and Requests.

Answer: A. Explain that testing for cure isn't recommended after clinical recovery, and document that her symptoms have resolved

CDC's acute-care guidance says not to repeat testing to establish cure after symptoms resolve and to test only appropriate unformed stool specimens. She has recovered clinically, and a test wouldn't guide her care.

Why not the others

• B. That's a test of cure on formed stool—two things the guidance advises against.
• C. Because tests of cure aren't recommended, a negative test isn't a treatment endpoint.
• D. Repeating the same unnecessary test does not make it useful. CDC notes that tests may stay positive for six weeks or longer after recovery.

Takeaway: For C. diff, test symptoms, not cure.

Source: CDC: Clinical Guidance for C. diff Infection Prevention in Acute Care Facilities, Confirm CDI in patients: symptoms resolved/no test of cure; unformed stool and persistent positive results.

Answer: C. IV verapamil

AHA's 2025 guideline labels verapamil and diltiazem as harmful in wide-complex tachycardia. Verapamil won't terminate a wide-complex tachycardia of ventricular origin and can cause profound hypotension leading to shock and cardiac arrest.

Why not the others

• A. Procainamide may be considered for wide-complex tachycardia. It must be infused no faster than 50 mg/min because it can cause hypotension.
• B. Amiodarone may be considered, though its onset is relatively slow.
• D. In a stable, regular, monomorphic wide-complex tachycardia, adenosine may be considered to treat or help diagnose the rhythm. It's avoided when the rhythm is unstable, irregular, or polymorphic.

Takeaway: Undifferentiated wide-complex tachycardia: avoid verapamil and diltiazem.

Source: AHA 2025 Guidelines, Part 9: Adult Advanced Life Support, Wide-Complex Tachycardia, recommendations 3–6 and supportive text.

Answer: B. 4-factor prothrombin complex concentrate (4F-PCC) plus IV vitamin K

Stop warfarin and reverse its effect as soon as possible. The AHA/ASA guideline's official clinical update pairs 4F-PCC with IV vitamin K for vitamin K antagonist–associated ICH at this INR. PCC supplies clotting factors rapidly; vitamin K makes reversal durable. Fresh frozen plasma is an alternative when PCC is unavailable or unsuitable, not the preferred plan here.

Why not the others

• A. PCC is preferred over plasma for urgent VKA-associated intracranial hemorrhage reversal when suitable and available. Plasma alone also omits the vitamin K needed for durable reversal.
• C. Vitamin K belongs in the plan, but the preferred approach pairs IV vitamin K with 4F-PCC for rapid reversal.
• D. Platelets don't reverse warfarin, which works by lowering vitamin K–dependent clotting factors.

Takeaway: Warfarin-associated ICH: 4F-PCC plus IV vitamin K, fast.

Sources: AHA/ASA 2022 spontaneous intracerebral hemorrhage guideline — official clinical update, Slide 13 (PDF p. 13), Hemostasis & Coagulopathy: immediate reversal and vitamin K antagonist pathway; Neurocritical Care Society/SCCM: Reversal of Antithrombotics in Intracranial Hemorrhage (2016), Printed pp. 16–17 (PDF pp. 11–12), Recommendations for VKA Reversal, 1–6.

Answer: D. Start norepinephrine through a monitored peripheral IV now, target a MAP of 65 mm Hg, and arrange credentialed help for central access if ongoing treatment requires it

The 2026 Surviving Sepsis Campaign guideline recommends norepinephrine as the first-line vasopressor and an initial MAP target of 65 mm Hg, and it suggests starting vasopressors peripherally rather than delaying until central access is secured. Use the hospital's peripheral-vasopressor monitoring protocol and arrange credentialed help if central access becomes necessary. This treats the shock without delaying for the procedure. AACN's AGACNP competencies include practicing within national, state, and institutional credentialing and scope of practice.

Why not the others

• A. Peripheral norepinephrine can start now, so there is no need to assume an emergency exception for a procedure outside the stated privileges. Emergency privileging rules depend on the institution and applicable law.
• B. The guideline suggests against delaying vasopressors for central access.
• C. When hypotension persists after initial fluid, the guideline suggests adding a vasopressor.

Takeaway: Don't let the line delay the pressor. Use a monitored peripheral route and follow the institution's credentialing and escalation process.

Sources: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Fluid resuscitation, vasopressor administration, mean arterial pressure, and vasopressor recommendations; source control; AACN ACNPC-AG Exam Handbook (July 2026), validated competencies, Validated Competencies, Clinical Judgment: national, state, and institutional credentialing/scope, printed p. 14.

Answer: A. Continuous waveform capnography

AHA's 2025 guideline recommends continuous waveform capnography, in addition to clinical assessment, as the most reliable method of confirming and monitoring endotracheal tube placement in adults in cardiac arrest.

Why not the others

• B. It's a clinical sign, not confirmation.
• C. Auscultation is part of clinical assessment, which AHA pairs with capnography rather than relying on alone.
• D. Saturation doesn't confirm where the tube is.

Takeaway: Confirm tube placement with clinical signs plus continuous waveform capnography.

Source: AHA 2025 Guidelines, Part 9: Adult Advanced Life Support, Advanced Airway Placement During Resuscitation, recommendation 3 and supportive text.

Answer: C. Honor his informed refusal, document his capacity and the discussion, and continue other care consistent with his goals

Under Medicare's hospital Conditions of Participation, patients have the right to make informed decisions about their care, including refusing treatment, and to have their advance directives followed. AMA ethics guidance says a patient with decision-making capacity may accept or refuse any recommended intervention. He understands the choice, reasons about it, and is consistent with his living will.

Why not the others

• A. His son isn't the decision-maker while he has capacity. Surrogates step in when a patient lacks capacity.
• B. A capacity evaluation helps when capacity is genuinely in doubt. Here he clearly shows understanding and reasoning, and disagreeing with the team isn't grounds to override him.
• D. The son can't consent over a capable patient's refusal.

Takeaway: A capable patient's informed refusal stands, even when family disagrees.

Sources: 42 CFR 482.13, Condition of participation: Patient's rights (eCFR), § 482.13(b)(2)–(3); AMA Code of Medical Ethics, Opinion 5.3: Withholding or Withdrawing Life-Sustaining Treatment, Opening principle and recommendations 2–5: capacity, refusal, documentation, and continued appropriate care; AMA Code of Medical Ethics, Opinion 2.1.2: Decisions for Adult Patients Who Lack Capacity, Opinion 2.1.2, introduction.

Answer: B. Don't send HIT testing; continue heparin and keep monitoring the platelet count

Her 4Ts score is 3: the platelet fall is (260 − 176) ÷ 260 = 32.3% (1 point), the fall is on day 2 without recent heparin exposure (0), there is no thrombosis (0), and there is no other apparent cause (2). That is low probability. With complete, reliable information, ASH recommends against routine HIT testing or empiric HIT treatment at a low-probability score. Continue indicated prophylaxis and monitor; recalculate if the clinical picture changes.

Why not the others

• A. Stopping heparin and starting a non-heparin anticoagulant is ASH's plan for intermediate- and high-probability scores, not low.
• C. Testing is exactly what ASH recommends against at this score.
• D. Nothing here calls for platelet transfusion: there is no bleeding, and the platelet count is 176,000/mm³.

Takeaway: Score the 4Ts before you test. A reliable low-probability score argues against routine HIT testing; reassess when new information changes the score.

Source: ASH: Diagnosis and Management of Heparin-Induced Thrombocytopenia — pocket guide, PDF p. 2: 4Ts score and low-probability pathway; exception for missing or uncertain information.

Answer: A. Fosphenytoin, valproic acid, or levetiracetam are all reasonable; the guideline found no clear evidence that one is better

In the American Epilepsy Society guideline's second-therapy phase (20 to 40 minutes of seizure activity), fosphenytoin, valproic acid, and levetiracetam are reasonable options, with no clear evidence that any one is better. IV phenobarbital is a reasonable alternative if none of the three is available.

Why not the others

• B. The guideline names three options and doesn't rank them.
• C. The guideline found no clear evidence that any of the three is better.
• D. Seizures are ongoing, so the guideline moves to second therapy now; some patients move even faster to third-phase treatment.

Takeaway: After adequate benzodiazepines fail, promptly choose an appropriate second-line agent—fosphenytoin, valproate, or levetiracetam—using the patient's contraindications and clinical context.

Source: American Epilepsy Society: guideline and treatment algorithm for convulsive status epilepticus, Second and third therapy phases.

Answer: D. Draw blood cultures now, then give empiric antimicrobials immediately—ideally within 1 hour

This is probable septic shock. The 2026 Surviving Sepsis Campaign guideline strongly recommends antimicrobials immediately, ideally within 1 hour of recognition, and blood cultures as soon as possible and ideally before antimicrobials. The CT still matters: the guideline suggests source control, when needed, ideally within 6 hours.

Why not the others

• A. Waiting 90 minutes or more for imaging misses the 1-hour target in shock.
• B. The guideline suggests clinical evaluation alone, not procalcitonin, to decide whether to start antimicrobials.
• C. Antibiotics shouldn't wait on the next fluid decision.

Version note: For patients 65 and older, the 2026 guideline suggests an initial MAP range of 60 to 65 mm Hg. A MAP of 58 is below that range.

Takeaway: Septic shock: cultures first if they don't delay things, antimicrobials within the hour.

Source: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Diagnostics, antibiotic initiation, and source control recommendations.

Answer: B. Test it on a small scale—say, one team for a few shifts—measure what happens, and refine it before expanding

IHI's Model for Improvement uses Plan-Do-Study-Act (PDSA) cycles to learn how a change works in the local setting. Early cycles should be scoped as small as possible, and teams refine the change before testing it more broadly and implementing it.

Why not the others

• A. Going wide first skips the learning, and any problems hit every unit at once.
• C. Planning without testing never tells you whether the change works.
• D. A checklist on paper isn't evidence of improvement. You have to measure the result.

Takeaway: Test small, learn, refine, then spread.

Source: IHI Model for Improvement, Testing Changes and Implementing Changes: small PDSA tests, learning, refinement, and spread.

Answer: C. Reassess and improve compression quality, aiming for an ETCO2 of at least 10 mm Hg and ideally 20 mm Hg or more

AHA's 2025 guideline says ETCO2 can be used to monitor and optimize CPR quality. Values below 10 mm Hg are generally linked with poor outcomes, and targeting compressions to at least 10—ideally 20 or more—may indicate mechanically adequate technique. Better compression depth can raise ETCO2, but ventilation, pulmonary blood flow, drugs, airway factors, and the cause of arrest also affect it.

Why not the others

• A. In an intubated patient, ETCO2 below 10 after 20 minutes of ALS may be considered as one part of a multimodal decision to stop. It doesn't justify stopping 4 minutes in, or on its own.
• B. With an advanced airway in place, AHA suggests about 1 breath every 6 seconds (10 per minute).
• D. Routine sodium bicarbonate isn't recommended in cardiac arrest.

Takeaway: Low ETCO2 during CPR should prompt a CPR-quality check. It is not a stand-alone measure of compression quality or a reason to stop resuscitation.

Source: AHA 2025 Guidelines, Part 9: Adult Advanced Life Support, Adjuncts for Performance of CPR, recommendation 6; Termination of Resuscitation, recommendation 4; Advanced Airway, recommendation 9; Nonvasopressor Medications, recommendation 5.

Answer: D. Refer him to an appropriate mental health professional for evaluation, and connect him with post-critical-illness follow-up and physical rehabilitation

The 2026 Surviving Sepsis Campaign guideline says sepsis survivors with symptoms of mental health disorders should be referred to appropriate professionals for evaluation and management. It also suggests offering mental health services, post-critical-illness follow-up, and physical rehabilitation for survivors who were ventilated for more than 48 hours.

Why not the others

• A. Reassurance without evaluation leaves possible post-ICU mental health problems untreated.
• B. Avoidance is one of his symptoms, not a treatment.
• C. Waiting six months delays the referral the guideline calls for.

Takeaway: After ICU sepsis, ask about mood, sleep, and nightmares, and refer persistent or concerning symptoms for evaluation.

Source: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Post-hospital evaluation, physical rehabilitation, and mental health services statements.

Answer: A. Screen patients for economic and social support needs—such as housing, food, finances, and spiritual support—and refer them to available resources

The guideline's good practice statement says hospitals and health systems should screen patients with sepsis for economic and social support needs, including housing, nutrition, financial, and spiritual support, and make referrals where available.

Why not the others

• B. The guideline does call for written and verbal discharge information, but a packet doesn't find unmet social needs.
• C. The statement puts screening on the hospital and health system.
• D. The statement calls for screening, not only responding when a patient asks for help.

Takeaway: Build social-needs screening into sepsis discharge, not just discharge paperwork.

Source: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Patient support and hospital discharge good practice statements.

Answer: C. Prone positioning for more than 12 hours a day

For moderate to severe sepsis-associated ARDS, the guideline suggests prone ventilation for more than 12 hours a day. If conventional ventilation still fails, it suggests venovenous ECMO in experienced centers.

Why not the others

• A. Increasing to 10 mL/kg would move away from the recommended initial lung-protective target of 6 mL/kg. Proning addresses oxygenation without making that change.
• B. The guideline recommends against an incremental PEEP titration strategy in moderate to severe ARDS.
• D. The guideline suggests intermittent neuromuscular blocker boluses over a continuous infusion.

Takeaway: Refractory hypoxemia on lung-protective settings: prone for more than 12 hours a day.

Source: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Mechanical ventilation and venovenous ECMO recommendations.

Answer: B. Start the goals-of-care and prognosis conversation early—within the first 72 hours—while treatment continues

The 2026 Surviving Sepsis Campaign guideline says clinicians should discuss goals of care and prognosis with patients or families, and suggests doing it early, within 72 hours. It also says palliative care principles belong in the plan when appropriate.

Why not the others

• A. That pushes the conversation past the window the guideline suggests.
• C. He currently lacks capacity, and his designated agent can participate now. The conversation need not wait for him to regain the ability to decide.
• D. The guideline suggests against routine formal palliative care for everyone; consultation is based on clinical judgment.

Takeaway: Goals-of-care conversations start early, alongside treatment, not instead of it.

Sources: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (SCCM recommendations page), Goals of care and palliative care statements; AMA Code of Medical Ethics, Opinion 2.1.2: Decisions for Adult Patients Who Lack Capacity, Opinion 2.1.2: designated surrogate and patient participation.