AOCNP Oncology Nurse Practitioner Certification Exam — Questions and Answers

Question 1: Which assessment finding requires the radiation oncology NP to immediately contact the treating physician during a course of pelvic radiation?

Grade 1 skin erythema in the field
Grade 1 diarrhea managed with loperamide
Mild fatigue reported at week 3
Gross hematuria, severe rectal bleeding, or signs of bowel perforation (Correct answer)

Correct answer: Gross hematuria, severe rectal bleeding, or signs of bowel perforation

Gross hematuria, significant rectal hemorrhage, or perforation signs indicate severe acute radiation toxicity requiring immediate evaluation and possible treatment interruption.

Question 2: The Edmonton Symptom Assessment System (ESAS) measures which of the following?

Opioid equianalgesic conversions
Prognosis using lab values and symptoms
Functional status using a 0–100% scale
Nine common symptoms including pain, fatigue, and anxiety on a 0–10 scale (Correct answer)

Correct answer: Nine common symptoms including pain, fatigue, and anxiety on a 0–10 scale

The ESAS assesses nine symptoms (pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, wellbeing, dyspnea) each on a 0–10 scale.

Question 3: A breast cancer survivor on long-term tamoxifen therapy is at increased risk for which gynecologic late effect requiring surveillance?

Cervical dysplasia
Ovarian cysts
Endometrial cancer (Correct answer)
Vaginal intraepithelial neoplasia

Correct answer: Endometrial cancer

Tamoxifen's partial estrogen agonist activity on the uterine endometrium increases the risk of endometrial cancer, requiring vigilance for abnormal uterine bleeding.

Question 4: Palliative sedation is ethically appropriate when:

The patient requests euthanasia
Refractory symptoms cannot be controlled by other means near end of life (Correct answer)
Family members request it without patient consent
Pain scores exceed 7 at any point in treatment

Correct answer: Refractory symptoms cannot be controlled by other means near end of life

Palliative sedation is ethically justified only for refractory, intractable symptoms at the end of life when all other interventions have failed.

Question 5: A 70-year-old woman asks about cervical cancer screening. Which recommendation is most appropriate for an average-risk woman her age?

Discontinue screening if she has had adequate prior screening with no abnormal results (Correct answer)
Begin colposcopy surveillance annually
Continue annual Pap smears indefinitely
Switch to HPV co-testing every 3 years

Correct answer: Discontinue screening if she has had adequate prior screening with no abnormal results

Women aged 65 and older with adequate prior negative screening can discontinue cervical cancer screening per USPSTF guidelines.

Question 6: A patient in the last hours of life becomes agitated and confused despite opioid therapy. Which intervention is most appropriate for managing terminal restlessness/agitation?

Apply physical restraints to protect the patient
Initiate empiric antibiotics for presumed delirium from infection
Add a benzodiazepine (e.g., midazolam or lorazepam) or neuroleptic (e.g., haloperidol) alongside opioids (Correct answer)
Increase opioid dose as the sole intervention

Correct answer: Add a benzodiazepine (e.g., midazolam or lorazepam) or neuroleptic (e.g., haloperidol) alongside opioids

Terminal agitation is best managed by combining opioids with a benzodiazepine (midazolam, lorazepam) or haloperidol to address the neuropsychiatric component of distress.

Question 7: A patient with small cell lung cancer presents with hyponatremia (Na 118 mEq/L), concentrated urine, and euvolemia. Which oncologic emergency is most likely?

Adrenal crisis
Cerebral salt wasting
Syndrome of inappropriate antidiuretic hormone (SIADH) (Correct answer)
Tumor lysis syndrome

Correct answer: Syndrome of inappropriate antidiuretic hormone (SIADH)

SIADH is a common paraneoplastic complication of small cell lung cancer presenting with euvolemic hyponatremia and urine osmolality inappropriately elevated relative to serum.

Question 8: Post-treatment surveillance guidelines for breast cancer survivors typically include clinical examination every 3–6 months for the first 3 years, then annually, combined with:

Semi-annual CT chest/abdomen/pelvis
Annual CA 15-3 serum marker measurement
Annual mammography of remaining breast tissue (Correct answer)
Annual PET/CT scan

Correct answer: Annual mammography of remaining breast tissue

ASCO and NCCN surveillance guidelines for breast cancer survivors recommend annual mammography as the primary imaging tool, along with clinical history and physical examination. Routine tumor markers (CA 15-3, CA 27-29) and CT/bone scans are NOT recommended for asymptomatic survivors due to lack of survival benefit and harms of overdiagnosis.

Question 9: The Rai and Binet staging systems are used to classify the prognosis of which hematologic malignancy?

Chronic myeloid leukemia (CML)
Hodgkin lymphoma
Multiple myeloma
Chronic lymphocytic leukemia (CLL) (Correct answer)

Correct answer: Chronic lymphocytic leukemia (CLL)

The Rai (US) and Binet (European) staging systems stratify CLL patients into risk groups based on lymphocytosis, lymphadenopathy, organomegaly, and cytopenias.

Question 10: Which agent is used as first-line prophylaxis against tumor lysis syndrome in high-risk patients?

Rasburicase
Allopurinol (Correct answer)
Hydroxyurea
Sodium bicarbonate

Correct answer: Allopurinol

Allopurinol inhibits xanthine oxidase and is the standard first-line prophylactic agent for intermediate- and high-risk TLS.

Question 11: Which laboratory finding is most consistent with tumor lysis syndrome?

Hypokalemia, hypophosphatemia, hypercalcemia
Hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia (Correct answer)
Hypernatremia, hypophosphatemia, hypercalcemia
Hyponatremia, hyperchloremia, hypercalcemia

Correct answer: Hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia

Tumor lysis syndrome is characterized by hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia from massive cell death.

Question 12: Which dosimetric parameter best predicts the risk of radiation-induced xerostomia when treating head and neck cancer?

Mean parotid gland dose exceeding 26 Gy (Correct answer)
V20 of the larynx exceeding 30%
Maximum spinal cord dose exceeding 45 Gy
Mean mandible dose exceeding 50 Gy

Correct answer: Mean parotid gland dose exceeding 26 Gy

A mean parotid gland dose above 26 Gy is strongly associated with permanent xerostomia in head and neck radiation therapy.

Question 13: A patient is diagnosed with acute promyelocytic leukemia (APL, AML-M3). Which agent is a cornerstone of induction therapy that induces differentiation of malignant promyelocytes?

Cytarabine (ara-C)
All-trans retinoic acid (ATRA) (Correct answer)
Daunorubicin
Hydroxyurea

Correct answer: All-trans retinoic acid (ATRA)

ATRA targets the PML-RARA fusion protein in APL, promoting differentiation of malignant promyelocytes and is combined with arsenic trioxide or anthracyclines for induction.

Question 14: Which statement about neutropenic enterocolitis (typhlitis) in oncology patients is CORRECT?

CT scan showing bowel wall thickening ≥4 mm supports the diagnosis (Correct answer)
It exclusively affects the sigmoid colon
Oral antibiotics are sufficient for mild cases
Immediate surgery is required in all confirmed cases

Correct answer: CT scan showing bowel wall thickening ≥4 mm supports the diagnosis

CT findings of bowel wall thickening ≥4 mm (particularly of the cecum/right colon) combined with neutropenia and abdominal pain support the diagnosis of typhlitis; initial management is usually conservative with bowel rest and broad-spectrum IV antibiotics.

Question 15: Which action is central to the NURSE communication framework used in delivering serious news to cancer patients?

Narrating the medical history clearly
Naming, understanding, respecting, supporting, and exploring emotions (Correct answer)
Assessing nurse competency in oncology
Notifying the family before the patient

Correct answer: Naming, understanding, respecting, supporting, and exploring emotions

The NURSE acronym (Name, Understand, Respect, Support, Explore) guides clinicians in empathically acknowledging and responding to patient emotions.

Question 16: A survivor of childhood ALL treated with high-dose methotrexate presents with learning difficulties and memory problems. This neurocognitive late effect is best described as:

Peripheral neuropathy
Leukoencephalopathy (Correct answer)
Radiation necrosis
Ototoxicity

Correct answer: Leukoencephalopathy

High-dose methotrexate and cranial radiation can cause leukoencephalopathy, manifesting as neurocognitive deficits including memory and learning impairment.

Question 17: A patient who received mantle field radiation for Hodgkin lymphoma 15 years ago presents for a routine visit. Which surveillance is most critically indicated?

Annual mammography starting 8–10 years after radiation or at age 25 for breast cancer screening (Correct answer)
Annual chest X-ray only
No additional surveillance beyond standard age-based screening
PSA testing only

Correct answer: Annual mammography starting 8–10 years after radiation or at age 25 for breast cancer screening

Mantle field radiation dramatically increases breast cancer risk; NCCN recommends annual MRI and mammography beginning 8–10 years post-treatment or at age 25, whichever is later.

Question 18: A patient with breast cancer is receiving doxorubicin. Which baseline assessment is most critical before initiating therapy?

Pulmonary function tests
Serum creatinine and eGFR
Liver biopsy
Echocardiogram or MUGA scan for cardiac function (Correct answer)

Correct answer: Echocardiogram or MUGA scan for cardiac function

Doxorubicin is cardiotoxic; baseline left ventricular ejection fraction must be established before starting therapy to monitor for cardiomyopathy.

Question 19: Compassionate use (expanded access) allows patients outside a clinical trial to receive an investigational drug when:

The drug has been approved in another country
The patient has a serious or life-threatening condition with no satisfactory alternatives and cannot enroll in the trial (Correct answer)
The drug has completed all Phase III trial requirements
The patient specifically requests to pay out-of-pocket for the drug

Correct answer: The patient has a serious or life-threatening condition with no satisfactory alternatives and cannot enroll in the trial

FDA's expanded access (compassionate use) program allows patients with serious or immediately life-threatening conditions to access investigational drugs outside of clinical trials when: (1) no comparable alternatives exist, (2) the patient cannot participate in the clinical trial, (3) potential benefit justifies risk, and (4) access will not interfere with trial completion.

Question 20: Which of the following best describes the concept of 'total pain' as used in palliative care?

The multidimensional suffering encompassing physical, psychological, social, and spiritual components (Correct answer)
Pain experienced only in the final 48 hours of life
Pain that is unresponsive to opioid therapy
The numeric pain rating on a 0–10 scale

Correct answer: The multidimensional suffering encompassing physical, psychological, social, and spiritual components

Dame Cicely Saunders defined 'total pain' as the interplay of physical, psychological, social, and spiritual dimensions of suffering.

Question 21: The MASCC score is used to stratify risk in which oncologic condition?

Febrile neutropenia (Correct answer)
Hypercalcemia of malignancy
Tumor lysis syndrome
Spinal cord compression

Correct answer: Febrile neutropenia

The Multinational Association for Supportive Care in Cancer (MASCC) score identifies low-risk febrile neutropenia patients who may be managed with oral antibiotics outpatient.

Question 22: Anticipatory grief is best described as:

Grief experienced only by the patient, not caregivers
Grief that is absent initially and surfaces months later
Grief experienced before an expected loss occurs (Correct answer)
Complicated grief requiring psychiatric diagnosis

Correct answer: Grief experienced before an expected loss occurs

Anticipatory grief occurs before the death and encompasses the losses already experienced and those expected, affecting both patients and families.

Question 23: An operation called a pneumonectomy is occasionally required to treat non-small-cell lung cancer. When performing a pneumonectomy, removal of:

One or more segments of a lung lobe
An entire lung field (Correct answer)
A small, wedge-shaped lung surface
One lobe of a lung

Correct answer: An entire lung field

An full lung field is removed during a pneumonectomy, which is used to treat non-small cell lung cancer that has not spread outside of the lung tissue. Patients who will have sufficient lung function in the unaffected lung are candidates for the procedure.

Question 24: Osteoradionecrosis is a late complication of radiation most commonly occurring in which anatomical site?

Femoral head (hip)
Mandible (jaw) (Correct answer)
Humeral head (shoulder)
Lumbar vertebral bodies

Correct answer: Mandible (jaw)

Osteoradionecrosis of the mandible is a severe late radiation complication in patients receiving head and neck radiation. Risk factors include dental extraction in irradiated fields, high cumulative doses, infection, and poor dentition. Prevention includes dental evaluation and extractions before radiation begins.

Question 25: Aspirin chemoprevention is associated with reduced risk of which cancer when taken long-term?

Lung cancer
Breast cancer
Prostate cancer
Colorectal cancer (Correct answer)

Correct answer: Colorectal cancer

Long-term aspirin use reduces colorectal cancer incidence and mortality by inhibiting COX-2-mediated prostaglandin synthesis that promotes colonic adenoma growth.

Question 26: Dense breast tissue on mammography increases breast cancer risk and also:

Only affects risk in postmenopausal women
Is not clinically relevant to screening protocols
Increases sensitivity of mammography
Reduces mammographic sensitivity, potentially requiring supplemental MRI or ultrasound (Correct answer)

Correct answer: Reduces mammographic sensitivity, potentially requiring supplemental MRI or ultrasound

Dense fibroglandular tissue masks lesions on mammography (masking effect) and is also an independent risk factor, prompting many states to mandate notification and offer supplemental screening.

Question 27: An oncology NP is advising a patient undergoing FOLFOX chemotherapy who wants to take high-dose St. John's Wort for depression. What is the primary clinical concern with this supplement?

St. John's Wort causes additive myelosuppression when combined with oxaliplatin
St. John's Wort directly inhibits cancer cell apoptosis, reducing chemotherapy efficacy
St. John's Wort causes peripheral neuropathy that mimics oxaliplatin toxicity
St. John's Wort is a potent CYP3A4 inducer that can significantly reduce plasma levels of chemotherapy and other co-administered drugs (Correct answer)

Correct answer: St. John's Wort is a potent CYP3A4 inducer that can significantly reduce plasma levels of chemotherapy and other co-administered drugs

St. John's Wort (Hypericum perforatum) is a potent inducer of CYP3A4 and P-glycoprotein, significantly increasing the metabolism and clearance of many drugs. In oncology patients, this can reduce plasma concentrations of chemotherapy agents, targeted therapies (including irinotecan's active metabolite SN-38), and other co-medications, potentially compromising treatment efficacy. This is a clinically significant and well-documented herb-drug interaction that the oncology NP must screen for.

Question 28: For recurrent breast cancer, a 56-year-old lady is currently undergoing radiation treatment to the chest wall. She makes a phone call to her doctor to let them know that she is having chest pain, burning, and difficulty swallowing. Which of the following radiation therapy side effects is A. She likely has radiation enteritis, therefore what's causing her symptoms?

Radiation enteritis
Esophagitis (Correct answer)
Stomatitis
Hiatal hernia

Correct answer: Esophagitis

Esophagitis is a typical side effect of radiation therapy for the chest wall and is characterized by difficulty swallowing, pain, and tightness in the chest.

Question 29: According to the TNM staging system, which descriptor indicates that cancer cells have spread to regional lymph nodes?

T2
G2
M1
N1 (Correct answer)

Correct answer: N1

In the TNM system, N describes regional lymph node involvement (N0 = no nodes, N1+ = regional node spread). T describes primary tumor size/extension, M describes distant metastasis, and G describes histologic grade. N1 specifically indicates spread to regional lymph nodes, which is a critical staging determinant affecting treatment planning.

Question 30: A patient with multiple myeloma develops acute flaccid paraplegia with urinary retention. MRI shows vertebral compression at T6 with epidural extension. Surgical evaluation is obtained. What is the PRIMARY factor determining eligibility for surgical decompression over radiation alone?

Presence of pathological fracture at the affected level
Sensitivity of the underlying malignancy to radiation
Patient's overall performance status and life expectancy (Correct answer)
Duration of neurological symptoms less than 24 hours

Correct answer: Patient's overall performance status and life expectancy

Patient performance status and prognosis (expected survival >3 months) are the primary determinants of whether surgical decompression is appropriate, as surgery offers no benefit to patients who cannot tolerate the procedure or have very limited life expectancy.

Question 31: Nine days after chemotherapy, a 36-year-old cancer patient exhibits warning signs of impending septic shock. Which of the following would the nurse anticipate to be present?

Flushing, decreased oxygen saturation, mild hypotension
Low-grade fever, chills, tachycardia (Correct answer)
High-grade fever, normal blood pressure, increased respirations
Elevated temperature, oliguria, hypotension

Correct answer: Low-grade fever, chills, tachycardia

One would anticipate that the patient will have compromised immunity nine days following chemotherapy. Changes in heart function, vascular resistance, cellular metabolism, and capillary permeability are reflected in the clinical manifestations of shock. Tachycardia, flushing, and a low-grade temperature could be the first indications of shock.

Question 32: Radiation pneumonitis typically presents within which timeframe after thoracic radiation?

Only during active treatment fractions
Within the first week of treatment
More than 2 years after treatment
1–6 months after completion of radiation (Correct answer)

Correct answer: 1–6 months after completion of radiation

Radiation pneumonitis presents 1–6 months after thoracic irradiation with dyspnea, cough, and low-grade fever as inflammatory cytokines accumulate in irradiated lung.

Question 33: During a community health fair, an NP screens attendees for oral cancer. Which finding warrants immediate referral rather than watchful waiting?

Angular cheilitis in a patient with dentures
Small aphthous ulcer healing over 2 weeks
Erythroplakia on the floor of the mouth persisting >2 weeks (Correct answer)
Geographic tongue with central red area

Correct answer: Erythroplakia on the floor of the mouth persisting >2 weeks

Erythroplakia carries up to a 51% risk of malignant transformation and persistent lesions >2 weeks require immediate biopsy referral.

Question 34: Which targeted therapy is a monoclonal antibody that blocks the HER2 receptor in HER2-positive breast cancer?

Bevacizumab
Imatinib
Erlotinib
Trastuzumab (Correct answer)

Correct answer: Trastuzumab

Trastuzumab (Herceptin) binds the extracellular domain of HER2, inhibiting downstream proliferative signaling and mediating antibody-dependent cytotoxicity.

Question 35: Which nursing assessment finding would MOST strongly suggest superior vena cava (SVC) syndrome in a patient with lung cancer?

Facial plethora, neck vein distension, and worsening dyspnea when supine (Correct answer)
Bilateral lower extremity pitting edema and ascites
New jugular venous pulsation with a split S2 heart sound
Sudden onset chest pain radiating to the left arm

Correct answer: Facial plethora, neck vein distension, and worsening dyspnea when supine

SVC syndrome causes impaired venous return from the upper body, resulting in facial plethora, neck vein distension, and positional dyspnea (worse when lying flat).

Question 36: A patient with polycythemia vera (PV) develops a new stroke. Which mutation drives the majority of PV cases and is used for diagnosis?

JAK2 V617F (Correct answer)
BCR-ABL1
MPL W515L
CALR exon 9

Correct answer: JAK2 V617F

JAK2 V617F is present in >95% of PV cases and is central to the 2016 WHO diagnostic criteria.

Question 37: Stereotactic body radiation therapy (SBRT) for a peripheral lung tumor uses a biologically effective dose (BED) of 100 Gy or more. This high BED is thought to achieve tumor control partly through which mechanism beyond direct DNA damage?

Enhanced repair of sublethal damage in tumor cells
Increased tumor oxygenation from vascular normalization
Upregulation of tumor suppressor genes
Ablation of tumor vasculature causing indirect tumor cell death (Correct answer)

Correct answer: Ablation of tumor vasculature causing indirect tumor cell death

High-dose-per-fraction SBRT is believed to destroy tumor vasculature, causing indirect tumor cell death through ischemia in addition to direct cytotoxicity.

Question 38: Which opioid is considered first-line for moderate-to-severe cancer pain according to the WHO analgesic ladder?

Tramadol
Morphine (Correct answer)
Acetaminophen
Codeine

Correct answer: Morphine

Morphine remains the WHO-recommended first-line strong opioid for moderate-to-severe cancer pain at Step 3 of the analgesic ladder.

Question 39: Prehabilitation in the preoperative period for cancer surgery focuses on which intervention?

Initiating radiation therapy to shrink the tumor before resection
Optimizing physical fitness, nutrition, and psychological readiness before surgery (Correct answer)
Administering preoperative chemotherapy exclusively
Completing all staging workup within 72 hours

Correct answer: Optimizing physical fitness, nutrition, and psychological readiness before surgery

Prehabilitation is a multimodal preoperative program including aerobic and resistance exercise, nutritional optimization (protein supplementation, addressing deficiencies), and anxiety management. It has been shown to reduce postoperative complications, shorten length of stay, and improve functional recovery particularly for major abdominal and thoracic cancer surgeries.

Question 40: A patient with colon cancer on bevacizumab presents with sudden-onset severe abdominal pain, tachycardia, and signs of peritonitis. Which bevacizumab-associated oncologic emergency should be suspected?

Gastrointestinal perforation (Correct answer)
Bevacizumab-induced thrombocytopenia
Hypersensitivity anaphylaxis
Venous thrombosis of mesenteric vessels

Correct answer: Gastrointestinal perforation

Gastrointestinal perforation is a serious known complication of bevacizumab (VEGF inhibitor) due to impaired wound healing and mucosal integrity, occurring in approximately 1-2% of treated patients.

Question 41: A patient with malignant bowel obstruction is not a surgical candidate. Which combination is most appropriate for symptom management?

Opioids for pain, an antisecretory agent, and antiemetics (Correct answer)
High-dose laxatives and oral fluids only
High-fiber diet and prokinetic agents
Parenteral nutrition and nasogastric suction indefinitely

Correct answer: Opioids for pain, an antisecretory agent, and antiemetics

Malignant bowel obstruction is managed with opioids for pain/colic, antisecretory agents (e.g., octreotide or hyoscine) to reduce secretions, and antiemetics.

Question 42: A cancer patient presents with fever, confusion, and diffuse petechiae. Labs show thrombocytopenia, elevated D-dimer, prolonged PT/PTT, and low fibrinogen. Which emergent condition requires immediate treatment?

Thrombotic thrombocytopenic purpura (TTP)
Disseminated intravascular coagulation (DIC) (Correct answer)
Immune thrombocytopenic purpura (ITP)
Heparin-induced thrombocytopenia (HIT)

Correct answer: Disseminated intravascular coagulation (DIC)

DIC is characterized by simultaneous thrombosis and hemorrhage with consumption of clotting factors (low fibrinogen, elevated D-dimer, prolonged PT/PTT) and is a life-threatening emergency requiring urgent treatment.

Question 43: Which non-pharmacological intervention has the strongest evidence for reducing cancer-related fatigue?

Aerobic exercise (Correct answer)
Vitamin C supplementation
Prolonged bed rest
Methylphenidate alone

Correct answer: Aerobic exercise

Aerobic exercise is the most evidence-based intervention for cancer-related fatigue, improving both physical and psychological components.

Question 44: What is the primary mechanism by which ionizing radiation kills cancer cells?

Inhibiting angiogenesis within the tumor microenvironment
Activating natural killer cells to attack tumor cells
Inducing DNA double-strand breaks leading to apoptosis or mitotic catastrophe (Correct answer)
Directly disrupting cell membrane integrity

Correct answer: Inducing DNA double-strand breaks leading to apoptosis or mitotic catastrophe

Radiation kills cells primarily through direct and indirect (free radical-mediated) DNA double-strand breaks. Cells unable to repair this damage undergo apoptosis, necrosis, or mitotic catastrophe. Rapidly dividing cells are most sensitive due to less time for DNA repair between divisions.

Question 45: A patient on venetoclax for AML develops tumor lysis syndrome (TLS). Which lab finding is NOT a feature of TLS?

Hypercalcemia (Correct answer)
Hyperphosphatemia
Hyperuricemia
Hyperkalemia

Correct answer: Hypercalcemia

TLS causes hypocalcemia (not hypercalcemia) because phosphate released from lysed cells binds calcium, lowering serum levels.

Question 46: Which electrolyte abnormality is NOT typically associated with tumor lysis syndrome (TLS)?

Hyperkalemia
Hypocalcemia
Hyperphosphatemia
Hypernatremia (Correct answer)

Correct answer: Hypernatremia

TLS is characterized by hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia resulting from massive cell lysis; sodium levels are not directly affected by intracellular contents.

Question 47: A patient receiving cisplatin-based chemotherapy develops tinnitus and high-frequency hearing loss. Which intervention is the nurse's priority?

Notify the oncologist immediately and document findings (Correct answer)
Administer amifostine as ordered
Reassure the patient this is a temporary side effect
Schedule an audiologist referral for next week

Correct answer: Notify the oncologist immediately and document findings

Ototoxicity is a serious cisplatin toxicity that should be promptly reported to the oncologist as it may require dose modification or discontinuation.

Question 48: Which grading system is used by oncology nurses to assess and document radiation-induced side effects including mucositis and dermatitis?

Karnofsky Performance Scale
CTCAE (Common Terminology Criteria for Adverse Events) (Correct answer)
ECOG Performance Status Scale
NCI-ODWG grading

Correct answer: CTCAE (Common Terminology Criteria for Adverse Events)

The CTCAE (published by NCI) is the standardized system for grading adverse events in oncology, grading toxicities from 1 (mild) to 5 (death). Radiation-induced dermatitis, mucositis, esophagitis, and other toxicities are all graded using CTCAE criteria.

Question 49: The primary tool used to formally screen cancer survivors for distress at regular intervals is:

The SF-36 Health Survey
The NCCN Distress Thermometer and Problem List (Correct answer)
The PHQ-9 (Patient Health Questionnaire-9)
The Hamilton Anxiety Rating Scale

Correct answer: The NCCN Distress Thermometer and Problem List

The NCCN Distress Thermometer (DT) with the accompanying Problem List is the most widely used validated rapid distress screening tool in oncology. A score ≥4 on the 0–10 scale indicates clinically significant distress warranting psychosocial evaluation. It screens across practical, family, emotional, spiritual, and physical domains.

Question 50: For a patient with head and neck cancer undergoing concurrent chemoradiation who cannot maintain adequate oral intake due to mucositis, which nutritional support route is most appropriate?

Total parenteral nutrition (TPN) via central venous access
Enteral nutrition via nasogastric or gastrostomy tube (Correct answer)
Intravenous dextrose infusions to maintain caloric needs
High-calorie oral supplements alone with appetite stimulants

Correct answer: Enteral nutrition via nasogastric or gastrostomy tube

When the GI tract is functional, enteral nutrition (via NG tube or prophylactic PEG/RIG) is the preferred route and is supported by ASPEN, ESPEN, and ASCO guidelines for patients who cannot maintain adequate oral intake. Enteral feeding maintains gut integrity, reduces infection risk, and is more physiologic than parenteral nutrition. TPN is reserved for patients with a non-functional GI tract. Oral supplements alone are insufficient if mucositis prevents adequate intake. IV dextrose provides calories but no protein or micronutrients.

Question 51: Methylnaltrexone (Relistor) treats opioid-induced constipation by:

Blocking peripheral mu-opioid receptors in the GI tract without reversing central analgesia (Correct answer)
Inhibiting serotonin in the gut
Stimulating intestinal smooth muscle directly
Increasing intestinal secretions

Correct answer: Blocking peripheral mu-opioid receptors in the GI tract without reversing central analgesia

Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist that reverses GI opioid effects without crossing the blood-brain barrier.

Question 52: Which of the following is the FIRST-LINE treatment for malignant spinal cord compression (MSCC) once the diagnosis is confirmed?

Emergent radiation therapy
IV bisphosphonate therapy
High-dose corticosteroids (dexamethasone) (Correct answer)
Surgical decompression

Correct answer: High-dose corticosteroids (dexamethasone)

High-dose dexamethasone should be initiated immediately upon suspicion or confirmation of MSCC to reduce cord edema and preserve neurological function while definitive therapy is arranged.

Question 53: Rasburicase is contraindicated in which patient population due to risk of hemolytic anemia?

Patients receiving steroids
Patients with renal impairment
Patients with G6PD deficiency (Correct answer)
Patients with hepatic failure

Correct answer: Patients with G6PD deficiency

Rasburicase generates hydrogen peroxide as a byproduct, which causes oxidative hemolysis in patients with G6PD deficiency.

Question 54: Radiation-induced xerostomia (dry mouth) is most effectively prevented by which technique when treating head and neck cancers?

Intensity-modulated radiation therapy (IMRT) with parotid gland sparing (Correct answer)
Using brachytherapy for all head and neck cancers
Reducing the total radiation dose below 30 Gy
Amifostine premedication before every fraction

Correct answer: Intensity-modulated radiation therapy (IMRT) with parotid gland sparing

IMRT allows dose sculpting that significantly spares the parotid glands (mean dose <26 Gy), substantially reducing the incidence and severity of permanent xerostomia compared to conventional 3D-conformal techniques. Amifostine has modest benefit and significant toxicity.

Question 55: Which blood count threshold typically prompts platelet transfusion in a non-bleeding oncology patient per standard guidelines?

Platelet count below 50,000/mm³
Platelet count below 100,000/mm³
Platelet count below 75,000/mm³
Platelet count below 10,000/mm³ (Correct answer)

Correct answer: Platelet count below 10,000/mm³

Current guidelines recommend prophylactic platelet transfusion at <10,000/mm³ in non-bleeding, hemodynamically stable patients to reduce spontaneous hemorrhage risk.

Question 56: A patient asks about the difference between adjuvant and neoadjuvant chemotherapy. The BEST explanation is:

Neoadjuvant is given before primary treatment to downstage disease; adjuvant is given after to reduce recurrence risk (Correct answer)
Adjuvant is given to shrink the tumor before surgery; neoadjuvant is given after surgery to kill residual disease
Both terms refer to chemotherapy given concurrently with radiation therapy
Neoadjuvant refers to chemotherapy for metastatic disease; adjuvant refers to localized disease only

Correct answer: Neoadjuvant is given before primary treatment to downstage disease; adjuvant is given after to reduce recurrence risk

Neoadjuvant chemotherapy is administered before primary treatment (surgery/radiation) to reduce tumor size, while adjuvant chemotherapy is given afterward to eliminate micrometastatic disease.

Question 57: A patient with CML has a BCR-ABL transcript level that increases 1-log after being on imatinib for 12 months. What is the most appropriate next step?

Proceed to allogeneic stem cell transplant immediately
Continue imatinib and recheck in 6 months
Switch to a second-generation TKI such as dasatinib or nilotinib (Correct answer)
Add hydroxyurea to imatinib

Correct answer: Switch to a second-generation TKI such as dasatinib or nilotinib

Loss of major molecular response or increasing BCR-ABL transcripts on imatinib indicates treatment failure, and switching to a second-generation TKI is recommended.

Question 58: A patient with metastatic breast cancer develops altered mental status, polyuria, and constipation. Calcium is 14.2 mg/dL. Which mechanism is MOST responsible for hypercalcemia in solid tumors without bone metastases?

Primary hyperparathyroidism
Osteoclast activation by bone metastases
Excess 1,25-dihydroxyvitamin D production
PTHrP (parathyroid hormone-related protein) secretion (Correct answer)

Correct answer: PTHrP (parathyroid hormone-related protein) secretion

Humoral hypercalcemia of malignancy (HHM) is most commonly caused by tumor secretion of PTHrP, which mimics PTH and increases bone resorption and renal calcium reabsorption.

Question 59: A hospice patient develops myoclonic jerks and hyperalgesia after high-dose morphine. Which action best addresses opioid-induced neurotoxicity?

Discontinue all opioids and treat with NSAIDs
Increase morphine to overcome tolerance
Opioid rotation to a different agent such as hydromorphone (Correct answer)
Add lorazepam to suppress myoclonus only

Correct answer: Opioid rotation to a different agent such as hydromorphone

Opioid rotation (switching to an equianalgesic dose of a different opioid) reduces neurotoxic metabolite accumulation and relieves opioid-induced neurotoxicity.

Question 60: Which toxicity is most specifically associated with bleomycin and requires monitoring with pulmonary function tests?

Pulmonary fibrosis and pneumonitis (Correct answer)
Hepatotoxicity with elevated transaminases
Nephrotoxicity with rising creatinine
Cardiotoxicity with reduced ejection fraction

Correct answer: Pulmonary fibrosis and pneumonitis

Bleomycin causes pulmonary toxicity ranging from pneumonitis to fibrosis, which can be life-threatening and requires baseline and serial PFTs.

Question 61: Which of the following best describes the mechanism of action of trastuzumab (Herceptin)?

It blocks programmed death-ligand 1 (PD-L1) to restore T-cell activity
It binds HER2 receptors and inhibits downstream PI3K/Akt signaling (Correct answer)
It inhibits BCR-ABL tyrosine kinase to block cell proliferation
It intercalates DNA and inhibits topoisomerase II

Correct answer: It binds HER2 receptors and inhibits downstream PI3K/Akt signaling

Trastuzumab is a monoclonal antibody that binds the extracellular domain of HER2, inhibiting HER2-mediated signaling and promoting antibody-dependent cellular cytotoxicity.

Question 62: The mechanism of action of methotrexate is:

Inhibition of topoisomerase II
Inhibition of dihydrofolate reductase, depleting folate required for DNA synthesis (Correct answer)
Intercalation between DNA base pairs
Binding to tubulin to prevent spindle formation

Correct answer: Inhibition of dihydrofolate reductase, depleting folate required for DNA synthesis

Methotrexate inhibits DHFR, preventing reduction of folate to its active form and thereby blocking thymidylate and purine synthesis.

Question 63: A patient with advanced lung cancer reports severe dyspnea at rest despite supplemental oxygen. Which intervention has the strongest evidence for relieving refractory dyspnea in this setting?

Increase inspired oxygen concentration to 100%
Low-dose systemic opioids (Correct answer)
Nebulized furosemide
Anxiolytics alone without opioids

Correct answer: Low-dose systemic opioids

Low-dose systemic opioids (e.g., oral morphine) are the most evidence-based pharmacologic intervention for refractory dyspnea in advanced cancer.

Question 64: Which first-line intervention is indicated for hypercalcemia of malignancy with corrected serum calcium > 14 mg/dL?

IV bisphosphonate alone
Furosemide alone
Oral calcitonin
Aggressive IV normal saline hydration followed by bisphosphonate (Correct answer)

Correct answer: Aggressive IV normal saline hydration followed by bisphosphonate

Aggressive IV normal saline rehydration is the immediate priority, followed by a bisphosphonate such as zoledronic acid to lower calcium.

Question 65: A patient is newly diagnosed with diffuse large B-cell lymphoma (DLBCL). Which staging system is most appropriate for this hematologic malignancy?

Lugano classification (modified Ann Arbor staging) (Correct answer)
Dukes classification
FIGO staging
TNM (tumor-node-metastasis) staging

Correct answer: Lugano classification (modified Ann Arbor staging)

The Lugano classification, a refinement of the Ann Arbor staging system, is used for lymphomas including DLBCL. It uses Stages I–IV based on nodal and extranodal involvement and incorporates PET-CT findings. TNM is used for solid tumors. FIGO is for gynecologic cancers. Dukes classification is an older system for colorectal cancer.

Question 66: A clinical trial uses a 2×2 factorial design. What is the primary advantage of this design?

It guarantees blinding of all participants
It eliminates the need for a placebo control
It allows simultaneous testing of two independent interventions in one trial (Correct answer)
It requires fewer statistical analyses than parallel-group designs

Correct answer: It allows simultaneous testing of two independent interventions in one trial

Factorial designs test two or more interventions simultaneously, increasing efficiency by answering multiple questions with one sample.

Question 67: A patient with lung cancer develops facial plethora, arm edema, and distended neck veins. Which imaging study is the priority?

Bone scan
CT chest with contrast (Correct answer)
Echocardiogram
MRI brain

Correct answer: CT chest with contrast

CT chest with contrast delineates the extent of superior vena cava (SVC) obstruction and identifies the underlying mass causing it.

Question 68: Radiation-induced mucositis in the oral cavity is best managed with:

Corticosteroid mouthwash as monotherapy
Antibiotics regardless of infection signs
Frequent saline rinses, pain assessment, and nutritional support (Correct answer)
Prophylactic antifungals only

Correct answer: Frequent saline rinses, pain assessment, and nutritional support

Saline rinses maintain oral hygiene, regular pain assessment guides analgesic escalation, and nutritional support prevents the weight loss associated with mucositis.

Question 69: Which serum tumor marker, when significantly elevated at diagnosis of a testicular mass, is most specific for non-seminomatous germ cell tumors (NSGCTs)?

PSA (prostate-specific antigen)
CEA (carcinoembryonic antigen)
AFP (alpha-fetoprotein) (Correct answer)
CA-125

Correct answer: AFP (alpha-fetoprotein)

AFP is characteristically elevated in non-seminomatous germ cell tumors (embryonal carcinoma, yolk sac tumor) and is not produced by pure seminomas. Its elevation helps differentiate NSGCT from pure seminoma, which is critical because treatment approaches differ. CA-125 is used for ovarian cancer. PSA for prostate cancer. CEA is a non-specific marker used in colorectal, lung, and breast cancers.

Question 70: A patient with multiple myeloma presents with severe back pain, lower extremity weakness, and urinary retention. Which oncologic emergency does this presentation suggest?

Superior vena cava syndrome
Tumor lysis syndrome
Hypercalcemia of malignancy
Spinal cord compression (Correct answer)

Correct answer: Spinal cord compression

Spinal cord compression presents with back pain, motor weakness, and autonomic dysfunction such as urinary retention or incontinence.

Question 71: Which biomarker is most useful for monitoring response to therapy in patients with hepatocellular carcinoma?

CEA
CA 19-9
PSA
Alpha-fetoprotein (AFP) (Correct answer)

Correct answer: Alpha-fetoprotein (AFP)

Alpha-fetoprotein (AFP) is the primary tumor marker used to monitor treatment response and surveillance in hepatocellular carcinoma.

Question 72: Which antiemetic class is the MOST effective for preventing acute chemotherapy-induced nausea and vomiting (CINV) from highly emetogenic regimens?

Lorazepam alone
5-HT3 receptor antagonists combined with NK1 antagonists and dexamethasone (Correct answer)
Prochlorperazine alone
Metoclopramide as monotherapy

Correct answer: 5-HT3 receptor antagonists combined with NK1 antagonists and dexamethasone

Triple antiemetic prophylaxis with a 5-HT3 antagonist, NK1 antagonist (aprepitant), and dexamethasone is the guideline-recommended standard for highly emetogenic chemotherapy.

Question 73: The International Prognostic Index (IPI) for aggressive non-Hodgkin lymphoma includes which of the following five adverse factors?

Age >60, bone marrow involvement, elevated LDH, B symptoms, Stage III–IV
Age >60, elevated LDH, low hemoglobin, Stage III–IV, >1 nodal site
Age >60, elevated LDH, ECOG PS ≥2, Stage III–IV, >1 extranodal site (Correct answer)
Elevated LDH, low albumin, elevated beta-2 microglobulin, ECOG PS ≥2, Stage IV

Correct answer: Age >60, elevated LDH, ECOG PS ≥2, Stage III–IV, >1 extranodal site

The five IPI factors are age >60 years, elevated serum LDH, ECOG performance status ≥2, Ann Arbor Stage III or IV, and >1 extranodal site of disease involvement.

Question 74: Which cancer type is most commonly associated with disseminated intravascular coagulation (DIC) in adults?

Colorectal cancer
Renal cell carcinoma
Melanoma
Acute promyelocytic leukemia (APL) (Correct answer)

Correct answer: Acute promyelocytic leukemia (APL)

APL releases tissue factor and procoagulant granules, causing the most severe DIC of any malignancy.

Question 75: A 58-year-old woman with dense breasts on mammography has a negative mammogram. Which supplemental screening modality has the strongest evidence for increasing cancer detection in this population?

Supplemental MRI for women with extremely dense breasts and average risk
Annual ultrasound added to mammography (Correct answer)
Thermography of the breasts
Digital breast tomosynthesis (3D mammography) as the primary screen

Correct answer: Annual ultrasound added to mammography

Supplemental ultrasound increases cancer detection by approximately 4 per 1,000 women with dense breasts, though it also increases false-positive rates; MRI is reserved for higher-risk women.

Question 76: A female cancer survivor treated with cyclophosphamide-based chemotherapy reports amenorrhea and hot flashes. These symptoms are most likely related to:

Hypothyroidism from radiation scatter
Premature ovarian insufficiency (POI) / chemotherapy-induced menopause (Correct answer)
Paraneoplastic syndrome
Adrenal insufficiency from chemotherapy

Correct answer: Premature ovarian insufficiency (POI) / chemotherapy-induced menopause

Alkylating agents (cyclophosphamide, ifosfamide) and platinum compounds are the most gonadotoxic chemotherapy drugs, causing premature ovarian insufficiency (POI) in premenopausal women through direct destruction of primordial follicles. POI manifests as amenorrhea, vasomotor symptoms, infertility, sexual dysfunction, and accelerated bone loss.

Question 77: Which finding on a mammogram is classified as BI-RADS 5 and requires immediate biopsy?

Highly suggestive of malignancy, tissue sampling recommended (Correct answer)
Probably benign finding, short-interval follow-up suggested
Negative, routine screening recommended
Incomplete, additional imaging needed

Correct answer: Highly suggestive of malignancy, tissue sampling recommended

BI-RADS 5 indicates findings that are highly suggestive of malignancy (>95% likelihood), such as irregular spiculated masses with pleomorphic microcalcifications. Tissue biopsy is mandatory for all BI-RADS 5 findings.

Question 78: Which intervention is most effective for managing malignant bowel obstruction in a patient with poor prognosis who is not a surgical candidate?

High-dose laxatives
Octreotide plus corticosteroids plus antiemetics (Correct answer)
Total parenteral nutrition as primary therapy
Nasogastric tube feeding indefinitely

Correct answer: Octreotide plus corticosteroids plus antiemetics

Octreotide reduces intestinal secretions, corticosteroids reduce perilesional edema, and antiemetics manage nausea — this triad palliates MBO without surgery.

Question 79: A patient receiving palliative radiation for painful bone metastases asks when to expect pain relief. The nurse practitioner should counsel that onset of analgesic effect typically occurs:

Pain relief from radiation is unpredictable and rarely occurs
Within 2–4 hours of the first fraction
Only after completing the full fractionated course (6–10 weeks)
Within 1–4 weeks after the start of treatment (Correct answer)

Correct answer: Within 1–4 weeks after the start of treatment

Palliative radiotherapy for bone pain typically produces a response within 1–4 weeks; partial or complete pain relief is achieved in approximately 60–70% of patients.

Question 80: A patient with advanced cancer develops hypercalcemia of malignancy (serum calcium 13.5 mg/dL). Which is the first-line pharmacologic treatment?

Intravenous bisphosphonate such as zoledronic acid after IV hydration (Correct answer)
Oral corticosteroids as the primary treatment
Oral calcium supplements to recalibrate serum levels
Subcutaneous calcitonin as the sole long-term agent

Correct answer: Intravenous bisphosphonate such as zoledronic acid after IV hydration

IV hydration followed by an IV bisphosphonate (zoledronic acid or pamidronate) is the first-line treatment for malignancy-associated hypercalcemia.

Question 81: Which of the following conditions best describes stage III of the Hodgkin's disease staging system?

Involvement of lymph node regions or structures on both sides of the diaphragm (Correct answer)
Involvement of extralymphatic organs or tissues
Involvement of two or more lymph node regions or structures
Involvement of single lymph node region or structure

Correct answer: Involvement of lymph node regions or structures on both sides of the diaphragm

To assess the severity of the condition and the extent of the disease's spread, Hodgkin lymphoma is divided into phases. Nodes on both sides of the diaphragm are involved in stage III.

Question 82: Which prognostic tool is validated to estimate survival in weeks to months for palliative care patients?

Karnofsky score alone
Palliative Performance Scale (PPS) (Correct answer)
ECOG Performance Status alone
MASCC score

Correct answer: Palliative Performance Scale (PPS)

The Palliative Performance Scale integrates ambulation, activity, self-care, oral intake, and consciousness to provide a validated survival estimate.

Question 83: What is the most appropriate route of opioid administration for a cancer patient who can no longer swallow and has uncontrolled pain at home?

Rectal suppository
Subcutaneous infusion via syringe driver (Correct answer)
Intramuscular injection
Intravenous bolus in the ED

Correct answer: Subcutaneous infusion via syringe driver

Subcutaneous infusion via a syringe driver provides continuous pain control for patients who cannot swallow, and is well tolerated at home.

Question 84: Which preoperative condition in a surgical oncology patient requires MANDATORY cardiology clearance before elective major cancer surgery under general anesthesia, per ACC/AHA guidelines?

Well-controlled hypertension on two medications
Asymptomatic mild aortic stenosis
History of coronary artery bypass grafting more than 5 years ago
Active unstable angina (Correct answer)

Correct answer: Active unstable angina

Active cardiac conditions including unstable angina are major clinical predictors that require mandatory evaluation and stabilization before elective non-cardiac surgery per ACC/AHA guidelines.

Question 85: An AOCNP is counseling the family of a dying patient about the 'death rattle.' Which statement is most accurate?

It only occurs in patients who received opioids
The sound indicates the patient is in severe pain
It is caused by retained secretions and is usually not distressing to the patient (Correct answer)
Suctioning the throat is the most effective treatment

Correct answer: It is caused by retained secretions and is usually not distressing to the patient

The death rattle results from retained oropharyngeal secretions in a semi-comatose patient and is typically not distressing to the patient, though it may distress families.

Question 86: A survivor of colorectal cancer asks about surveillance colonoscopy timing. According to ASCO guidelines, when should the first post-treatment colonoscopy be performed after curative resection?

2 years post-surgery
5 years post-surgery
6 months post-surgery
1 year post-surgery (Correct answer)

Correct answer: 1 year post-surgery

ASCO recommends a colonoscopy 1 year after curative resection of colorectal cancer to detect metachronous lesions.

Question 87: R0 resection in surgical oncology means:

Palliative debulking with gross disease remaining
Resection with intraoperative frozen section only
Complete resection with negative (clear) surgical margins (Correct answer)
Residual microscopic disease at the margins

Correct answer: Complete resection with negative (clear) surgical margins

R0 resection indicates microscopically negative surgical margins (no residual tumor), representing the gold standard goal of curative surgery. R1 resection has microscopic positive margins; R2 has macroscopic residual disease. R0 status is a major determinant of recurrence risk and survival.

Question 88: A randomized controlled trial (RCT) in oncology is considered the gold standard for evidence because:

It is faster and less expensive than observational studies
All patients receive the experimental treatment
Randomization controls for confounding variables and reduces selection bias, allowing causal inference (Correct answer)
RCTs always include placebo control arms

Correct answer: Randomization controls for confounding variables and reduces selection bias, allowing causal inference

The RCT is the gold standard because random allocation to treatment and control groups balances known and unknown confounders, minimizing selection bias. This allows valid causal inference about treatment effects. Blinding further controls for performance and detection bias.

Question 89: A patient with newly diagnosed AML has a FLT3-ITD mutation. What is the clinical significance of this finding?

It predicts complete remission with standard chemotherapy alone
It confers a favorable prognosis and no additional targeted therapy is needed
It is associated with poor prognosis and warrants addition of a FLT3 inhibitor such as midostaurin (Correct answer)
It indicates the patient has APL and should receive ATRA

Correct answer: It is associated with poor prognosis and warrants addition of a FLT3 inhibitor such as midostaurin

FLT3-ITD mutations in AML are associated with high relapse rates and poor overall survival; adding midostaurin (a FLT3 inhibitor) to standard induction chemotherapy improves outcomes.

Question 90: Syndrome of inappropriate antidiuretic hormone secretion (SIADH) in cancer is best managed initially with:

Diuresis with furosemide alone
Fluid restriction to 800–1000 mL/day (Correct answer)
Oral sodium supplementation
IV 3% hypertonic saline immediately

Correct answer: Fluid restriction to 800–1000 mL/day

Mild to moderate SIADH is first managed with fluid restriction; hypertonic saline is reserved for severe symptomatic hyponatremia.

Question 91: A patient undergoing allogeneic hematopoietic stem cell transplant develops a diffuse erythematous rash, diarrhea, and elevated bilirubin on day 25. What condition is MOST likely?

Cytomegalovirus (CMV) colitis
Acute graft-versus-host disease (aGVHD) (Correct answer)
Veno-occlusive disease (VOD/SOS)
Engraftment syndrome

Correct answer: Acute graft-versus-host disease (aGVHD)

Rash, diarrhea, and liver dysfunction appearing within 100 days post-allogeneic SCT are the classic triad of acute graft-versus-host disease.

Question 92: Secondary prevention in oncology differs from primary prevention in that secondary prevention focuses on:

Detecting cancer early in asymptomatic individuals (Correct answer)
Preventing recurrence after curative therapy
Reducing risk factors before cancer develops
Treating cancer to prevent metastasis

Correct answer: Detecting cancer early in asymptomatic individuals

Secondary prevention involves early detection of cancer through screening programs in asymptomatic populations, enabling treatment at an earlier, more curable stage. Primary prevention aims to reduce risk factors before cancer occurs.

Question 93: A patient with Hodgkin lymphoma achieves complete remission after ABVD chemotherapy. What is the standard surveillance approach regarding PET-CT imaging after treatment completion?

Annual PET-CT for 10 years is standard of care
PET-CT every 3 months for 5 years regardless of symptoms
PET-CT only if the patient develops a new palpable lymph node
Routine PET-CT surveillance is not recommended after complete remission due to low yield and radiation risk; symptom-directed evaluation is preferred (Correct answer)

Correct answer: Routine PET-CT surveillance is not recommended after complete remission due to low yield and radiation risk; symptom-directed evaluation is preferred

Current guidelines (NCCN, ESMO) do not recommend routine surveillance PET-CT after complete remission in Hodgkin lymphoma because it does not improve survival and leads to false positives and unnecessary interventions.

Question 94: An oncology NP reviews a study reporting a hazard ratio (HR) of 0.72 with 95% CI 0.58–0.89 for overall survival. How should this be interpreted?

The treatment increases the risk of death by 28%
The CI crossing 1.0 means the result is not significant
The treatment has no effect because HR is less than 1
The treatment reduces the risk of death by 28% and the result is statistically significant (Correct answer)

Correct answer: The treatment reduces the risk of death by 28% and the result is statistically significant

HR < 1 favors the treatment arm, and a 95% CI that does not cross 1.0 indicates statistical significance.

Question 95: Which laboratory finding is NOT part of the classic tumor lysis syndrome (TLS) triad?

Hyperphosphatemia
Hypocalcemia
Hyperkalemia
Hypernatremia (Correct answer)

Correct answer: Hypernatremia

TLS is characterized by hyperkalemia, hyperphosphatemia, hyperuricemia, and secondary hypocalcemia — hypernatremia is not a feature.

Question 96: PARP inhibitors such as olaparib are most effective in tumors with defects in which repair pathway?

Base excision repair only
Homologous recombination (BRCA1/2 mutations) (Correct answer)
Nucleotide excision repair
Mismatch repair

Correct answer: Homologous recombination (BRCA1/2 mutations)

BRCA1/2-mutated tumors rely solely on PARP-mediated base excision repair; olaparib blocks PARP, causing lethal synthetic lethality in HR-deficient cells.

Question 97: A 67-year-old male who smoked 1 PPD for 25 years and quit 20 years ago asks about lung cancer screening. What is the correct guidance?

He does not qualify because he quit more than 15 years ago (Correct answer)
He should have annual chest X-ray as an alternative
He qualifies for annual LDCT based on 25 pack-year history alone
He qualifies because age 67 falls within the 50-80 range

Correct answer: He does not qualify because he quit more than 15 years ago

USPSTF criteria require quitting within the past 15 years; this patient quit 20 years ago so does not meet eligibility despite age and pack-year history.

Question 98: A patient with metastatic melanoma on ipilimumab develops diarrhea with 7 stools above baseline per day and cramping. The MOST appropriate management is:

Discontinue ipilimumab permanently and start infliximab immediately
Administer loperamide and continue ipilimumab at the same dose
Reduce ipilimumab dose by 50% and add bismuth subsalicylate
Hold ipilimumab and initiate high-dose systemic corticosteroids (prednisone 1–2 mg/kg/day) (Correct answer)

Correct answer: Hold ipilimumab and initiate high-dose systemic corticosteroids (prednisone 1–2 mg/kg/day)

Grade 3 immune-mediated colitis (≥7 stools above baseline) requires drug hold and high-dose systemic corticosteroids; infliximab is reserved for steroid-refractory cases.

Question 99: A patient develops sudden-onset dyspnea, muffled heart sounds, hypotension, and jugular venous distension. Which emergency is this?

Acute heart failure
Tension pneumothorax
Cardiac tamponade (Correct answer)
Pulmonary embolism

Correct answer: Cardiac tamponade

Beck's triad of hypotension, muffled heart sounds, and jugular venous distension is the hallmark of cardiac tamponade requiring urgent pericardiocentesis.

Question 100: Checkpoint inhibitors targeting PD-1 (e.g., pembrolizumab) cause a distinctive class of toxicities called:

Infusion-related reactions only
Immune-related adverse events (irAEs) (Correct answer)
Cytokine release syndrome
Tumor lysis syndrome

Correct answer: Immune-related adverse events (irAEs)

By unleashing T-cell activity, PD-1 inhibitors can cause immune-related adverse events across any organ, including colitis, pneumonitis, hepatitis, and endocrinopathies.

Question 101: Opioid rotation is indicated when a patient experiences:

Only when switching from oral to IV route
Solely when insurance requires a generic
Inadequate analgesia or intolerable side effects despite dose optimization (Correct answer)
Any mild side effect within 24 hours

Correct answer: Inadequate analgesia or intolerable side effects despite dose optimization

Opioid rotation is indicated for inadequate pain control or unmanageable adverse effects, exploiting incomplete cross-tolerance to achieve a better balance.

Question 102: When converting a patient from IV hydromorphone 1.5 mg/hour continuous infusion to oral extended-release opioids, the nurse practitioner should:

Double the IV dose to account for oral bioavailability
Calculate total 24-hour IV dose, apply equianalgesic conversion, and reduce by 25–30% for incomplete cross-tolerance (Correct answer)
Simply stop IV and start the oral agent at the same numeric dose
Use a 1:1 ratio because IV and oral doses are equivalent

Correct answer: Calculate total 24-hour IV dose, apply equianalgesic conversion, and reduce by 25–30% for incomplete cross-tolerance

Equianalgesic conversion tables are used to calculate the equivalent oral dose, then a 25–30% reduction is applied to account for incomplete cross-tolerance during opioid rotation.

Question 103: In a patient with febrile neutropenia and an absolute neutrophil count (ANC) of 400 cells/µL, which scenario mandates inpatient hospitalization and IV antibiotics rather than outpatient oral therapy?

Patient has controlled diabetes and lives 20 minutes from the hospital
Patient has active pneumonia and hypotension (Correct answer)
Patient has a MASCC score of 22
Patient reports mild nausea but is able to swallow pills

Correct answer: Patient has active pneumonia and hypotension

Active pneumonia with hemodynamic instability (hypotension) indicates high-risk febrile neutropenia requiring immediate inpatient IV antibiotics; a MASCC score ≥21 supports low-risk outpatient management.

Question 104: Which wound complication is most specifically associated with colorectal resection surgery and manifests as separation of abdominal fascial layers?

Anastomotic leak
Wound dehiscence (fascial separation) (Correct answer)
Superficial surgical site infection
Enterocutaneous fistula formation

Correct answer: Wound dehiscence (fascial separation)

Wound dehiscence (separation of fascial wound layers) is a serious complication of abdominal surgery, more common in patients who are immunocompromised, malnourished, obese, or received preoperative radiation/steroids. It requires urgent surgical consultation and may progress to evisceration if full-thickness.

Question 105: A patient with advanced pancreatic cancer reports severe neuropathic pain described as burning and shooting despite adequate opioid dosing. Which adjuvant analgesic has the best evidence as a first-line addition?

Tricyclic antidepressant (nortriptyline) or gabapentinoid (gabapentin/pregabalin) (Correct answer)
Oral antihistamine (diphenhydramine)
Vitamin B12 supplementation
Topical capsaicin 0.025% cream alone

Correct answer: Tricyclic antidepressant (nortriptyline) or gabapentinoid (gabapentin/pregabalin)

Tricyclic antidepressants and gabapentinoids are first-line adjuvant analgesics for neuropathic pain in cancer patients, per NCCN and WHO guidelines.

Question 106: Which medication is first-line for neuropathic pain in cancer patients?

Methadone as monotherapy
Codeine
Ibuprofen
Gabapentin or pregabalin (Correct answer)

Correct answer: Gabapentin or pregabalin

Gabapentinoids (gabapentin or pregabalin) are first-line adjuvant analgesics for neuropathic pain in cancer patients.

Question 107: The BRCA Exchange and NCCN recommend annual MRI screening for BRCA1/2 mutation carriers beginning at what age?

Age 20
Age 25–30 (Correct answer)
Age 40
Age 35

Correct answer: Age 25–30

NCCN recommends annual breast MRI with contrast beginning at age 25–30 for BRCA1/2 carriers and other high-risk individuals. MRI detects occult tumors not visible on mammography due to dense breast tissue common in younger women.

Question 108: Which dosimetric parameter best predicts the risk of radiation-induced pneumonitis in a lung cancer patient receiving thoracic radiotherapy?

D95 of the planning target volume
V20 of the contralateral lung only
Mean lung dose (MLD) (Correct answer)
Maximum dose to the spinal cord

Correct answer: Mean lung dose (MLD)

Mean lung dose (MLD) is one of the strongest predictors of radiation pneumonitis risk, with higher MLD correlating with increased incidence.

Question 109: Which tool is specifically validated for assessing symptom burden in patients with advanced cancer across multiple symptom domains?

Karnofsky Performance Status (KPS)
Numeric Rating Scale (NRS)
Palliative Performance Scale (PPS)
Edmonton Symptom Assessment System (ESAS) (Correct answer)

Correct answer: Edmonton Symptom Assessment System (ESAS)

The Edmonton Symptom Assessment System (ESAS) is a validated, multidimensional tool that rates nine common symptoms (pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, wellbeing, dyspnea) in palliative patients.

Question 110: A 35-year-old with Burkitt lymphoma receives CODOX-M/IVAC chemotherapy. Which prophylactic medication is most critical to prevent a life-threatening metabolic complication?

Acyclovir
Fluconazole
Rasburicase (Correct answer)
Trimethoprim-sulfamethoxazole

Correct answer: Rasburicase

Burkitt lymphoma has an extremely high proliferative rate; rasburicase rapidly degrades uric acid to prevent severe tumor lysis syndrome during induction.

Question 111: Which term describes a trial design where a new agent is tested across multiple cancer types based on a shared molecular target (biomarker) rather than tumor histology?

Umbrella trial
Basket trial (Correct answer)
Crossover trial
Platform trial

Correct answer: Basket trial

Basket trials (also called histology-agnostic or tumor-agnostic trials) enroll patients across different tumor types that share a specific molecular alteration (e.g., NTRK fusion, MSI-H, BRAF V600E), testing whether a targeted therapy works regardless of tissue of origin. Examples: larotrectinib (NTRK), pembrolizumab (MSI-H).

Question 112: Which measurement best indicates that a patient is at high risk of imminent death (hours to days) in the inpatient palliative setting?

Pain score of 8/10 with stable vitals
Decreased urine output, mottling, irregular respirations, and unresponsiveness (Correct answer)
Mild confusion in the morning
Refusal of one meal

Correct answer: Decreased urine output, mottling, irregular respirations, and unresponsiveness

Decreased urine output, mottled skin, irregular breathing patterns, and unresponsiveness are reliable clinical signs of imminent death within hours to days.

Question 113: Which laxative regimen should ALWAYS accompany opioid therapy to prevent constipation?

Osmotic laxatives only as needed
Bulk-forming agents such as psyllium
A stimulant laxative such as senna (Correct answer)
High-fiber diet alone

Correct answer: A stimulant laxative such as senna

A stimulant laxative (senna or bisacodyl) should be initiated prophylactically with opioids because tolerance to constipation, unlike other opioid side effects, does not develop.

Question 114: A Lynch syndrome carrier presents for cancer risk counseling. Which screening recommendation is MOST appropriate for endometrial cancer surveillance?

Endometrial biopsy every 5 years starting at age 40
Annual Pap smear starting at age 21
Annual endometrial biopsy or transvaginal ultrasound starting at age 30-35 (Correct answer)
No surveillance needed unless symptomatic

Correct answer: Annual endometrial biopsy or transvaginal ultrasound starting at age 30-35

For Lynch syndrome carriers, annual endometrial surveillance with biopsy or transvaginal ultrasound beginning at age 30-35 is recommended due to significantly elevated endometrial cancer risk.

Question 115: Which statement correctly describes the principle of double effect in palliative care?

Only nurses can invoke double effect principles
An action with both a beneficial and harmful effect is permissible if the intent is the beneficial effect (Correct answer)
Symptom control must be withheld if it may cause respiratory depression
Any drug that may shorten life is unethical

Correct answer: An action with both a beneficial and harmful effect is permissible if the intent is the beneficial effect

The principle of double effect allows administration of analgesics or sedatives where the intent is symptom relief even if a foreseeable, unintended consequence is hastening death.

Question 116: A 52-year-old woman has a BRCA2 pathogenic variant. Regarding ovarian cancer screening, what is the evidence-based recommendation?

Transvaginal ultrasound every 6 months starting at age 50
Screening is not recommended; risk-reducing salpingo-oophorectomy is preferred (Correct answer)
Annual CA-125 plus transvaginal ultrasound is recommended
Annual pelvic MRI is the preferred modality

Correct answer: Screening is not recommended; risk-reducing salpingo-oophorectomy is preferred

Evidence shows CA-125 and transvaginal ultrasound have not reduced ovarian cancer mortality in BRCA carriers; risk-reducing salpingo-oophorectomy at appropriate age is the preferred strategy.

Question 117: An oncology NP is managing a patient with cancer anorexia-cachexia syndrome. Which pharmacologic agent has demonstrated short-term improvement in appetite and quality of life in this population?

High-dose multivitamin supplementation
Erythropoiesis-stimulating agents
Metformin
Megestrol acetate (Megace) (Correct answer)

Correct answer: Megestrol acetate (Megace)

Megestrol acetate (a progestational agent) improves appetite and caloric intake in cancer-related anorexia-cachexia, though it does not improve survival.

Question 118: Milking or stripping surgical drains placed after oncologic surgery is now generally discouraged because:

It creates excessive negative pressure that can damage healing tissue and increase drainage volume (Correct answer)
It causes immediate patient discomfort during dressing changes
Drains should never be touched by nurses
It reduces the risk of infection by maintaining suction

Correct answer: It creates excessive negative pressure that can damage healing tissue and increase drainage volume

Research has shown that aggressive milking/stripping of surgical drains creates excessive negative pressure (up to -300 mmHg) that can damage delicate healing tissue, disrupt lymphatic sealing, and paradoxically increase drainage volume. Current evidence-based guidelines recommend gentle stripping only to clear clots when drains are not functioning.

Question 119: Chimeric antigen receptor T-cell (CAR-T) therapy requires T cells to be genetically engineered to express a receptor targeting which antigen in most approved hematologic malignancy indications?

PD-L1
CD20
CD3
CD19 or BCMA (Correct answer)

Correct answer: CD19 or BCMA

FDA-approved CAR-T products (axicabtagene ciloleucel, tisagenlecleucel, lisocabtagene maraleucel) target CD19 on B-cell malignancies (ALL, DLBCL, FL). BCMA-targeted CAR-T (idecabtagene vicleucel, ciltacabtagene autoleucel) is approved for multiple myeloma.

Question 120: A patient who received mantle field radiation for Hodgkin lymphoma 20 years ago is now diagnosed with coronary artery disease at age 42. This represents which category of late radiation effect?

Accelerated atherosclerosis as a radiation late effect (Correct answer)
Radiation-induced cardiomyopathy
Pericarditis constrictiva
Secondary malignancy

Correct answer: Accelerated atherosclerosis as a radiation late effect

Mediastinal radiation accelerates atherosclerosis in the coronary arteries, leading to premature coronary artery disease in Hodgkin lymphoma survivors, a well-recognized late cardiovascular toxicity.

Question 121: Neoadjuvant therapy in surgical oncology refers to treatment given:

After surgery to eliminate residual disease
During surgery as intraoperative chemotherapy
Only to patients who are not surgical candidates
Before surgery to downstage tumors and improve resectability (Correct answer)

Correct answer: Before surgery to downstage tumors and improve resectability

Neoadjuvant therapy is administered before the definitive surgical procedure with goals of tumor downstaging, improving resectability (e.g., rectal cancer, locally advanced breast cancer), eliminating micrometastases, and assessing tumor biology based on pathologic response. It may convert unresectable tumors to resectable.

Question 122: Which hereditary cancer syndrome is characterized by mismatch repair (MMR) gene mutations and confers a markedly elevated lifetime risk of colorectal and endometrial cancers?

Li-Fraumeni syndrome
Lynch syndrome (Hereditary Nonpolyposis Colorectal Cancer) (Correct answer)
Cowden syndrome
Familial adenomatous polyposis (FAP)

Correct answer: Lynch syndrome (Hereditary Nonpolyposis Colorectal Cancer)

Lynch syndrome is caused by germline mutations in MMR genes (MLH1, MSH2, MSH6, PMS2) and accounts for the most common hereditary colorectal cancer syndrome. Lifetime colorectal cancer risk can reach 80% and endometrial cancer risk 40–60%. FAP involves APC mutations and thousands of polyps. Li-Fraumeni involves TP53. Cowden involves PTEN and thyroid/breast risk.

Question 123: In febrile neutropenia, an absolute neutrophil count (ANC) below which threshold defines high-risk neutropenia?

< 1500 cells/mm³
< 500 cells/mm³ (Correct answer)
< 2000 cells/mm³
< 1000 cells/mm³

Correct answer: < 500 cells/mm³

An ANC < 500 cells/mm³ (or < 1000 with predicted decline to < 500) defines high-risk neutropenia requiring prompt empiric antibiotics.

Question 124: Which perioperative nursing assessment is most critical before major oncologic surgery involving general anesthesia?

Confirming the patient has fasted for less than 2 hours
Administering prophylactic antibiotics 48 hours before surgery
Ensuring the patient has received chemotherapy within 2 weeks preoperatively
Comprehensive assessment of functional status, nutritional state, and comorbidities (Correct answer)

Correct answer: Comprehensive assessment of functional status, nutritional state, and comorbidities

Preoperative assessment of functional status (ECOG/Karnofsky), nutritional status (weight loss, albumin/prealbumin), comorbidities, medication review, and psychosocial factors determines surgical risk, guides perioperative planning, and identifies need for prehabilitation to optimize outcomes.

Question 125: A patient receiving cisplatin-based chemotherapy develops sudden hemoptysis, chest pain, and dyspnea. CT shows a filling defect in the pulmonary artery. Which risk factor most predisposed this patient?

Radiation-induced pericarditis
Tumor lysis syndrome
Thrombocytopenia from chemotherapy
Cisplatin-induced hypercoagulable state (Correct answer)

Correct answer: Cisplatin-induced hypercoagulable state

Cisplatin is associated with endothelial damage and a hypercoagulable state, significantly increasing the risk of venous thromboembolism including pulmonary embolism.

Question 126: Which statement best describes the 'intention-to-treat' (ITT) principle in oncology RCT analysis?

Patients who cross over to the other arm are excluded from analysis
Only patients achieving an objective response are included in survival analysis
All randomized patients are analyzed in their originally assigned group regardless of protocol adherence (Correct answer)
Patients are analyzed only if they complete all planned treatment cycles

Correct answer: All randomized patients are analyzed in their originally assigned group regardless of protocol adherence

ITT analysis includes all randomized participants in their assigned group, preserving the benefits of randomization and minimizing bias.

Question 127: When interpreting a pathology report, a tumor is described as 'poorly differentiated.' What does this histologic grade indicate about the tumor's behavior?

The tumor shows moderate resemblance to normal tissue
The tumor has not yet invaded beyond the basement membrane
The tumor bears little resemblance to normal tissue and is likely more aggressive (Correct answer)
The tumor closely resembles normal tissue and likely grows slowly

Correct answer: The tumor bears little resemblance to normal tissue and is likely more aggressive

Histologic grade reflects how closely tumor cells resemble normal cells. Poorly differentiated (high-grade, Grade 3) tumors have lost most normal cell characteristics, indicating more aggressive behavior and typically worse prognosis. Well-differentiated tumors (Grade 1) closely resemble normal tissue. Moderately differentiated = Grade 2. Invasion beyond the basement membrane relates to staging, not grading.

Question 128: A patient receiving atezolizumab develops new-onset polyuria, polydipsia, and hyperglycemia. Which immune-related endocrinopathy should be suspected?

Hypothyroidism
Type 1 diabetes mellitus (Correct answer)
Adrenal insufficiency
Hypophysitis

Correct answer: Type 1 diabetes mellitus

Checkpoint inhibitors can trigger autoimmune type 1 diabetes, presenting with new hyperglycemia and symptoms of insulin deficiency.

Question 129: Which scale is most widely validated for assessing pain intensity in cognitively intact cancer patients?

FLACC scale
Wong-Baker FACES scale
CPOT scale
Numeric Rating Scale (NRS 0–10) (Correct answer)

Correct answer: Numeric Rating Scale (NRS 0–10)

The 0–10 Numeric Rating Scale is the most widely validated and recommended self-report pain intensity tool for cognitively intact adults.

Question 130: A patient on long-acting opioids reports breakthrough pain. The appropriate breakthrough dose is approximately:

A fixed 5 mg morphine dose regardless of baseline
50% of the total daily opioid dose
100% of the single long-acting dose
10–15% of the total daily opioid dose (Correct answer)

Correct answer: 10–15% of the total daily opioid dose

Breakthrough doses are typically 10–15% of the total 24-hour opioid dose to provide proportionate rapid-onset analgesia.

Question 131: A patient receiving FOLFOX for colorectal cancer reports cold-induced paresthesias when touching cold surfaces. This is MOST characteristic of toxicity from which agent in the regimen?

Leucovorin
Fluorouracil (5-FU)
Oxaliplatin (Correct answer)
Bevacizumab

Correct answer: Oxaliplatin

Cold-induced dysesthesia and paresthesias are hallmark acute neurotoxicity symptoms of oxaliplatin, distinct from the cumulative peripheral neuropathy it also causes.

Question 132: A patient with a known brain metastasis develops sudden-onset severe headache, vomiting, and altered consciousness. What is the priority intervention?

Lumbar puncture
Oral analgesics and observation
Dexamethasone IV and urgent CT head (Correct answer)
Antiemetics alone

Correct answer: Dexamethasone IV and urgent CT head

Increased intracranial pressure from cerebral herniation requires immediate dexamethasone to reduce edema and urgent imaging to guide further management.

Question 133: A patient with AML develops bleeding gums, petechiae, prolonged PT/PTT, low fibrinogen, and elevated D-dimer. Which treatment is specific to this etiology?

Fresh frozen plasma alone
Platelet transfusion alone
Heparin infusion
All-trans retinoic acid (ATRA) (Correct answer)

Correct answer: All-trans retinoic acid (ATRA)

ATRA induces differentiation of promyelocytes in APL-associated DIC, addressing the underlying cause rather than just replacing clotting factors.

Question 134: A patient with a 2.5 cm breast mass has biopsy confirming invasive ductal carcinoma. Imaging shows 2 ipsilateral axillary lymph nodes with malignant features and no distant metastasis. What is the clinical TNM stage?

Stage IV (T2 N1 M1)
Stage IIB (T2 N1 M0) (Correct answer)
Stage IIIA (T2 N2 M0)
Stage IIA (T2 N1 M0)

Correct answer: Stage IIB (T2 N1 M0)

Per AJCC 8th edition, a primary tumor 2–5 cm (T2) with metastasis in 1–3 ipsilateral axillary lymph nodes (N1) and no distant metastasis (M0) classifies as Stage IIB. Stage IIA would be T0-T2 N1 M0 only if T0-1; with T2 and N1, the anatomic stage is IIB. Stage IIIA requires N2 (4–9 nodes) with T2, or T3 with N1. Stage IV requires distant metastasis (M1).

Question 135: Which electrolyte abnormality most immediately threatens cardiac function in tumor lysis syndrome?

Hyperkalemia (Correct answer)
Hypocalcemia
Hyperuricemia
Hyperphosphatemia

Correct answer: Hyperkalemia

Hyperkalemia causes fatal arrhythmias and is the most immediately life-threatening electrolyte disturbance in TLS.

Question 136: When titrating opioids for cancer pain, a patient on oral morphine 60 mg/day has inadequate relief. What is the appropriate dose increase per standard palliative care guidelines?

Increase by 25–33% (Correct answer)
Add a second opioid at the same dose
Increase by 10–15%
Double the dose immediately

Correct answer: Increase by 25–33%

Standard practice recommends increasing the total daily opioid dose by 25–33% when pain is inadequately controlled.

Question 137: A patient with cancer-related dyspnea refractory to oxygen is best treated with:

Inhaled beta-agonists
Nebulized furosemide
High-dose benzodiazepines alone
Low-dose opioids (Correct answer)

Correct answer: Low-dose opioids

Low-dose opioids are the most evidence-based pharmacological treatment for refractory dyspnea in cancer patients.

Question 138: Which component is REQUIRED in a comprehensive survivorship care plan according to ASCO guidelines?

Summary of treatments received and schedule for recommended follow-up (Correct answer)
Employment history during treatment
Genetic testing results for all family members
Insurance coverage details

Correct answer: Summary of treatments received and schedule for recommended follow-up

ASCO mandates that survivorship care plans include a treatment summary and a follow-up care plan outlining surveillance schedules and management of late effects.

Question 139: Which intervention has the strongest evidence for reducing cancer-related fatigue during active treatment?

Methylphenidate
High-dose corticosteroids
Complete bed rest
Aerobic exercise (Correct answer)

Correct answer: Aerobic exercise

Aerobic exercise has the strongest evidence base for reducing cancer-related fatigue during and after treatment, improving both physical and psychological well-being.

Question 140: Which grading system is most commonly used in clinical trials to document radiation therapy toxicities?

WHO Performance Status Scale
Eastern Cooperative Oncology Group (ECOG) Toxicity Scale
Radiation Therapy Oncology Group (RTOG) Karnofsky Scale
NCI Common Terminology Criteria for Adverse Events (CTCAE) (Correct answer)

Correct answer: NCI Common Terminology Criteria for Adverse Events (CTCAE)

The NCI CTCAE is the standardized grading system used to classify and document adverse events including radiation toxicities in clinical trials and practice.

Question 141: Fertility preservation counseling is a standard of care recommendation that should be offered:

Only to women under age 35 with hormone-sensitive cancers
Only after treatment is complete and fertility is confirmed lost
Only if the patient specifically requests it
To all patients of reproductive age BEFORE initiation of potentially gonadotoxic therapy (Correct answer)

Correct answer: To all patients of reproductive age BEFORE initiation of potentially gonadotoxic therapy

ASCO and NCCN guidelines mandate that fertility preservation options (oocyte cryopreservation, embryo cryopreservation, ovarian tissue cryopreservation, sperm banking) be discussed with all patients of reproductive age BEFORE initiating gonadotoxic therapy, with urgent referral to reproductive endocrinology when indicated.

Question 142: Which intervention is contraindicated in the initial management of SVC syndrome with thrombosis?

Glucocorticoids for symptom relief
Catheter-directed thrombolysis
Anticoagulation
Immediate surgical resection as first-line therapy (Correct answer)

Correct answer: Immediate surgical resection as first-line therapy

Immediate surgery is not first-line for SVC syndrome with thrombosis; less invasive options such as anticoagulation, thrombolysis, and stenting are preferred.

Question 143: A patient with multiple myeloma is at greatest risk for which skeletal complication?

Pathological fractures due to osteolytic lesions (Correct answer)
Avascular necrosis of the femoral head
Osteosarcoma of the long bones
Osteoblastic lesions causing bone sclerosis

Correct answer: Pathological fractures due to osteolytic lesions

Multiple myeloma causes osteolytic (bone-destroying) lesions that significantly weaken bone structure, increasing the risk of pathological fractures.

Question 144: Which malignancy is MOST commonly associated with malignant pericardial effusion and cardiac tamponade?

Hepatocellular carcinoma
Colorectal carcinoma
Cervical cancer
Lung and breast cancer (Correct answer)

Correct answer: Lung and breast cancer

Lung cancer and breast cancer account for the majority of malignant pericardial effusions due to their high incidence and tendency for mediastinal and pericardial involvement.

Question 145: A bone marrow biopsy is required to complete staging for which of the following cancers?

Localized prostate cancer (PSA < 10, Gleason 6)
Stage I endometrial cancer
Stage II non-small cell lung cancer
Multiple myeloma (Correct answer)

Correct answer: Multiple myeloma

Bone marrow biopsy is an essential diagnostic and staging tool for multiple myeloma (and other plasma cell dyscrasias), as plasma cell percentage in the marrow is a diagnostic criterion and prognostic factor per IMWG criteria. Lung, prostate, and endometrial cancers at the stages described do not routinely require bone marrow evaluation as part of standard staging workup.

Question 146: The survivorship care plan should include which minimum components per ASCO/IOM recommendations?

Diagnosis date and pathology report only
Insurance and billing information with treatment codes
Only a list of current medications and allergies
Treatment summary, surveillance schedule, late effect information, and referrals for ongoing care needs (Correct answer)

Correct answer: Treatment summary, surveillance schedule, late effect information, and referrals for ongoing care needs

Per ASCO and IOM standards, the survivorship care plan must include: (1) treatment summary (diagnosis, staging, treatments received with dates/doses), (2) surveillance/monitoring schedule for recurrence, (3) potential late and long-term effects with management guidance, and (4) referrals and resources (primary care, mental health, rehabilitation, community support).

Question 147: Which test result is REQUIRED before initiating treatment with PARP inhibitors (e.g., olaparib) in ovarian cancer?

KRAS mutation status via liquid biopsy
BRCA1/BRCA2 germline or somatic mutation testing (Correct answer)
HER2 amplification by FISH
PD-L1 combined positive score (CPS)

Correct answer: BRCA1/BRCA2 germline or somatic mutation testing

PARP inhibitors exploit homologous recombination deficiency; BRCA1/2 mutation status determines eligibility and expected magnitude of benefit.

Question 148: Dump syndrome following gastric surgery or esophagectomy is characterized by which symptom cluster?

Constipation, abdominal distension, weight gain
Severe heartburn and regurgitation
Nausea, diarrhea, diaphoresis, palpitations after eating (early) or hypoglycemia (late) (Correct answer)
Obstipation and progressive vomiting

Correct answer: Nausea, diarrhea, diaphoresis, palpitations after eating (early) or hypoglycemia (late)

Dumping syndrome results from rapid gastric emptying of hyperosmolar contents into the small bowel. Early dumping (within 30 min) causes GI symptoms (nausea, cramping, diarrhea) and vasomotor symptoms (flushing, diaphoresis, tachycardia). Late dumping (1–3 h) causes reactive hypoglycemia. Management includes dietary modifications and small frequent meals.

Question 149: What is the preferred initial antibiotic for low-risk febrile neutropenia being managed outpatient?

IV meropenem
Ciprofloxacin plus amoxicillin-clavulanate (Correct answer)
Oral metronidazole
IV vancomycin

Correct answer: Ciprofloxacin plus amoxicillin-clavulanate

Oral ciprofloxacin combined with amoxicillin-clavulanate is the IDSA-recommended outpatient regimen for low-risk febrile neutropenia.

Question 150: Superior vena cava (SVC) syndrome with acute airway compromise and cerebral edema should be treated FIRST with which intervention?

High-dose systemic corticosteroids alone
Anticoagulation with unfractionated heparin
Surgical bypass grafting of the SVC
Emergent SVC stenting or radiation therapy (Correct answer)

Correct answer: Emergent SVC stenting or radiation therapy

Emergent endovascular SVC stenting provides the fastest relief of obstruction and is preferred for acute life-threatening SVC syndrome; radiation may follow once airway is stabilized.

Question 151: Bispecific T-cell engager (BiTE) blinatumomab works by simultaneously binding which two targets?

VEGFR and PDGFR
CD3 on T cells and CD19 on B-cell tumors (Correct answer)
HER2 and EGFR
PD-1 and CTLA-4

Correct answer: CD3 on T cells and CD19 on B-cell tumors

Blinatumomab is a bispecific antibody that bridges CD3 (on cytotoxic T cells) and CD19 (on B-cell malignancies), directing T cells to kill leukemic B cells. It is approved for relapsed/refractory ALL and minimal residual disease (MRD)-positive B-cell ALL.

Question 152: A patient asks about joining a basket trial. Which best describes this trial design?

Randomizes patients between two standard chemotherapy regimens
Enrolls patients with the same tumor histology regardless of molecular profile
Tests a single drug only in patients with early-stage cancers
Enrolls patients with the same molecular alteration across multiple tumor types (Correct answer)

Correct answer: Enrolls patients with the same molecular alteration across multiple tumor types

Basket trials enroll patients based on a shared molecular alteration (e.g., BRAF V600E) regardless of tumor histology.

Question 153: A patient with lymphoma undergoing induction chemotherapy develops rising creatinine, oliguria, and uric acid of 12 mg/dL. Allopurinol was started 24 hours ago. Which agent should be added to address established hyperuricemia?

Colchicine
Probenecid
Rasburicase (Correct answer)
Febuxostat

Correct answer: Rasburicase

Rasburicase is a recombinant urate oxidase that rapidly converts existing uric acid to allantoin (a soluble metabolite) and is preferred when hyperuricemia is already established, unlike allopurinol which only prevents new formation.

Question 154: A patient with locally advanced rectal cancer is scheduled for abdominoperineal resection (APR). Which preoperative bowel preparation practice is currently supported by enhanced recovery after surgery (ERAS) protocols?

Mechanical bowel preparation alone without oral antibiotics
Mandatory mechanical bowel preparation plus oral antibiotics (Correct answer)
Neither mechanical prep nor oral antibiotics are recommended
Oral antibiotics alone without mechanical bowel preparation

Correct answer: Mandatory mechanical bowel preparation plus oral antibiotics

Current ERAS evidence for colorectal surgery supports combined mechanical bowel preparation with oral antibiotics to reduce surgical site infection rates.

Question 155: A patient receiving paclitaxel develops hypersensitivity within minutes of starting the infusion. What is the FIRST nursing intervention?

Flush the line and switch to a different chemotherapy agent
Stop the infusion, maintain IV access, and call for emergency assistance (Correct answer)
Slow the infusion rate and administer diphenhydramine
Administer epinephrine intramuscularly without delay

Correct answer: Stop the infusion, maintain IV access, and call for emergency assistance

Stopping the infusion immediately and maintaining IV access while calling for help is the first step in managing chemotherapy hypersensitivity reactions.

Question 156: Disseminated intravascular coagulation (DIC) is one of the most dangerous blood coagulation side effects for cancer patients and those receiving cancer therapy. This bleed disorder's most typical cause is:

Sepsis (Correct answer)
Brain metastasis
Intravenous heparin therapy
Underlying liver disease

Correct answer: Sepsis

The Hageman factor, also known as coagulation factor XII, is activated by bacterial endotoxins generated by gram-negative bacteria. By inhibiting coagulation through the homeostasis pathway, this substance also promotes fibrinolysis.

Question 157: Which biologic agent works by depleting CD20-positive B cells and is used in certain lymphomas?

Rituximab (Correct answer)
Cetuximab
Ramucirumab
Denosumab

Correct answer: Rituximab

Rituximab is a chimeric anti-CD20 monoclonal antibody that depletes CD20-expressing B cells through ADCC, CDC, and direct apoptosis induction.

Question 158: A patient with SCLC and SIADH has a serum sodium of 115 mEq/L with severe neurological symptoms (seizures). What is the appropriate rate of sodium correction?

Maintain correction below 5 mEq/L per 24 hours to avoid rebound
Increase sodium by 20 mEq/L in the first 4 hours
Increase sodium by no more than 8-10 mEq/L per 24 hours (Correct answer)
Correct sodium at any rate needed to stop seizures

Correct answer: Increase sodium by no more than 8-10 mEq/L per 24 hours

The safe rate of sodium correction is ≤8-10 mEq/L per 24 hours (up to 1-2 mEq/L/hr in acute symptomatic cases) to prevent osmotic demyelination syndrome while managing neurological symptoms.

Question 159: A male patient is hospitalized to an acute care center with a cerebellar brain tumor. Risk of damage is the nursing diagnostic made by the nurse. Which term should the nurse add as a "related-to" to finish the nursing diagnosis statement?

Related to difficulty swallowing
Related to psychomotor seizures
Related to visual field deficits
Related to impaired balance (Correct answer)

Correct answer: Related to impaired balance

A patient with a cerebellar brain tumor may experience balance issues, abnormal walking patterns, and lack of coordination.

Question 160: Which imaging finding on MRI spine best confirms malignant spinal cord compression requiring urgent treatment?

Epidural tumor impinging on the thecal sac (Correct answer)
Disc degeneration with osteophytes
Vertebral body sclerosis without cord contact
Paraspinal muscle edema only

Correct answer: Epidural tumor impinging on the thecal sac

Epidural tumor directly impinging on the thecal sac confirms cord compression and necessitates urgent corticosteroids and radiation or surgery.

Question 161: A patient receiving high-dose methotrexate suddenly develops fever, rigors, and hypotension. Which oncologic emergency is most likely?

Cardiac tamponade
Septic shock (Correct answer)
Anaphylaxis
Disseminated intravascular coagulation

Correct answer: Septic shock

Febrile neutropenia with hemodynamic compromise meets criteria for septic shock and requires immediate broad-spectrum antibiotics and fluid resuscitation.

Question 162: Which modifiable risk factor has the strongest evidence for reducing colorectal cancer incidence?

Increasing dietary fiber intake
Regular physical activity and maintaining healthy weight (Correct answer)
Taking daily vitamin D supplements
Avoiding red meat entirely

Correct answer: Regular physical activity and maintaining healthy weight

Regular physical activity and maintaining a healthy body weight have the strongest evidence for reducing colorectal cancer risk among modifiable lifestyle factors.

Question 163: When obtaining informed consent for a Phase I oncology clinical trial, which element distinguishes informed consent in this context from standard treatment consent?

Patients must be informed that the primary purpose is to determine safety and dose, not to achieve tumor response (Correct answer)
Consent can be waived if the patient has limited treatment options
A legally authorized representative may consent on behalf of a competent adult patient
Patients in Phase I trials are not permitted to withdraw consent after enrollment

Correct answer: Patients must be informed that the primary purpose is to determine safety and dose, not to achieve tumor response

A critical and ethically mandated element of Phase I trial consent is explicitly informing participants that the primary objective is to evaluate safety, pharmacokinetics, and determine the maximum tolerated dose — not to provide therapeutic benefit. This distinction addresses therapeutic misconception, where participants mistakenly believe the trial is primarily designed to help them. Consent cannot be waived for competent adults. A competent adult must consent personally. Withdrawal of consent is always permitted.

Question 164: A patient with metastatic melanoma is started on ipilimumab and develops colitis with diarrhea >7 stools/day above baseline. What is the first-line treatment?

Loperamide 4 mg PO
Infliximab 5 mg/kg IV
Oral prednisone 1 mg/kg/day
IV methylprednisolone 1-2 mg/kg/day (Correct answer)

Correct answer: IV methylprednisolone 1-2 mg/kg/day

Grade 3-4 immune-related colitis requires high-dose IV corticosteroids as initial therapy.

Question 165: Which antiemetic is most appropriate for opioid-induced nausea acting via the chemoreceptor trigger zone?

Dexamethasone
Prochlorperazine (Correct answer)
Metoclopramide
Ondansetron

Correct answer: Prochlorperazine

Prochlorperazine (a dopamine antagonist) acts on the chemoreceptor trigger zone (CTZ), which is the primary mechanism of opioid-induced nausea.

Question 166: Which ethical principle is most directly invoked when a palliative care NP provides high-dose opioids for refractory symptoms, accepting that respiratory depression is a possible but unintended side effect?

Veracity
Autonomy
Doctrine of double effect (Correct answer)
Justice

Correct answer: Doctrine of double effect

The doctrine of double effect justifies an action with both good (symptom relief) and potentially bad (respiratory depression) effects when the intent is the good effect and the good outweighs the harm.

AOCNP Oncology Nurse Practitioner Certification Exam

The Advanced Oncology Certified Nurse Practitioner (AOCNP) Exam by ONCC tests advanced oncology nursing knowledge including cancer diagnosis, treatment, oncologic emergencies, and palliative care for nurse practitioners.

165

Questions

240 min

Time Limit

70%

To Pass

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds