Core Competencies
24%of exam
PathophysiologyPharmacologyPhysical AssessmentAcid-Base/ABGOlder Adult
Clinical Practice
43%of exam
HemodynamicsMechanical VentilationACS/STEMISepsis BundleVasopressorsSedation
Professional Role
33%of exam
Evidence-Based PracticeQuality ImprovementScope of PracticeHealthcare Policy
Quick Facts
- Exam
- AGACNP-BC
- Credential
- Adult-Gerontology Acute Care NP
- Questions
- 175 (150 scored + 25 pretest)
- Time
- 3.5 hours
- Pass
- Scaled score 350/500
- Format
- CBT at Prometric
- Level
- Post-master's/DNP APRN
- Blueprint
- Mar 2025 (rev Aug)
MUDPILES (High Anion Gap)
Gap acidosis differential: 8 classic causes
Methanol, uremia, DKAPropylene glycol, iron, INHLactate, ethylene glycol, salicylates
Prerenal AKI vs ATN
Prerenal AKI
- FeNa <1%
- Low urine sodium
- Reversible with fluids
ATN
- FeNa >2%
- High urine sodium
- Tubular cell damage
FeNa <1 vs >2
Glucose Emergency Picker
- Glucose <70, alert patient→15-20g oral fast carbs
- Glucose <70, unconscious patient→Glucagon IM or IV dextrose
- Glucose >250, ketones, gap→Diagnose DKA
- K+ <3.3 before insulin→Replete potassium first
Acid-Base & ABG Interpretation
- Normal pH
- 7.35-7.45
- Normal PaCO2
- 35-45 mmHg
- Normal HCO3
- 22-26 mEq/L
- Anion gap formula
- Na - (Cl+HCO3)
- Normal anion gap
- 8-12 mEq/L
- Winters formula
- 1.5(HCO3)+8, +-2
- High-gap acidosis
- MUDPILES mnemonic causes
Delirium vs Dementia
Delirium
- Acute onset
- Fluctuating course
- Often reversible
Dementia
- Chronic onset
- Stable consciousness
- Progressive, irreversible
Acute/reversible vs chronic/progressive
High-Yield Pathophysiology
- Aortic dissection
- BP differential, tearing pain
- Prerenal AKI
- FeNa <1%, low UNa
- ATN
- FeNa >2%, high UNa
- Septic shock physiology
- catecholamine hyporeactivity, vasodilation
- Hepatic encephalopathy
- ammonia neurotoxicity
- Toxic megacolon
- colon >6cm, colitis
High-Yield Pharmacology
- Warfarin reversal (INR>8.5)
- oral vitamin K, minor bleed
- ACEI cough mechanism
- bradykinin accumulation
- Apixaban MOA
- direct factor Xa inhibition
- HIT treatment
- argatroban, avoid all heparin
- Steady state
- reached in 4-5 half-lives
- Digoxin toxicity
- hyperkalemia, visual disturbances
Older-Adult Considerations
- Atypical MI presentation
- dyspnea/confusion, no chest pain
- Beers Criteria
- flags inappropriate drugs, elderly
- Delirium
- acute, fluctuating, reversible
- Dementia
- chronic, stable, progressive
- Renal dosing
- reduced clearance, adjust doses
- Frailty phenotype
- weight loss, weakness, exhaustion
SIRS Criteria Mnemonic
Temp, heart rate, resp rate, WBC
Temp >38 or <36CHR >90, RR >20WBC >12k or <4k
STEMI vs NSTEMI
STEMI
- ST elevation present
- Transmural infarct
- Emergent PCI/lytics
NSTEMI
- ST depression/T inversion
- Partial-thickness infarct
- Urgent (non-emergent) cath
Elevation = emergent
Shock Type Picker (Hemodynamics)
- Low CO, high SVR, high PCWP→Cardiogenic shock
- Low CO, high SVR, low PCWP→Hypovolemic shock
- High CO, low SVR, low PCWP→Septic shock (warm)
- Low CO, high SVR, PCWP variable→Obstructive shock(PE, tamponade)
- Low CO, low SVR, bradycardia→Neurogenic shock
Hemodynamic Norms (PA Catheter)
- CVP / RAP
- 2-8 mmHg
- PA Pressure (sys/dia)
- 15-30 / 4-12 mmHg
- PCWP (wedge)
- 4-12 mmHg
- Cardiac Output (CO)
- 4-8 L/min
- Cardiac Index (CI)
- 2.5-4.0 L/min/m2
- SVR
- 800-1200 dynes.sec.cm-5
- SvO2 (mixed venous)
- 60-80%
Sepsis Hour-1 Bundle
Lactate, cultures, antibiotics, fluids, pressors
Measure lactate levelCultures before antibiotics30 mL/kg fluid bolusVasopressors if MAP <65
Septic vs Cardiogenic Shock
Septic shock
- Warm extremities
- Low SVR
- High cardiac output
Cardiogenic shock
- Cold extremities
- High SVR
- Low cardiac output
Warm vasodilated vs cold pump-failure
Vasopressor Selection Logic
- Septic shock, first-line agent→Norepinephrine
- Persistent hypotension on norepi→Add vasopressin
- Cardiogenic shock, low CO→Dobutamine or milrinone
- Anaphylaxis or cardiac arrest→Epinephrine
- Vasodilatory shock with tachyarrhythmia→Phenylephrine(no inotropy)
Mechanical Ventilation & ARDS
- Lung-protective Vt
- 4-8 mL/kg PBW
- Plateau pressure goal
- <30 cmH2O
- Mild ARDS (Berlin)
- P/F 200-300 mmHg
- Moderate ARDS (Berlin)
- P/F 100-200 mmHg
- Severe ARDS (Berlin)
- P/F <=100 mmHg
- RSBI <105
- predicts extubation success
- SBT pass criteria
- FiO2 <=40%, stable vitals
- Physiologic PEEP
- 5 cmH2O baseline
PADIS Sedation Priority
Treat pain first, then light sedation
Analgesia before sedationRASS goal -2 to 0Avoid benzodiazepine infusions
Sepsis vs Septic Shock
Sepsis
- Infection present
- Organ dysfunction (SOFA rise)
- No pressor need
Septic shock
- Vasopressors required
- Lactate >2 mmol/L
- MAP <65 despite fluids
Shock needs pressors + lactate
Ventilator Weaning Readiness
- FiO2 <=40%, PEEP <=5-8→Attempt SBT
- RSBI <105 on SBT→Predicts extubation success
- NIF more negative than -25→Adequate respiratory strength
- SBT tolerated 30-120 minutes→Extubate
- Auto-PEEP suspected clinically→Increase expiratory time
ACS / STEMI Essentials
- STEMI ECG
- >=1mm, 2 contiguous leads
- V2-V3 cutoff
- >=2mm men, >=1.5mm women
- Door-to-balloon goal
- <=90 minutes (PCI)
- Door-to-needle goal
- <=30 minutes (lytics)
- First med given
- aspirin 162-325mg chewed
- Nitro contraindication
- SBP <90, RV infarct
- RV infarct leads
- V4R (right-sided)
Stroke Time Windows
3 hours standard, 4.5 extended, 24 thrombectomy
tPA: 3h standard windowtPA: 4.5h extended windowThrombectomy: up to 24h
tPA Standard vs Extended Window
Standard (0-3h)
- Broader eligibility
- Fewer exclusions
Extended (3-4.5h)
- Age <=80 preferred
- No anticoagulant use
- No diabetes + prior stroke
3h broad, 4.5h stricter
Acute Chest Pain Triage
- ST elevation, 2 contiguous leads→Activate cath lab(STEMI)
- BP differential, tearing pain→CT angiography(dissection)
- Pulsatile epigastric mass→Gentle exam, urgent imaging
- SBP <90, RV infarct→Avoid nitrates, give fluids
Sepsis & SSC Hour-1 Bundle
- Hour-1 bundle order
- cultures before antibiotics
- Fluid bolus
- 30 mL/kg crystalloid
- MAP goal
- >=65mmHg; 60-65 if elderly
- Lactate trigger
- >2 mmol/L, remeasure serially
- Septic shock defined
- pressors + lactate >2
- qSOFA criteria
- RR>=22, SBP<=100, altered mentation
- First-line pressor
- norepinephrine
Norepinephrine vs Phenylephrine
Norepinephrine
- Alpha-1 + beta-1
- Adds inotropy
Phenylephrine
- Pure alpha-1 only
- No inotropy
- Reflex bradycardia risk
Need inotropy vs pure vasoconstriction
DKA Management
- DKA diagnosis
- glucose >250, pH <7.3
- DKA diagnosis (gap)
- bicarb <18, anion gap >12
- Insulin infusion rate
- 0.1 units/kg/hr
- Hold insulin bolus
- if K+ <3.3
- Add dextrose
- glucose <200-250 mg/dL
- DKA resolution
- gap closed, pH >7.3
Acute Stroke & tPA
- Standard tPA window
- 3 hours
- Extended tPA window
- up to 4.5 hours
- Pre-tPA BP limit
- <185/110 mmHg
- Post-tPA BP goal
- <180/105 mmHg, 24h
- Thrombectomy window (LVO)
- up to 24 hours
- NIHSS severe
- score 21-42
Vasopressors & Inotropes
- Norepinephrine
- alpha-1+beta-1, first-line septic
- Epinephrine
- alpha+beta, arrest/anaphylaxis
- Vasopressin
- fixed 0.03 units/min, adjunct
- Dobutamine
- beta-1 inotrope, can hypotend
- Phenylephrine
- pure alpha-1, no inotropy
- Milrinone
- PDE-3 inhibitor, inodilator
Sedation & Analgesia
- RASS goal
- -2 to 0
- Analgosedation
- treat pain before sedation
- Propofol risk
- PRIS, hypertriglyceridemia
- Dexmedetomidine
- alpha-2, no respiratory depression
- Avoid benzodiazepines
- higher delirium risk
- Daily SAT/SBT pairing
- reduces ventilator days
EBP & Quality Improvement
- Strongest evidence
- RCT, Level I
- PDSA - Do phase
- small-scale test implementation
- RCA method
- "5 Whys" technique
- RCA focus
- systems, not individual blame
- Power (1-beta)
- detects true difference
- Accreditor
- Joint Commission (TJC)
Scope, Legal & Ethics
- APRN Consensus 4 roles
- NP, CNS, CRNA, CNM
- Mandatory reporting
- suspected abuse, immediately
- Patient autonomy
- competent refusal honored
- AGACNP scope
- acutely/critically ill adults
- HIPAA rights
- record access + amendment
- Teach-back method
- verifies low-literacy education
Common Traps
Cardiogenic Shock ≠ Septic Shock
Cold, high SVR ≠ Warm, low SVR
SIRS ≠ Sepsis
Vital-sign criteria only ≠ Infection + organ dysfunction
Delirium ≠ Dementia
Acute, fluctuating, reversible ≠ Chronic, progressive, stable
Prerenal AKI ≠ ATN
FeNa <1%, reversible ≠ FeNa >2%, tubular damage
Norepinephrine ≠ Phenylephrine
Alpha + beta, inotropy ≠ Pure alpha, no inotropy
STEMI ≠ NSTEMI
ST elevation, emergent PCI ≠ ST depression, urgent cath
Dexmedetomidine ≠ Midazolam
Alpha-2, less delirium ≠ Benzodiazepine, more delirium risk
Last Minute
- 1.Weights: Core 24, Clinical 43%
- 2.Professional Role weight: 33%
- 3.175 questions, 150 scored, 3.5h
- 4.Passing scaled score: 350/500
- 5.Aspirin first in suspected STEMI
- 6.Cultures before antibiotics in sepsis
- 7.MAP 65 (60-65 if elderly)
- 8.Hold insulin bolus if K+<3.3
- 9.tPA: 3h standard, 4.5h extended
- 10.RASS goal: -2 to 0
- 11.Norepinephrine first-line in septic shock
- 12.RSBI <105 predicts extubation success
- 13.FeNa <1% points to prerenal
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