Acute care nurse practitioners work where seconds matter. The AGACNP certification exam is built around that reality. It tests how you assess unstable adults, make fast, safe decisions, and coordinate care in complex hospital settings. This guide focuses on the inpatient and emergency content that tends to show up: hemodynamics, respiratory failure, shock, sepsis, neurologic crises, metabolic storms, and safe procedures. You’ll get practical frameworks, high-yield numbers, and case-style reasoning so you can think like an acute care NP on the floor and in the exam room.
What the AGACNP Exam Expects
The exam rewards clear priorities and safe choices. Most questions ask for the best next step. That means you must recognize what kills fastest and act in order.
- Core domains: focused assessment, differential diagnosis, immediate stabilization, definitive management, and reassessment. Professional practice and systems-based care also appear (handoffs, consults, safety).
- Patient mix: adults and older adults, high acuity, multiple comorbidities, polypharmacy, and atypical presentations.
- Question style: 1) interpret a vignette with subtle vital trends or labs; 2) pick the safest early action; 3) justify with physiology. If two answers seem correct, choose the one that stabilizes the airway, breathing, or circulation first.
Core Clinical Frameworks You’ll Use at the Bedside
- ABCDE primary survey: Airway, Breathing, Circulation, Disability (neuro), Exposure. Why: fixes the most dangerous problems first; prevents anchoring on a diagnosis while the patient decompensates.
- Shock triad: decreased perfusion, cellular hypoxia, organ dysfunction. Classify by cause:
- Distributive (sepsis, anaphylaxis): vasodilation. Needs fluids and vasoconstriction.
- Cardiogenic: pump failure. Needs decongestion and inotropy, not large fluid boluses.
- Obstructive: blocked flow (PE, tamponade, tension pneumothorax). Needs to remove the block.
- Hypovolemic: fluid loss. Needs volume replacement.
- Oxygenation vs ventilation: Hypoxemia is low O2 deliverability; hypercapnia is inadequate ventilation. Why: guides whether you adjust FiO2/PEEP (oxygenation) or tidal volume/respiratory rate (ventilation).
- Preload–afterload–contractility: Most hemodynamic decisions boil down to which lever you need to pull. Why: prevents giving fluids to cardiogenic shock or vasodilators to distributive shock without support.
- Sepsis bundle logic: give volume to fill dilated vasculature, antibiotics to stop ongoing tissue injury, pressors to maintain MAP and organ perfusion. Timing matters because hypotension and delayed antibiotics increase mortality.
Mastering Inpatient Assessment
- History sources: patient, family, EMS handoff, medication lists, prior notes, pharmacy. Why: older adults often have limited recall; missing meds leads to rebound crises (clonidine, beta-blockers, steroids).
- Focused exam: trend vitals; look for shock signs (cool clammy skin vs warm vasodilated), JVP for volume status, lung auscultation for overload/airway obstruction, abdominal tenderness for source, neuro deficits for stroke or encephalopathy.
- Labs you must interpret fast: ABG/VBG patterns, lactate for perfusion, troponin trends (delta matters), BMP for electrolytes/renal, CBC for infection and anemia, coagulation for bleeding/thrombosis risk.
- Imaging: CXR for tubes/lines, edema, pneumothorax. Head CT non-contrast for acute neuro change. Consider POCUS to speed decisions: IVC collapsibility for volume status, lung sliding for pneumothorax, B-lines for pulmonary edema, cardiac views for tamponade or poor contractility.
- Medication safety: renal dosing, QTc risk, drug–drug interactions (amiodarone/warfarin; macrolides and QT; NSAIDs and kidney injury). Why: inpatient polypharmacy causes many complications.
Emergency Management: The First 5 Minutes
- Airway: look for voice changes, stridor, AMS, trauma. If threatened airway, call for help early. Use high-flow O2. Set up suction, BVM, and plan for intubation.
- Breathing: hypoxia algorithm: airway positioning, 15 L non-rebreather, consider NIV for COPD and cardiogenic edema, look for tension pneumothorax (needle decompression if unstable), then intubate if failing.
- Circulation: two large-bore IVs; draw labs and type & screen. If shock, start fluids unless cardiogenic/obstructive suspected. Target MAP ≥ 65 mmHg. Start vasopressors early if fluids fail.
- Reversible rapid fixes: give naloxone for suspected opioid toxicity; dextrose for hypoglycemia; thiamine before glucose in malnutrition/alcohol use to reduce Wernicke risk; benzodiazepines for status epilepticus; IM epinephrine for anaphylaxis.
Cardiovascular High-Yield
- Acute coronary syndrome: give antiplatelet and anticoagulant unless contraindicated, manage pain and blood pressure, nitrates if no right ventricular infarct or severe aortic stenosis. Early cardiology involvement for invasive strategy. Why: limits infarct size and complications.
- Acute decompensated heart failure: if hypertensive and wet, use nitrates and diuresis; avoid large fluid boluses. If hypotensive with low output, consider inotrope support and cautious vasopressors.
- Atrial fibrillation with RVR: unstable gets synchronized cardioversion. Stable with preserved EF: beta-blocker or diltiazem. Decompensated HF or hypotension: amiodarone preferred for rate/rhythm. Anticoagulate when not contraindicated to lower stroke risk.
- Bradycardia/heart block: symptomatic bradycardia gets atropine, then transcutaneous pacing if no response. Look for causes (ischemia, hyperkalemia, meds).
- Vasopressors and inotropes:
- Norepinephrine: first-line for septic shock (alpha-1 with some beta-1; raises MAP without much tachycardia).
- Vasopressin: add-on in sepsis to reduce norepi dose; replaces relative deficiency.
- Epinephrine: anaphylaxis, refractory shock; watch for lactate rise and tachyarrhythmias.
- Dobutamine: inotrope for cardiogenic shock with low output; monitor for tachycardia.
- Phenylephrine: pure alpha; consider if tachyarrhythmias limit other agents.
Start low and titrate per protocol; set a MAP goal and reassess perfusion (urine output, mentation, lactate).
- Hypertensive emergency: reduce MAP by about 20–25% over the first hour unless stroke subtypes dictate otherwise. Why: prevents hypoperfusion injury from rapid drops.
- Aortic catastrophe: tearing chest/back pain, pulse deficit, mediastinal widening. Control BP and heart rate; avoid excess afterload. Emergency surgery if dissection proximal.
Pulmonary and Ventilation Essentials
- ABG shortcuts: hypoxemia = low PaO2; hypercapnia = high PaCO2. A–a gradient helps separate V/Q mismatch from hypoventilation. Respiratory acidosis demands ventilation support; respiratory alkalosis suggests pain/anxiety, hypoxemia, or early sepsis.
- NIV: BiPAP helps COPD and cardiogenic pulmonary edema by unloading work of breathing. Avoid if vomiting risk, facial trauma, or inability to protect airway.
- Intubation triggers: persistent hypoxemia, rising CO2 with fatigue, airway compromise, altered mental status, hemodynamic crash.
- Vent basics: start low tidal volume (≈ 6 mL/kg predicted body weight), set RR to control CO2, adjust PEEP/FiO2 for oxygenation. For ARDS, keep plateau pressures low to reduce barotrauma.
- Asthma/COPD flare: short-acting bronchodilators, systemic steroids, magnesium for severe asthma, early NIV for COPD with hypercapnia. Watch for silent chest (fatigue and impending failure).
- Pulmonary embolism suspicion: pleuritic pain, tachycardia, hypoxia, DVT signs. Right heart strain on bedside echo supports urgent anticoagulation unless contraindicated.
Neurologic and Endocrine Emergencies
- Stroke: check last-known-well, glucose, non-contrast head CT. If ischemic and within treatment windows, coordinate reperfusion. BP targets differ for thrombolysis candidacy. If hemorrhagic, reverse anticoagulation and control BP while avoiding hypotension.
- Status epilepticus: benzodiazepines first, then antiseizure medication. Check glucose, electrolytes, and consider toxins or infection. Protect airway if ongoing seizures.
- Thyroid storm: fever, tachycardia, agitation. Treat with beta-blocker, antithyroid agent, iodine after thionamide, and steroids. Why: blocks hormone effects, synthesis, and release.
- Myxedema coma: hypothermia, bradycardia, hyponatremia, hypoventilation. Give thyroid hormone and stress-dose steroids; support ventilation.
- Adrenal crisis: refractory hypotension, hyponatremia, hyperkalemia. Give stress-dose steroids promptly. Why: delays cost lives; diagnosis is clinical.
- DKA/HHS: fluids first, then insulin infusion and potassium management. Close anion gap before transition to subcutaneous insulin. In HHS, prioritize fluid and slow correction of osmolality.
Renal, Electrolytes, and Acid–Base
- AKI: pre-renal (volume loss, low perfusion), intrinsic (ATN, nephritis), post-renal (obstruction). Use history + exam + urinalysis + ultrasound to classify. Avoid nephrotoxins and dose meds for GFR.
- Hyperkalemia rescue: ECG changes or K+ ≥ 6: calcium to stabilize the myocardium, insulin plus dextrose, beta-agonist, bicarbonate if acidosis, remove K+ with diuretics, binders, or dialysis. Why: preventing arrhythmia is the first priority.
- Hyponatremia: severe symptoms need hypertonic saline boluses; otherwise correct slowly (generally ≤ 8 mEq/L per 24 hours) to avoid osmotic demyelination. Identify cause (SIADH, hypovolemia, diuretics).
- Acid–base: calculate anion gap. For high-gap acidosis, use delta–delta to look for mixed disorders. Why: mixed problems are common in sepsis (lactate) plus respiratory alkalosis.
Infection, Sepsis, and Antibiotic Stewardship
- Sepsis steps: recognize SIRS/qSOFA patterns plus suspected source, measure lactate, obtain cultures quickly, start broad antibiotics and fluids, then pressors to MAP ≥ 65. Repeat lactate and reassess volume responsiveness.
- Empiric antibiotics: choose by source (lungs, urinary, intra-abdominal, skin), severity, and local resistance. De-escalate once cultures return. Why: early broad coverage saves lives; de-escalation reduces resistance and C. diff.
- Source control: drain abscess, remove infected catheters, debride necrosis. Antibiotics alone often fail without it.
Hematology/Oncology and Transfusion
- Anticoagulation reversal: warfarin with vitamin K and PCC; dabigatran with specific antidote where available or hemodialysis in extremes; factor Xa inhibitors with reversal agent or PCC per protocol. Why: time-sensitive bleeding requires fast reversal.
- HIT suspicion: platelet fall plus thrombosis after heparin exposure. Stop heparin; start non-heparin anticoagulant. Confirm with testing but do not wait to act.
- Neutropenic fever: start broad-spectrum antipseudomonal coverage immediately; delays increase mortality. Look for catheter and mucosal sources.
- Transfusion: restrictive thresholds are safe for most (Hb ~7 g/dL), but individualize for acute coronary ischemia, active bleeding, or severe hypoxemia. Watch for reactions (TRALI, TACO) and act early (stop transfusion, supportive care).
Procedures and Bedside Skills
- Ultrasound-guided vascular access: reduces complications and improves success. Full sterile technique and time-out every time. Why: infections and line misplacements are preventable harms.
- Paracentesis/thoracentesis: bedside ultrasound to pick a safe site, correct coagulopathy if needed, monitor for bleeding and re-expansion pulmonary edema.
- Lumbar puncture: check for focal deficits or signs of increased ICP; image first if concerned. Why: risk of herniation with mass effect.
- Chest tube: tension pneumothorax needs immediate decompression; hemothorax or large symptomatic effusion often needs drainage.
- Sedation/analgesia: treat pain before sedating. Use the lightest effective sedation; monitor airway and hemodynamics. Daily sedation interruptions in ventilated patients improve outcomes.
Study Plan: Four Weeks to Exam Readiness
- Week 1: Build frameworks. Review shock types, ventilator basics, ABG, electrolytes, sepsis steps. Create one-page algorithms you can recall quickly.
- Week 2: Systems blocks. Do daily case questions on cardio and pulmonary. End each session by writing your top three takeaways and one mistake to avoid.
- Week 3: Neuro, endocrine, renal, heme/onc, antibiotics. Practice mixed sets to force switching gears, like on call nights.
- Week 4: Timed exams and targeted review. Track weak topics; re-read your algorithms. Do two full-length simulations with strict timing and minimal breaks.
- Daily: 25–50 questions with review, 15 minutes of high-yield flashcards, 10 minutes of POCUS/ECG image drills.
Test-Taking Skills That Raise Your Score
- Stabilize first: airway and perfusion beat diagnostics. If hypotensive and altered, start resuscitation before CT scans.
- Choose the safest option: when two answers work, pick the one with fewer harms or that buys time (e.g., NIV trial before intubation in COPD if appropriate).
- Numbers matter: MAP goals, sodium correction limits, glucose thresholds, QTc risk. Misreading a value is a common way to miss a question.
- Avoid anchoring: reassess after each intervention; look for new data that might redirect the plan.
- Eliminate aggressively: discard answers that violate physiology (big fluid bolus in pulmonary edema) or safety (beta-blocker in severe bronchospasm).
Case Walkthroughs: How to Think on the Exam and the Unit
- Case 1: Septic shock
- 72-year-old with fever, cough, BP 82/50, HR 118, RR 26, SpO2 90% on room air, lactate 4.2.
- Best next step: high-flow oxygen, blood cultures, broad antibiotics, and 30 mL/kg crystalloid. Why: corrects life-threatening hypoperfusion and treats the source early.
- If MAP stays < 65 after fluids, start norepinephrine and reassess with bedside ultrasound for volume responsiveness and cardiac function.
- Case 2: A-fib with hypotension
- 68-year-old with dyspnea, BP 88/60, HR 160 irregular, JVD, crackles.
- Best next step: synchronized cardioversion. Why: unstable patient with shock physiology; rate-controlling drugs can worsen blood pressure and delay stabilization.
- Case 3: DKA
- 28-year-old with polyuria, vomiting, Kussmaul respirations, glucose 520, anion gap 24, K+ 4.9.
- Best next step: isotonic fluids, then insulin infusion with careful potassium monitoring. Why: fluids restore perfusion; insulin closes the gap. Start potassium replacement when K+ trends down; avoid insulin if K+ < 3.3 until corrected.
What to Memorize vs What to Reason
- Memorize these:
- MAP goal ≥ 65 in shock.
- Sepsis: lactate, cultures, antibiotics, fluids, pressors, source control.
- Severe hyponatremia correction limit: about ≤ 8 mEq/L per 24 hours.
- Hyperkalemia emergency sequence: calcium → shift (insulin/dextrose, beta-agonist, bicarbonate if acidotic) → remove (diuretic, binder, dialysis).
- Low tidal volume ventilation ≈ 6 mL/kg predicted body weight in ARDS.
- Anaphylaxis: IM epinephrine promptly; add airway support and antihistamines/steroids after.
- Anticoag reversal basics: warfarin (vit K + PCC), dabigatran (specific antidote or dialysis), Xa inhibitors (specific antidote or PCC per protocol).
- Adrenal crisis: give steroids early in undifferentiated refractory shock.
- Reason through these:
- Which shock you’re treating and the right lever (fluid, pressor, inotrope, or source control).
- Whether hypoxemia is from V/Q mismatch, shunt, or hypoventilation.
- Mixed acid–base disorders using anion gap and expected compensation.
- When to intubate vs trial NIV based on cause and trajectory.
- Whether to rate-control or cardiovert A-fib based on stability and heart failure status.
Common Pitfalls and How to Avoid Them
- Giving fluids in cardiogenic pulmonary edema: use POCUS and exam to guide; look for B-lines, JVD, poor LV function.
- Over-correcting sodium: slow down and recheck frequently; adjust for risk factors (malnutrition, chronic hyponatremia).
- Missing adrenal crisis: refractory shock with hyponatremia/hyperkalemia—give steroids; do not wait for labs.
- Over-oxygenating CO2 retainers: titrate O2 to target saturations; avoid suppressing hypoxic drive and worsening V/Q mismatch.
- Treating asymptomatic bacteriuria: avoid unless pregnant or before urologic procedures; reduces resistance and adverse effects.
- Neglecting DVT prophylaxis: reassess bleeding risk daily and start mechanical/chemical prophylaxis when safe.
- Not de-escalating antibiotics: narrow therapy when cultures result; reduces C. diff and nephrotoxicity.
- Forgetting thiamine in malnourished patients: give before glucose to lower encephalopathy risk.
Final Week Checklist
- Re-run core algorithms: ABCDE, shock, sepsis, ventilator adjustments, electrolyte rescues.
- Review must-know numbers: MAP, sodium correction limits, ventilator tidal volumes, glucose targets, transfusion thresholds.
- Do two timed mixed question blocks daily; review rationale, not just the answer.
- Skim POCUS images for IVC, lung B-lines, pneumothorax signs, and basic cardiac windows.
- Write out the first five minutes for: septic shock, A-fib with hypotension, DKA, COPD crash, stroke, anaphylaxis.
- Sleep, hydrate, and plan your test day logistics. Clear mind beats crammed facts.
Bottom line: The AGACNP exam tests your ability to stabilize, prioritize, and explain your choices. Use physiologic frameworks to guide each step. Practice with real scenarios. When in doubt, protect the airway, maintain perfusion, and choose the safest path while you clarify the diagnosis.
I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.
Mail- Sachin@pharmacyfreak.com