Certified Pediatric Hematology Oncology Nurse (CPHON) — Questions and Answers

Question 1: The nurse is preparing a 14-year-old patient for her first chemotherapy treatment when she starts to cry and says, "I don't think I can do this." The nurse's top priorities are to:

complete the treatment.
allow the patient to express her feelings. (Correct answer)
reassure the patient.
notify the physician that the treatment must be delayed.

Correct answer: allow the patient to express her feelings.

Before and throughout chemotherapy, almost all patients experience anxiety and worry, so the nurse's top duty should be to provide the patient a chance to communicate her thoughts. Giving a patient some time to vent their emotions and gather their composure usually suffices to allow them to continue with their therapy, but the patient should be given as much time as necessary and should not be pressured into receiving treatment she is not emotionally ready for.

Question 2: A pediatric patient is receiving radiation to the spine for medulloblastoma. Which side effect should the nurse anticipate months after therapy?

Skin breakdown at the radiation site only
Growth retardation due to vertebral growth plate damage (Correct answer)
Immediate paralysis
Acute bowel obstruction

Correct answer: Growth retardation due to vertebral growth plate damage

Spinal radiation in children damages vertebral growth plates, leading to impaired spinal growth and short stature as a late effect.

Question 3: A nurse receives an order for opioid analgesia for a child in cancer pain. Before administering, which assessment is most critical to perform and document?

Respiratory rate and level of sedation using a validated sedation scale (Correct answer)
Pupil size and oral mucosa assessment
Blood pressure and heart rate only
Temperature and skin integrity

Correct answer: Respiratory rate and level of sedation using a validated sedation scale

Opioids can cause respiratory depression — the most life-threatening side effect. Baseline and post-dose respiratory rate and level of sedation must be assessed and documented before and after opioid administration per safety standards.

Question 4: A parent of a child with terminal cancer asks why morphine is being increased so frequently, saying: 'I'm afraid giving more pain medicine will make him die faster.' The nurse's most appropriate response addresses which ethical principle?

The principle of double effect: the intent is to relieve suffering, not hasten death, and adequate pain control is both an ethical obligation and does not shorten life when used appropriately (Correct answer)
Autonomy: the parent has the right to refuse pain medication on the child's behalf
Beneficence alone justifies administering any dose without parental explanation
Justice: all patients deserve equal pain management regardless of diagnosis

Correct answer: The principle of double effect: the intent is to relieve suffering, not hasten death, and adequate pain control is both an ethical obligation and does not shorten life when used appropriately

The principle of double effect addresses the ethical concern that a medication given to relieve suffering may have a foreseeable side effect of potentially hastening death. Evidence shows appropriate opioid titration for pain does not shorten life.

Question 5: A nurse is priming IV tubing for a cisplatin infusion. Which solution is appropriate for this agent?

Lactated Ringer's
D5W
D5 0.45% NS
0.9% Normal Saline (Correct answer)

Correct answer: 0.9% Normal Saline

Cisplatin must be administered in normal saline because dextrose-containing solutions can cause cisplatin degradation and precipitation.

Question 6: When caring for a child receiving high-dose cytarabine (Ara-C), which ocular prophylaxis is routinely administered?

Steroid eye drops (Correct answer)
Antibiotic eye drops
Artificial tears only
Antiviral eye drops

Correct answer: Steroid eye drops

Steroid (dexamethasone) eye drops are given prophylactically to prevent cytarabine-induced conjunctivitis and keratitis.

Question 7: A 16-year-old oncology patient tells the nurse she no longer wants chemotherapy because of severe side effects and feels that no one respects her opinion. Which nursing action best demonstrates adolescent-centered family care?

Tell the patient she is a minor and must follow her parents' decisions
Agree with the patient and document her refusal without further discussion
Encourage her parents to make the decision and not involve the patient further
Take her concerns seriously, facilitate a private conversation between the patient and the care team, and advocate for including her voice in care decisions (Correct answer)

Correct answer: Take her concerns seriously, facilitate a private conversation between the patient and the care team, and advocate for including her voice in care decisions

Adolescents have increasing capacity for autonomous decision-making and a recognized right to be heard in their own medical care. The nurse should advocate for inclusion of the adolescent's voice in care decisions while facilitating structured family and team discussion.

Question 8: What is the role of granulocyte colony-stimulating factor (G-CSF) in HSCT, and when is it typically given?

Given to the recipient before conditioning to mobilize their own stem cells
Given to the donor before marrow harvest to increase cell yield only in autologous transplants
Used to treat GVHD by stimulating regulatory T-cell production
Administered post-transplant to accelerate neutrophil engraftment and shorten the duration of neutropenia (Correct answer)

Correct answer: Administered post-transplant to accelerate neutrophil engraftment and shorten the duration of neutropenia

G-CSF (filgrastim) is given to HSCT recipients after stem cell infusion to stimulate proliferation and differentiation of donor-derived neutrophil precursors, shortening the duration of post-transplant neutropenia.

Question 9: Which late effect is associated with corticosteroid use during childhood cancer treatment?

Renal tubular necrosis
Secondary leukemia
Avascular necrosis of bone (Correct answer)
Pulmonary fibrosis

Correct answer: Avascular necrosis of bone

Prolonged high-dose corticosteroid use impairs blood supply to bone, most commonly affecting the femoral head and causing avascular necrosis (osteonecrosis), which can lead to joint collapse and chronic pain.

Question 10: The nurse is caring for a child post-bone marrow transplant with a CMV-negative status. Which blood product should be ordered?

Non-irradiated packed red blood cells
CMV-seronegative or leukoreduced blood products (Correct answer)
Fresh whole blood
ABO-incompatible platelets

Correct answer: CMV-seronegative or leukoreduced blood products

CMV-seronegative or leukoreduced products reduce the risk of CMV transmission to CMV-negative immunocompromised patients.

Question 11: A teen who is taking chemotherapy and has oral mucositis claims that using toothpaste and brushing makes her mouth hurt worse. What other treatment options should the patient consider?

Salt water (Correct answer)
Lidocaine-based mouthwash.
water only
Standard mouthwash.

Correct answer: Salt water

Oral mucositis causes painful inflammation and sores in the mouth. Salt water rinses are a common and effective treatment because they are isotonic, helping to cleanse the mouth, reduce inflammation, and promote healing without causing further irritation. Unlike standard mouthwashes which often contain alcohol and can be irritating, or lidocaine which only numbs, salt water provides gentle, antiseptic relief.

Question 12: Typhlitis, also known as neutropenic enterocolitis, has been identified in a patient. The main course of action is:

palliative care only.
surgical bowel excision.
volume resuscitation.
broad-spectrum antibiotics. (Correct answer)

Correct answer: broad-spectrum antibiotics.

The main treatment for someone who has been diagnosed with neutropenic enterocolitis (typhlitis) is a broad-spectrum antibiotic. Typhlitis is primarily a bacterial infection of the cecum, though it can also affect the colon. It is possible for ulcerations to form on the lining of the intestine and cecum, leading to perforation. The pathogens Clostridium difficile and Pseudomonas aeruginosa are most frequently linked to neutropenic enterocolitis.

Question 13: A nurse is educating the parents of a neutropenic child about infection precautions at home. Which teaching point is INCORRECT and must be corrected?

'It is fine to use alcohol-based hand sanitizer instead of soap and water if your child has a C. difficile infection' (Correct answer)
'Call the oncology team immediately if your child's temperature reaches 38.3°C or higher'
'Your child should not eat raw fruits that cannot be peeled'
'Your child should avoid contact with anyone who recently received a live vaccine'

Correct answer: 'It is fine to use alcohol-based hand sanitizer instead of soap and water if your child has a C. difficile infection'

Alcohol-based hand sanitizers do NOT kill Clostridium difficile spores. For C. diff-positive patients and their caregivers, soap and water handwashing is mandatory because mechanical friction physically removes spores that alcohol cannot kill.

Question 14: A child with a central venous catheter develops a temperature of 38.5°C. The nurse should FIRST:

Draw blood cultures from the central line and a peripheral site (Correct answer)
Remove the central catheter immediately
Increase IV fluid rate
Administer acetaminophen and recheck in 2 hours

Correct answer: Draw blood cultures from the central line and a peripheral site

Blood cultures from both the central line and a peripheral vein are necessary before antibiotics to identify the source of the infection.

Question 15: A pediatric patient undergoing allogeneic hematopoietic stem cell transplant (HSCT) develops a skin rash, diarrhea, and elevated bilirubin 3 weeks post-transplant. The nurse recognizes this as which complication?

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

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

Acute GVHD classically presents within 100 days of allogeneic HSCT with involvement of skin (maculopapular rash), GI tract (diarrhea, cramping, nausea), and liver (elevated bilirubin, alkaline phosphatase).

Question 16: Which nursing diagnosis has HIGHEST priority for a child with febrile neutropenia?

Activity intolerance
Disturbed body image
Risk for imbalanced nutrition
Risk for infection related to immune suppression (Correct answer)

Correct answer: Risk for infection related to immune suppression

Febrile neutropenia is a life-threatening emergency; preventing infection spread and initiating antibiotics are the primary nursing priorities.

Question 17: What is the graft-versus-leukemia (GVL) effect, and why is it clinically important in allogeneic HSCT?

Donor T cells attacking residual leukemic cells in the recipient, reducing relapse risk (Correct answer)
The conditioning regimen's direct cytotoxic effect on residual leukemia
Donor cells producing antibodies against leukemia-specific antigens
Recipient NK cells eliminating donor leukemia-contaminated cells

Correct answer: Donor T cells attacking residual leukemic cells in the recipient, reducing relapse risk

The GVL effect refers to donor T and NK cells recognizing and eliminating residual host leukemic cells that express alloantigens, providing an immune-mediated anti-tumor effect that reduces relapse rates.

Question 18: A child who received cranial radiation therapy at age 4 is most at risk for which long-term neurocognitive deficit?

Decline in processing speed and working memory (Correct answer)
Bilateral hearing loss
Visual field deficits requiring glasses
Expressive aphasia and language loss

Correct answer: Decline in processing speed and working memory

Cranial irradiation commonly damages developing white matter pathways, leading to deficits in processing speed, attention, and working memory, particularly when administered to young children.

Question 19: A child with neuroblastoma is scheduled for a MIBG scan. Which medication must be given before the procedure?

Ondansetron to prevent nausea
Potassium iodide to protect the thyroid (Correct answer)
Hydrocortisone to reduce inflammation
Diphenhydramine to prevent allergic reaction

Correct answer: Potassium iodide to protect the thyroid

Potassium iodide (or Lugol's solution) is given before MIBG scans to block thyroid uptake of radioactive iodine.

Question 20: What is the most effective strategy for preventing CLABSI in pediatric oncology patients according to evidence-based practice?

Routine prophylactic antibiotic infusion through the central line
Using heparin flushes twice daily in all central line lumens
Adherence to a central line bundle including hand hygiene, maximal sterile barrier, chlorhexidine skin antisepsis, optimal site selection, and daily assessment of line necessity (Correct answer)
Changing the central line every 72 hours regardless of infection signs

Correct answer: Adherence to a central line bundle including hand hygiene, maximal sterile barrier, chlorhexidine skin antisepsis, optimal site selection, and daily assessment of line necessity

The CDC's central line bundle (CLABSI prevention bundle) is the most evidence-based intervention for preventing CLABSI: hand hygiene, maximal sterile barrier precautions during insertion, chlorhexidine antisepsis, subclavian/PICC site preference, and daily reassessment of line necessity.

Question 21: A child with ALL is admitted with a fever and ANC of 200/mm³. Within how many minutes should empiric antibiotics be initiated?

Within 60 minutes (Correct answer)
Within 4 hours
Within 30 minutes
Within 24 hours

Correct answer: Within 60 minutes

Febrile neutropenia guidelines recommend initiating empiric broad-spectrum antibiotics within 60 minutes of triage to prevent septic shock.

Question 22: A toddler with Wilms tumor is post-nephrectomy. Which blood pressure parameter requires close monitoring?

Hypertension due to remaining kidney compensation (Correct answer)
Normal blood pressure is expected postoperatively
Hypotension due to fluid overload
Hypotension from renin depletion

Correct answer: Hypertension due to remaining kidney compensation

After unilateral nephrectomy, the remaining kidney may produce excess renin, leading to hypertension that requires close monitoring.

Question 23: According to the CTCAE grading scale, which finding characterizes grade 2 radiation dermatitis?

Confluent moist desquamation over areas of trauma
Skin necrosis requiring surgical intervention
Moderate to brisk erythema with patchy moist desquamation in skin folds (Correct answer)
Faint erythema with dry desquamation

Correct answer: Moderate to brisk erythema with patchy moist desquamation in skin folds

Grade 2 radiation dermatitis is defined by moderate to brisk erythema with patchy moist desquamation, primarily confined to skin folds.

Question 24: A child is diagnosed with Stage IV Hodgkin lymphoma. Which modality is MOST commonly used in treatment?

Surgery alone
Targeted antibody therapy alone
Radiation alone
Combination chemotherapy with or without radiation (Correct answer)

Correct answer: Combination chemotherapy with or without radiation

Advanced Hodgkin lymphoma is treated with combination chemotherapy (e.g., ABVD or BEACOPP-based regimens) often combined with involved-field radiation.

Question 25: What is the primary advantage of a tunneled central venous catheter (e.g., Broviac or Hickman) over a non-tunneled central line in pediatric oncology?

The subcutaneous tunnel reduces CLABSI risk and allows long-term use over months to years (Correct answer)
It can be placed without anesthesia at the bedside
It eliminates the need for heparin flushes
It has a larger lumen for faster blood product administration

Correct answer: The subcutaneous tunnel reduces CLABSI risk and allows long-term use over months to years

Tunneling the catheter under the skin creates a mechanical barrier to bacterial migration from the skin exit site to the bloodstream, reduces CLABSI rates, and makes the catheter suitable for long-term use (months to years) compared to non-tunneled devices.

Question 26: A nurse learns that the family of a newly diagnosed toddler has extremely limited English proficiency. Which action is the highest priority to ensure effective communication?

Use a hospital pocket language guide for all communication
Arrange for a qualified medical interpreter (in-person or video) before any clinical discussion or consent process (Correct answer)
Ask an older sibling to interpret medical information for the parents
Proceed with the consent discussion and have the family sign a standard English consent form

Correct answer: Arrange for a qualified medical interpreter (in-person or video) before any clinical discussion or consent process

Qualified medical interpreters (not family members or untrained staff) are required by law and ethical standards for all medical discussions involving patients/families with limited English proficiency, especially for consent processes.

Question 27: A child post-allogeneic HSCT is prescribed tacrolimus and methotrexate. What is the primary purpose of this combination?

GVHD prophylaxis by suppressing donor T-cell activation and proliferation (Correct answer)
Treatment of active acute GVHD
Prevention of viral reactivation
Promotion of faster engraftment

Correct answer: GVHD prophylaxis by suppressing donor T-cell activation and proliferation

Tacrolimus (a calcineurin inhibitor blocking IL-2 production) combined with short-course methotrexate (inhibiting T-cell proliferation) is the standard combination for acute GVHD prophylaxis in allogeneic HSCT.

Question 28: A neutropenic child develops perianal pain and redness. The nurse should avoid which common assessment action?

Oral temperature measurement
Application of topical barrier cream to protect skin integrity
Rectal temperature measurement and rectal examinations (Correct answer)
Inspection of the perianal area visually

Correct answer: Rectal temperature measurement and rectal examinations

Rectal temperatures and rectal examinations are absolutely contraindicated in neutropenic patients because the trauma to friable, poorly healing rectal mucosa can introduce bacteria from gut flora into the bloodstream, causing bacteremia.

Question 29: A child with osteosarcoma of the femur is preparing for limb-salvage surgery. Which nursing intervention is MOST important pre-operatively?

Avoid discussing the diagnosis with the child
Apply a pressure bandage to the tumor site
Teach the child about post-operative rehabilitation and expected functional outcomes (Correct answer)
Restrict all physical activity for 3 months

Correct answer: Teach the child about post-operative rehabilitation and expected functional outcomes

Pre-operative teaching about rehabilitation and realistic functional goals reduces anxiety and promotes engagement in post-operative recovery.

Question 30: Which late effect monitoring test is most important for a childhood cancer survivor who received high-dose cisplatin?

Bone density scan for osteoporosis
Audiogram for sensorineural hearing loss (Correct answer)
Dental panorex for root foreshortening
Ophthalmologic exam for cataracts

Correct answer: Audiogram for sensorineural hearing loss

Cisplatin is ototoxic, causing permanent sensorineural hearing loss—particularly in high frequencies. Regular audiologic monitoring is essential for survivors who received cisplatin.

Question 31: Which finding on physical examination of a neutropenic patient should prompt the nurse to suspect invasive pulmonary aspergillosis?

New onset pleuritic chest pain, non-productive cough, and hemoptysis in a patient with prolonged neutropenia (Correct answer)
Vesicular lesions on the torso following a dermatomal pattern
Profuse watery diarrhea and abdominal cramping
Frothy pink sputum and bilateral dependent rales

Correct answer: New onset pleuritic chest pain, non-productive cough, and hemoptysis in a patient with prolonged neutropenia

Invasive pulmonary aspergillosis (IPA) in neutropenic patients characteristically presents with pleuritic chest pain, dry cough, and hemoptysis — due to angio-invasive hyphae causing pulmonary infarction. The 'halo sign' on CT is pathognomonic.

Question 32: A Mediport (implanted venous access port) is accessed with a non-coring Huber needle. When removing the Huber needle after completing an infusion, which step is essential?

Leave the needle in place for 24 hours after access to minimize skin trauma
Clamp the extension tubing immediately before needle removal
Flush with sterile water instead of normal saline for the final flush
Maintain positive pressure on the syringe plunger while withdrawing the needle to prevent blood backflow into the port chamber (Correct answer)

Correct answer: Maintain positive pressure on the syringe plunger while withdrawing the needle to prevent blood backflow into the port chamber

When de-accessing an implanted port, maintaining positive pressure (by keeping the plunger pressed forward) while withdrawing the Huber needle prevents blood from being aspirated back into the port septum and reservoir, which can cause clot formation.

Question 33: Radiation therapy to which area requires monitoring for growth hormone deficiency in children?

Abdomen
Pelvis
Lower extremities
Cranial (hypothalamic-pituitary axis) (Correct answer)

Correct answer: Cranial (hypothalamic-pituitary axis)

Cranial radiation can damage the hypothalamus and pituitary gland, leading to growth hormone deficiency and impaired growth.

Question 34: Which source offers the most comprehensive information on all cancer types, including details on funding, clinical trials, and research, for both patients and medical professionals?

National Cancer Institute. (Correct answer)
American Cancer Society.
Cancer Care.
American Institute for Cancer Research.

Correct answer: National Cancer Institute.

The National Cancer Institute offers a comprehensive A-Z listing of all cancer kinds and provides information on genetics, statistics, risk factors, preventative measures, and treatment choices in addition to data on clinical trials, funding, and research.

Question 35: Which type of donor match provides the best outcomes in pediatric allogeneic HSCT?

Unrelated cord blood with 4/6 HLA match
Mismatched unrelated donor
10/10 HLA-matched sibling donor (Correct answer)
5/10 haploidentical parent

Correct answer: 10/10 HLA-matched sibling donor

A fully HLA-matched sibling donor (10/10 allele-level match) provides the best outcomes with the lowest rates of graft rejection, acute GVHD, and transplant-related mortality.

Question 36: What is the difference between autologous and allogeneic HSCT, and which type carries risk for graft-versus-host disease?

Autologous uses donor cells with GVHD risk; allogeneic uses patient's own cells without risk
Neither type carries GVHD risk in pediatric patients
Allogeneic uses donor stem cells and carries GVHD risk; autologous uses the patient's own cells and does not (Correct answer)
Both types carry equal GVHD risk

Correct answer: Allogeneic uses donor stem cells and carries GVHD risk; autologous uses the patient's own cells and does not

Allogeneic HSCT uses stem cells from a matched donor (sibling, unrelated, or cord blood), and the immunologic mismatch between donor T cells and host tissues is the basis for GVHD. Autologous HSCT uses the patient's own stored stem cells, so GVHD does not occur.

Question 37: A CPHON nurse reviews a newly prescribed opioid order: oral hydromorphone 2 mg every 4 hours for a 15 kg, 5-year-old child. The nurse's concern is based on which calculation?

Hydromorphone is contraindicated in children under 6 years of age
The dose is higher than the recommended starting dose of 0.03–0.08 mg/kg, which would be 0.45–1.2 mg for this child — a dose of 2 mg may be unsafe without prior opioid tolerance (Correct answer)
The dose interval is too long for hydromorphone
The dose is too low to provide adequate analgesia

Correct answer: The dose is higher than the recommended starting dose of 0.03–0.08 mg/kg, which would be 0.45–1.2 mg for this child — a dose of 2 mg may be unsafe without prior opioid tolerance

For a 15 kg child, the recommended pediatric starting dose of oral hydromorphone (0.03–0.08 mg/kg) is 0.45–1.2 mg per dose. A dose of 2 mg represents 0.13 mg/kg and exceeds the recommended opioid-naïve starting dose, requiring safety review before administration.

Question 38: A 9-year-old with osteosarcoma asks the nurse: 'Am I going to die?' The most therapeutically appropriate response is:

Acknowledge the question with honesty and gentleness, explore what prompted it, and involve the appropriate team member for the discussion (Correct answer)
Say 'Of course not — you are going to be just fine!' to provide reassurance
Redirect the child to a game or activity to avoid the conversation
Give a detailed statistical survival estimate immediately

Correct answer: Acknowledge the question with honesty and gentleness, explore what prompted it, and involve the appropriate team member for the discussion

Children with cancer have a right to honest, age-appropriate information. Dismissing or avoiding the question destroys trust. Exploring the question ('What made you think of that?'), acknowledging the reality of the illness, and involving the appropriate team (social work, child psychiatry) is the therapeutic approach.

Question 39: Which psychosocial late effect is most prevalent among childhood cancer survivors?

Bipolar disorder
Antisocial personality disorder
Schizophrenia
Post-traumatic stress symptoms and anxiety (Correct answer)

Correct answer: Post-traumatic stress symptoms and anxiety

Survivors of childhood cancer have significantly elevated rates of post-traumatic stress symptoms (PTSS), anxiety, and depression compared to healthy peers and siblings, related to the trauma of diagnosis and treatment.

Question 40: A child with rhabdomyosarcoma of the bladder undergoes surgery. The nurse should monitor post-operatively for:

Respiratory distress
Constipation only
Hearing loss
Urinary retention, hematuria, and bladder spasm (Correct answer)

Correct answer: Urinary retention, hematuria, and bladder spasm

Bladder rhabdomyosarcoma surgery can cause post-operative urinary retention, hematuria, and bladder spasms requiring careful monitoring.

Question 41: A child with ALL and mucositis rates her oral pain as 9/10. She is currently on scheduled oral oxycodone. The nurse recognizes that oral administration is problematic given the mucositis and should advocate for:

Conversion to an IV or transdermal opioid route that bypasses the painful, compromised oral mucosa (Correct answer)
Using ice chips alone for pain management
Crushing the oxycodone tablets and mixing with honey to ease swallowing
Stopping opioids until the mucositis heals

Correct answer: Conversion to an IV or transdermal opioid route that bypasses the painful, compromised oral mucosa

Severe mucositis makes oral medication swallowing extremely painful and unreliable for absorption. IV patient-controlled analgesia or transdermal fentanyl provides consistent analgesia without requiring oral administration through damaged mucosa.

Question 42: A child with a bone tumor on high-dose chemotherapy has an ANC of 85/µL. The parents report the child has been playing outdoors, and a neighbor child visited who had a mild runny nose. Which nursing education point is most important?

The child's neutropenia is mild and routine precautions are sufficient
Only fever above 39°C warrants a call to the oncology team at this ANC level
Outdoor play is fine but should be limited to 30 minutes daily
Avoid close contact with anyone who is ill; this level of neutropenia (ANC <100) constitutes profound immunosuppression and any viral exposure carries serious risk (Correct answer)

Correct answer: Avoid close contact with anyone who is ill; this level of neutropenia (ANC <100) constitutes profound immunosuppression and any viral exposure carries serious risk

ANC <100 is profound neutropenia. Even a mildly ill contact represents significant infection risk — common respiratory viruses can cause severe, disseminated infections in the profoundly neutropenic child. Families must understand that any fever (≥38.3°C) is an emergency.

Question 43: What is the primary advantage of proton therapy over conventional photon radiation in pediatric oncology patients?

Shorter overall treatment duration
Reduced exit dose and significantly less radiation to healthy surrounding tissues (Correct answer)
Higher tumor kill rate than photon therapy
Lower treatment cost and wider availability

Correct answer: Reduced exit dose and significantly less radiation to healthy surrounding tissues

Protons deposit maximum energy at the Bragg peak and produce minimal exit dose, dramatically reducing radiation exposure to healthy tissues beyond the tumor—critical in growing children.

Question 44: A HSCT recipient on day +45 develops fever, dry cough, and hypoxemia. Chest CT shows bilateral ground-glass opacities. The nurse should prepare the patient for which diagnostic procedure?

Thoracentesis
Open lung biopsy
Bronchoscopy with bronchoalveolar lavage (BAL) (Correct answer)
Sputum culture only

Correct answer: Bronchoscopy with bronchoalveolar lavage (BAL)

Bilateral ground-glass opacities in an immunocompromised HSCT patient require bronchoscopy with BAL to obtain lower respiratory tract specimens for culture, cytology, and PCR testing for fungi, bacteria, and viruses — minimally invasive compared to open biopsy.

Question 45: What is the correct technique for infusing hematopoietic stem cells (bone marrow or PBSC product)?

Pre-medicate with diuretics and infuse over 6 hours
Infuse the product slowly via central line with the patient on continuous cardiac monitor, without a leukocyte filter (Correct answer)
Infuse rapidly via peripheral IV to minimize cell death
Use a standard blood transfusion filter (170 micron) to remove debris

Correct answer: Infuse the product slowly via central line with the patient on continuous cardiac monitor, without a leukocyte filter

Stem cell infusions are given via central line with continuous vital sign monitoring. Leukocyte reduction filters must NOT be used as they trap the CD34+ progenitor cells; infusion rate is carefully titrated based on the patient's tolerance.

Question 46: Which prophylaxis can be applied if a child is receiving fludarabine as part of their leukemia treatment in order to prevent tumor lysis syndrome?

Colchicine.
Dexamethasone.
Antihistamine.
Allopurinol. (Correct answer)

Correct answer: Allopurinol.

Allopurinol may be used to stop tumor lysis syndrome in kids being treated with fludarabine for leukemia, particularly if there is a significant tumor load. Drinking enough water is also essential. As cells are killed and nucleic acids are liberated, cytotoxic chemotherapy might result in higher uric acid levels. Because an elevated uric acid level is one of the causes of tumor lysis syndrome, allopurinol aids in lowering uric acid levels.

Question 47: A long-term survivor of childhood Hodgkin lymphoma who received mantle field radiation is at significantly elevated risk for which secondary malignancy?

Breast cancer (Correct answer)
Colon cancer
Brain tumor
Thyroid cancer only

Correct answer: Breast cancer

Females who received mantle field radiation involving the chest are at markedly elevated lifetime risk for breast cancer, often presenting at a younger age than in the general population.

Question 48: A neutropenic child develops a central line-associated bloodstream infection. Blood cultures grow Pseudomonas aeruginosa. The nurse should anticipate which change in antibiotic therapy?

Discontinuing antibiotics once fever resolves
Adding vancomycin as the primary treatment for Pseudomonas
Addition of a second antipseudomonal agent (aminoglycoside or fluoroquinolone) for synergistic coverage (Correct answer)
Switching to oral amoxicillin for completion of therapy

Correct answer: Addition of a second antipseudomonal agent (aminoglycoside or fluoroquinolone) for synergistic coverage

Pseudomonas aeruginosa bacteremia carries high mortality in neutropenic patients and warrants combination therapy with a beta-lactam plus an aminoglycoside or fluoroquinolone for synergistic killing and reduced resistance emergence.

Question 49: A child is receiving immunotherapy with blinatumomab for relapsed ALL. The nurse monitors for which serious complication?

Peripheral neuropathy
Cytokine release syndrome (CRS) (Correct answer)
Alopecia
Hyperglycemia only

Correct answer: Cytokine release syndrome (CRS)

Blinatumomab is a bispecific T-cell engager; CRS is a serious immune activation complication characterized by fever, hypotension, and organ dysfunction.

Question 50: Which communication approach is most appropriate when a CPHON nurse needs to discuss a child's terminal prognosis with the family?

Allow only the oncologist to speak and have the nurse remain silent
Provide all information via written materials to reduce emotional impact
Use clear, compassionate, jargon-free language; assess what the family already knows; follow the child's lead regarding inclusion; and ensure a private, quiet setting (Correct answer)
Deliver the information quickly in the hallway to minimize distress

Correct answer: Use clear, compassionate, jargon-free language; assess what the family already knows; follow the child's lead regarding inclusion; and ensure a private, quiet setting

Best practice for delivering serious news involves choosing a private setting, assessing prior knowledge, using plain language, listening to the family's emotional response, and including age-appropriate communication with the child per their cues and parental guidance.

Question 51: Which type of central line requires a non-coring Huber needle for access and is fully implanted under the skin?

Implanted venous port (Mediport, Port-a-Cath) (Correct answer)
PICC line
Midline catheter
Tunneled Broviac catheter

Correct answer: Implanted venous port (Mediport, Port-a-Cath)

Implanted venous ports (Mediport, Port-a-Cath, etc.) are fully subcutaneous devices accessed by inserting a non-coring Huber needle through the skin and into the silicone septum. Standard needles core the septum and are prohibited.

Question 52: Which assessment finding is an early sign of superior vena cava (SVC) syndrome in a child with a mediastinal tumor?

Sudden onset bradycardia
Lower extremity edema
Abdominal distension with ascites
Facial edema and plethora that worsens when leaning forward (Correct answer)

Correct answer: Facial edema and plethora that worsens when leaning forward

SVC syndrome causes venous congestion above the obstruction, presenting with facial and upper extremity swelling and plethora, worsened by gravity.

Question 53: During a bone marrow biopsy in a pediatric patient, the nurse notes the child becomes acutely tachycardic and diaphoretic. What is the priority action?

Administer a bolus of normal saline
Document findings and continue monitoring
Increase the rate of analgesic infusion
Assess airway, breathing, and circulation and notify the provider immediately (Correct answer)

Correct answer: Assess airway, breathing, and circulation and notify the provider immediately

Acute tachycardia and diaphoresis during a procedure may indicate a vasovagal response, hemorrhage, or anesthetic reaction requiring immediate assessment.

Question 54: Regarding radiation safety, which statement is correct about pregnant nurses and patients receiving internal brachytherapy implants?

Pregnant nurses should avoid caring for patients with active brachytherapy implants entirely (Correct answer)
Pregnant nurses only need to wear a lead apron during direct care
Pregnant nurses may care for these patients as long as contact is under 30 minutes
Pregnant nurses may care for these patients if they stand at least 1 foot away

Correct answer: Pregnant nurses should avoid caring for patients with active brachytherapy implants entirely

Pregnant nurses should not care for patients with active brachytherapy implants because ionizing radiation poses a risk of harm to the developing fetus at any exposure level.

Question 55: When a pediatric oncology patient is being discharged to home on oral chemotherapy, family education should include all of the following EXCEPT:

Proper disposal of unused chemotherapy agents in designated containers
Signs and symptoms requiring immediate notification of the oncology team
Safe handling precautions including wearing gloves when handling oral chemotherapy
Teaching family members to crush and dissolve oral chemotherapy tablets in food to ensure the child swallows the full dose (Correct answer)

Correct answer: Teaching family members to crush and dissolve oral chemotherapy tablets in food to ensure the child swallows the full dose

Oral chemotherapy should NEVER be crushed, split, or dissolved unless specifically directed by the pharmacy/prescriber, as this destroys enteric coating, alters absorption, and creates hazardous aerosol exposure for caregivers.

Question 56: Which finding is characteristic of disseminated intravascular coagulation (DIC) in a pediatric oncology patient?

Isolated neutropenia
Elevated hemoglobin and hematocrit
Elevated platelet count and normal PT
Prolonged PT/PTT, low fibrinogen, and thrombocytopenia (Correct answer)

Correct answer: Prolonged PT/PTT, low fibrinogen, and thrombocytopenia

DIC is characterized by simultaneous clotting and bleeding, resulting in consumption of clotting factors and platelets, causing prolonged PT/PTT and low fibrinogen.

Question 57: A child with cancer is being transitioned to home hospice care. Which statement by the nurse BEST reflects understanding of hospice goals?

Hospice care means no medications will be given
Hospice care means we have given up on your child
Hospice is only for adult patients
Hospice focuses on comfort, dignity, and supporting the whole family (Correct answer)

Correct answer: Hospice focuses on comfort, dignity, and supporting the whole family

Hospice care is a specialized form of palliative care focused on comfort, quality of life, and holistic family support — not abandonment.

Question 58: A mother of a child receiving cancer treatment tells the nurse she feels guilty that she 'gave' her child cancer. Which response is most therapeutic?

Provide her with research articles about pediatric cancer etiology
Tell her that guilt feelings are irrational and she should focus on being positive
Acknowledge her feelings, then gently educate that childhood cancer is not caused by anything parents did, and refer to the social worker (Correct answer)
Reassure her briefly and redirect to the child's current treatment plan

Correct answer: Acknowledge her feelings, then gently educate that childhood cancer is not caused by anything parents did, and refer to the social worker

Parental guilt is extremely common following a child's cancer diagnosis. Therapeutic response involves first acknowledging the emotional experience, then offering evidence-based reassurance that most childhood cancers have no known parental cause, and connecting the family with psychosocial support.

Question 59: A child is receiving a continuous infusion through a double-lumen Broviac when the proximal lumen tubing disconnects accidentally. The most immediate nursing action is:

Reattach the disconnected tubing quickly without cleaning the hub
Remove the entire catheter to prevent air embolism
Clamp the proximal catheter hub immediately, then apply a sterile cap while maintaining aseptic technique (Correct answer)
Notify the physician before doing anything

Correct answer: Clamp the proximal catheter hub immediately, then apply a sterile cap while maintaining aseptic technique

Immediate clamping of the disconnected lumen prevents air entrainment (air embolism) and blood backflow. A sterile cap should then be placed on the hub using aseptic technique. The hub and connection should be cleaned with antiseptic before reconnecting new tubing.

Question 60: A child with leukemia has a platelet count of 10,000/mm³ and no active bleeding. Prophylactic platelet transfusion is typically indicated at this threshold to prevent:

Febrile neutropenia
Tumor lysis syndrome
Bone marrow failure
Spontaneous hemorrhage (Correct answer)

Correct answer: Spontaneous hemorrhage

A platelet count below 10,000–20,000/mm³ is the threshold for prophylactic transfusion to prevent spontaneous life-threatening bleeding.

Question 61: Which dietary recommendation is most appropriate for a child experiencing radiation-induced mucositis affecting the mouth and throat?

High-fiber foods to promote bowel motility and comfort
Soft, bland, cool foods that minimize irritation and are easy to swallow (Correct answer)
Carbonated beverages to keep the oral cavity moist
Spicy, highly seasoned foods to stimulate appetite

Correct answer: Soft, bland, cool foods that minimize irritation and are easy to swallow

Soft, bland, and cool foods minimize mechanical and chemical irritation to inflamed mucous membranes and reduce pain during swallowing.

Question 62: When caring for a child with severe mucositis, which oral care intervention is recommended?

Brush vigorously with a firm toothbrush
Use alcohol-based mouthwash four times daily
Rinse with normal saline or sodium bicarbonate solution (Correct answer)
Avoid all oral care to prevent pain

Correct answer: Rinse with normal saline or sodium bicarbonate solution

Normal saline or sodium bicarbonate rinses are gentle and help maintain oral pH, promoting healing without irritating damaged mucosa.

Question 63: A child undergoing a lumbar puncture for ALL staging will receive topical EMLA cream applied 60 minutes before the procedure. Which additional pharmacologic intervention most effectively reduces procedural pain for lumbar punctures in children?

General anesthesia for every lumbar puncture regardless of age
Oral acetaminophen 30 minutes before the procedure
Moderate procedural sedation with midazolam and a short-acting opioid (fentanyl) or ketamine (Correct answer)
Topical ice pack application immediately before needle insertion

Correct answer: Moderate procedural sedation with midazolam and a short-acting opioid (fentanyl) or ketamine

While topical anesthetics address skin puncture pain, LP involves deeper dural puncture and positioning discomfort best managed by procedural sedation/analgesia, which has been shown to significantly reduce distress, improve success rates, and reduce long-term procedure-related trauma.

Question 64: When developing a care plan for a child with terminal cancer, the nurse includes which priority goal?

Maintain comfort and quality of life (Correct answer)
Maximize aggressive treatment
Cure the underlying malignancy
Prevent all family visits

Correct answer: Maintain comfort and quality of life

For terminal pediatric cancer, palliative and comfort-focused goals center on maximizing quality of life, not curative intervention.

Question 65: A 6-year-old with beta-thalassemia major requires chronic transfusion therapy. Which complication must the nurse monitor for over time?

Iron overload (hemosiderosis) (Correct answer)
Hypocalcemia
Vitamin B12 deficiency
Hypokalemia

Correct answer: Iron overload (hemosiderosis)

Repeated transfusions in thalassemia major lead to iron overload, damaging the heart, liver, and endocrine organs.

Question 66: To assess pain in a 3-year-old child with leukemia who cannot verbalize pain level, the nurse should use:

McGill Pain Questionnaire
Numeric rating scale (0–10)
Visual analog scale
FLACC behavioral pain scale (Correct answer)

Correct answer: FLACC behavioral pain scale

The FLACC scale (Face, Legs, Activity, Cry, Consolability) is validated for assessing pain in pre-verbal and young children via behavioral observation.

Question 67: The parents of a 4-year-old with leukemia are divorcing during treatment. The child has become clingy, regressed to bedwetting, and refuses to let go of parents when they leave. The nurse should:

Assure the parents that regression always resolves spontaneously without intervention
Acknowledge this is expected stress response, validate parental concerns, involve child life, and communicate the behavior pattern to the oncology social worker (Correct answer)
Tell the parents the regression is abnormal and psychiatric referral is urgent
Recommend the parents not tell the child about the divorce

Correct answer: Acknowledge this is expected stress response, validate parental concerns, involve child life, and communicate the behavior pattern to the oncology social worker

Regression and separation anxiety are normal stress responses in young children facing medical illness plus family disruption. The appropriate nursing response is validation, child life involvement, and social work referral to support the whole family system.

Question 68: Which adjuvant medication is most appropriate to add for a child with cancer pain from nerve compression causing neuropathic symptoms (burning, shooting pain)?

Acetaminophen 1000 mg
Ondansetron
Diphenhydramine
Gabapentin (Neurontin) (Correct answer)

Correct answer: Gabapentin (Neurontin)

Gabapentin (a gabapentinoid/anticonvulsant) blocks voltage-gated calcium channels in dorsal horn neurons, reducing neuropathic pain transmission. It is the first-line adjuvant for pediatric neuropathic cancer pain.

Question 69: During chemotherapy, a patient experiences excruciating vesicular and crusting blisters on the lips, mouth, and gums. The nurse's anticipated diagnosis is:

oral herpes simplex virus. (Correct answer)
oral mucositis.
gingivitis.
oral candidiasis.

Correct answer: oral herpes simplex virus.

Oral herpes simplex virus is the likely diagnosis if a patient experiences excruciating vesicular and crusting blisters on the lips, mouth, and gums while receiving chemotherapy. Due to immunosuppression, chemotherapy might cause the herpes simplex virus to reactivate. Usually, the lesions last for one to two weeks. Antiviral medications like acyclovir, valacyclovir, or famciclovir are used in treatment. Antiviral prophylaxis may be administered to some patients.

Question 70: Which laboratory finding would the nurse expect in iron-deficiency anemia?

Normal MCV and low reticulocyte count
Elevated MCV and elevated ferritin
Elevated direct bilirubin and spherocytes
Low MCV, low serum ferritin, elevated TIBC (Correct answer)

Correct answer: Low MCV, low serum ferritin, elevated TIBC

Iron-deficiency anemia causes microcytic (low MCV) anemia, depleted iron stores (low ferritin), and increased iron-binding capacity (elevated TIBC).

Question 71: A child with aplastic anemia has an ANC of 150 cells/mm³. The nurse should place the child in:

Protective (reverse) isolation (Correct answer)
Standard precautions only
Droplet precautions
Contact isolation

Correct answer: Protective (reverse) isolation

An ANC below 500 cells/mm³ indicates severe neutropenia; protective isolation minimizes exposure to pathogens in this immunocompromised child.

Question 72: A CPHON nurse is educating the family of a child who will undergo autologous HSCT for neuroblastoma. Which statement by the parent indicates a need for further teaching?

'My child's counts will drop very low after the conditioning chemotherapy'
'My child can receive any blood product because we're using their own cells' (Correct answer)
'We'll need to avoid people with illness for several months after transplant'
'My child will need to stay in the hospital during the conditioning and engraftment period'

Correct answer: 'My child can receive any blood product because we're using their own cells'

This statement is incorrect — even autologous HSCT patients require irradiated and CMV-safe blood products to prevent transfusion-associated GVHD and CMV transmission during immunosuppression.

Question 73: A pediatric patient receiving abdominal radiation reports sudden onset of severe, worsening abdominal pain with a board-like rigid abdomen. What is the nurse's priority action?

Notify the physician immediately as this may indicate bowel perforation or obstruction (Correct answer)
Apply a warm compress to the abdomen for comfort
Document loose stools as an expected radiation side effect
Administer the scheduled antiemetic and continue monitoring

Correct answer: Notify the physician immediately as this may indicate bowel perforation or obstruction

Sudden severe abdominal pain with rigidity is a potential sign of bowel perforation or obstruction—a rare but life-threatening complication of abdominal radiation requiring immediate medical evaluation.

Question 74: A 5-year-old who received craniospinal irradiation for medulloblastoma is at highest risk for which long-term endocrine complication?

Growth hormone deficiency due to hypothalamic-pituitary axis injury (Correct answer)
Hyperthyroidism due to thyroid stimulation
Hyperprolactinemia requiring dopamine agonist therapy
Adrenal insufficiency from direct adrenal irradiation

Correct answer: Growth hormone deficiency due to hypothalamic-pituitary axis injury

Growth hormone deficiency is the most common endocrine late effect of craniospinal irradiation in children, resulting from radiation damage to the highly radiosensitive hypothalamic-pituitary axis.

Question 75: Which antiemetic class works by blocking serotonin (5-HT3) receptors and is first-line for chemotherapy-induced nausea?

Serotonin (5-HT3) antagonists (ondansetron) (Correct answer)
Phenothiazines
Antihistamines
Benzodiazepines

Correct answer: Serotonin (5-HT3) antagonists (ondansetron)

5-HT3 antagonists like ondansetron block serotonin receptors in the gut and brain that trigger nausea during chemotherapy.

Question 76: A child 6 months post-allogeneic HSCT develops dry eyes, oral mucosal changes, joint contractures, and skin tightening. This clinical picture is most consistent with:

Chronic graft-versus-host disease (cGVHD) (Correct answer)
Post-transplant lymphoproliferative disorder
Late cytomegalovirus end-organ disease
Drug-induced scleroderma

Correct answer: Chronic graft-versus-host disease (cGVHD)

Chronic GVHD is a multi-system inflammatory and fibrotic disorder occurring after 100 days post-transplant, resembling autoimmune connective tissue diseases with features of scleroderma, Sjögren's, and lichen planus.

Question 77: A 10-year-old with leukemia refuses to take oral medication. The BEST nursing approach is to:

Collaborate with the child and family to problem-solve acceptability (Correct answer)
Force the medication immediately
Crush and hide medication in food without telling the child
Document refusal and skip the dose without further action

Correct answer: Collaborate with the child and family to problem-solve acceptability

A child-centered approach that involves the child and family in problem-solving increases adherence and respects developmental autonomy.

Question 78: During a nursing handoff, the nurse learns a child with a brain tumor has new onset of unequal pupils. This finding suggests:

Increased intracranial pressure — notify provider immediately (Correct answer)
Dehydration
Medication side effect from antiemetics
Normal variation in lighting

Correct answer: Increased intracranial pressure — notify provider immediately

Unequal pupils (anisocoria) in a patient with a brain tumor is a neurological emergency indicating possible herniation or increased ICP.

Question 79: Which statement correctly describes the difference between physical dependence and addiction in the context of opioid use for pediatric cancer pain?

Children with cancer cannot develop physical dependence on opioids
Physical dependence is an expected physiologic adaptation causing withdrawal if opioids are abruptly stopped; addiction involves psychological craving and compulsive drug-seeking despite harm — addiction is very rare when opioids are used appropriately for cancer pain (Correct answer)
Addiction is common in children who receive opioids for cancer pain and should discourage opioid use
Physical dependence and addiction are the same condition in children

Correct answer: Physical dependence is an expected physiologic adaptation causing withdrawal if opioids are abruptly stopped; addiction involves psychological craving and compulsive drug-seeking despite harm — addiction is very rare when opioids are used appropriately for cancer pain

Physical dependence (predictable withdrawal upon abrupt cessation) is an expected pharmacologic phenomenon in any patient on chronic opioids; it requires gradual dose tapering. Addiction (compulsive craving and harmful use) is extremely rare when opioids are used appropriately for genuine pain.

Question 80: Desmopressin (DDAVP) is used in mild hemophilia A because it:

Increases platelet production
Stimulates the release of endogenous factor VIII and vWF (Correct answer)
Provides exogenous factor VIII directly
Reverses the effects of anticoagulants

Correct answer: Stimulates the release of endogenous factor VIII and vWF

DDAVP stimulates endothelial cells to release stored factor VIII and vWF, temporarily raising their plasma levels in mild cases.

Question 81: What is the standard SI unit used to measure absorbed radiation dose in radiation therapy?

Sievert (Sv)
Gray (Gy) (Correct answer)
Roentgen
Rad

Correct answer: Gray (Gy)

The Gray (Gy) is the SI unit of absorbed radiation dose, defined as 1 joule of energy absorbed per kilogram of tissue.

Question 82: A nurse is preparing to access an implanted venous port in a 7-year-old for chemotherapy. In what order should the following steps be performed?

Clean the site → insert Huber needle → apply anesthetic cream after insertion
Insert Huber needle first → then apply antiseptic → verify by flushing → aspirate blood
Apply topical anesthetic → palpate septum → clean with chlorhexidine → insert Huber needle → verify placement by aspirating blood → flush with normal saline (Correct answer)
Aspirate first to confirm placement → then clean the site → insert needle → apply anesthetic

Correct answer: Apply topical anesthetic → palpate septum → clean with chlorhexidine → insert Huber needle → verify placement by aspirating blood → flush with normal saline

The correct sequence for port access is: apply topical anesthetic (well in advance) → palpate the port septum → clean with chlorhexidine antiseptic → insert Huber needle perpendicular to septum → verify with blood aspiration → flush with normal saline.

Question 83: When converting a child from IV morphine to oral morphine, the nurse should apply which pharmacokinetic principle?

Oral and IV morphine are equivalent in potency and require no dose adjustment
Oral morphine is more potent than IV morphine and requires a lower dose
No conversion is needed as the opioid receptor response is the same regardless of route
Oral morphine is approximately 3 times less potent than IV morphine due to first-pass hepatic metabolism, so the oral dose is 3 times higher than the IV dose (Correct answer)

Correct answer: Oral morphine is approximately 3 times less potent than IV morphine due to first-pass hepatic metabolism, so the oral dose is 3 times higher than the IV dose

Oral morphine undergoes significant first-pass metabolism in the liver, reducing its bioavailability to approximately 30–40% of the IV dose. The equianalgesic ratio is IV:PO = 1:3 — thus the oral dose is approximately 3 times the IV dose to achieve equivalent analgesia.

Question 84: A child with a hemoglobin of 6.5 g/dL is scheduled for a packed red blood cell transfusion. The nurse should transfuse over:

15 minutes
30 minutes
2–4 hours (Correct answer)
12 hours

Correct answer: 2–4 hours

Packed red blood cells should be transfused over 2–4 hours to avoid fluid overload and allow physiologic adaptation, especially in children.

Question 85: The nurse notes a child with sickle cell disease has a spleen that is markedly enlarged and the hemoglobin dropped from 9 to 5 g/dL acutely. This presentation suggests:

Splenic sequestration crisis (Correct answer)
Aplastic crisis
Hyperhemolytic crisis
Acute chest syndrome

Correct answer: Splenic sequestration crisis

Splenic sequestration crisis involves rapid pooling of blood in the spleen causing acute anemia, splenomegaly, and circulatory compromise.

Question 86: When irradiated blood products are ordered for a pediatric oncology patient, the PRIMARY reason is to prevent:

Transfusion-associated GVHD (Correct answer)
CMV transmission
Alloimmunization to platelets
Iron overload

Correct answer: Transfusion-associated GVHD

Irradiation kills donor lymphocytes in blood products, preventing them from engrafting and attacking the immunocompromised recipient (TA-GVHD).

Question 87: A childhood ALL survivor's parents ask about dental late effects from their child's chemotherapy and radiation. Which finding is most expected?

Parotid gland atrophy
Mandibular osteonecrosis
Root foreshortening and enamel hypoplasia (Correct answer)
Gingival hyperplasia

Correct answer: Root foreshortening and enamel hypoplasia

Chemotherapy and cranial/jaw radiation during dental development cause root foreshortening, enamel hypoplasia, and microdontia as developing tooth buds are damaged.

Question 88: A child undergoing allogeneic stem cell transplant develops a new rash, diarrhea, and elevated bilirubin on day +30. The nurse suspects:

Engraftment failure
Graft-versus-host disease (GVHD) (Correct answer)
Cytomegalovirus infection
Sinusoidal obstruction syndrome

Correct answer: Graft-versus-host disease (GVHD)

Classic acute GVHD presents with the triad of skin rash, diarrhea, and liver dysfunction (elevated bilirubin) after allogeneic transplant.

Question 89: Which marker is used to distinguish B-cell from T-cell ALL?

CD20 for T-cell, CD3 for B-cell
CD3 and TdT for T-cell; CD19 and CD10 for B-cell (Correct answer)
HLA-DR for T-cell, CD20 for B-cell
CD45 for both equally

Correct answer: CD3 and TdT for T-cell; CD19 and CD10 for B-cell

T-cell ALL is positive for CD3 and TdT; B-cell precursor ALL is positive for CD19, CD10, and TdT on immunophenotyping.

Question 90: Radiation therapy directed to the thorax in a pediatric oncology patient most commonly causes which acute pulmonary complication?

Pulmonary fibrosis
Spontaneous pneumothorax
Radiation pneumonitis (Correct answer)
Massive pleural effusion

Correct answer: Radiation pneumonitis

Radiation pneumonitis typically develops 4–12 weeks after thoracic irradiation and presents with cough, dyspnea, and low-grade fever due to acute inflammatory injury.

Question 91: A child undergoing stem cell transplant is on neutropenic precautions. Which food should the nurse instruct the family to AVOID?

Cooked vegetables
Well-done meats
Fresh salads and raw fruits (Correct answer)
Pasteurized dairy products

Correct answer: Fresh salads and raw fruits

Raw fruits, vegetables, and salads can harbor bacteria and fungi that are dangerous to severely immunocompromised patients.

Question 92: Which site assessment finding requires immediate removal of a peripheral IV catheter in a pediatric oncology patient receiving vesicant chemotherapy?

IV rate running 10 mL/hr slower than prescribed
Slight redness at the catheter insertion site without swelling
Blood return not visible in the tubing
Swelling, blanching, or pain at the infusion site indicating extravasation (Correct answer)

Correct answer: Swelling, blanching, or pain at the infusion site indicating extravasation

Swelling, blanching (skin pallor from vesicant infiltration into tissue), or pain at or around the IV site indicates extravasation of a vesicant — an oncologic emergency requiring immediate IV cessation and antidote administration.

Question 93: A child is prescribed bleomycin as part of a lymphoma protocol. Which baseline test is MOST important before starting therapy?

Bone marrow biopsy
Echocardiogram
Pulmonary function tests (Correct answer)
Renal ultrasound

Correct answer: Pulmonary function tests

Bleomycin causes pulmonary fibrosis; baseline pulmonary function tests help detect early lung toxicity during treatment.

Question 94: Which is the most appropriate nursing intervention for a child experiencing vincristine-induced constipation?

Hold vincristine until bowel function normalizes
Increase dietary fiber and wait for natural resolution
Administer enemas after each vincristine dose
Prophylactic bowel regimen with stimulant laxatives started at initiation of vincristine (Correct answer)

Correct answer: Prophylactic bowel regimen with stimulant laxatives started at initiation of vincristine

Vincristine causes autonomic neuropathy leading to constipation; a prophylactic bowel regimen is standard practice from the start of therapy.

Question 95: A child receiving vincristine develops jaw pain and peripheral tingling. The nurse recognizes these as signs of:

Peripheral neuropathy (Correct answer)
Hypersensitivity reaction
Tumor lysis syndrome
Extravasation

Correct answer: Peripheral neuropathy

Vincristine is a known neurotoxin; jaw pain and peripheral tingling are hallmark signs of vinca alkaloid-induced peripheral neuropathy.

Question 96: A child with cancer develops cachexia. Which intervention should the nurse prioritize?

Enforce strict calorie restriction
Restrict all protein intake
Consult a registered dietitian and consider enteral nutrition (Correct answer)
Encourage only high-sugar foods

Correct answer: Consult a registered dietitian and consider enteral nutrition

Cancer cachexia requires collaboration with a dietitian to optimize nutrition; enteral support may be needed if oral intake is inadequate.

Question 97: The nurse is teaching a family about radiation therapy side effects for a child receiving cranial radiation. Which long-term effect is MOST important to discuss?

Mild temporary headache
Neurocognitive effects including learning difficulties and memory impairment (Correct answer)
Temporary fatigue only
Temporary skin tan in the field

Correct answer: Neurocognitive effects including learning difficulties and memory impairment

Cranial radiation in young children can cause lasting neurocognitive impairment, including learning disabilities, memory deficits, and reduced IQ.

Question 98: A child with cancer reports a pain score of 8/10 from bone metastases. Current pain management includes acetaminophen 15 mg/kg PO every 6 hours. Per the WHO analgesic ladder for pediatric pain, the next appropriate step is:

Adding a second non-opioid NSAID
Waiting to see if the pain resolves spontaneously
Addition of an opioid analgesic (e.g., oral morphine or oxycodone) as the pain has not responded to non-opioid therapy alone (Correct answer)
Increasing the acetaminophen dose beyond the maximum

Correct answer: Addition of an opioid analgesic (e.g., oral morphine or oxycodone) as the pain has not responded to non-opioid therapy alone

The WHO analgesic ladder calls for step-up to opioid analgesics (Step 2: mild opioids, or Step 3: strong opioids like morphine) when pain is not controlled by non-opioid analgesics. A pain score of 8/10 uncontrolled on acetaminophen requires opioid initiation.

Question 99: Which pediatric cancer is associated with a characteristic abdominal mass that does not cross the midline in young children?

Wilms' tumor (nephroblastoma) (Correct answer)
Neuroblastoma
Hepatoblastoma
Rhabdomyosarcoma

Correct answer: Wilms' tumor (nephroblastoma)

Wilms' tumor arises from the kidney and typically presents as a smooth, firm unilateral abdominal mass that does not cross the midline.

Question 100: Family-centered care (FCC) in pediatric oncology nursing is best defined as:

A philosophy of care that recognizes the family as the constant in the child's life and integrates the family as partners in all aspects of care (Correct answer)
A model in which the nurse makes all care decisions to protect the child from parental anxiety
A policy that restricts visitation to protect immunocompromised patients
An approach that focuses exclusively on the child's physical needs without parental input

Correct answer: A philosophy of care that recognizes the family as the constant in the child's life and integrates the family as partners in all aspects of care

Family-centered care recognizes that the family is the primary source of strength for the child; it involves families as full partners in care planning, decision-making, and daily caregiving activities across all settings.

Question 101: A child's chemotherapy protocol calls for dexamethasone pre-medication. The PRIMARY purpose of this is to:

Prevent tumor lysis syndrome
Stimulate red blood cell production
Reduce the risk of hypersensitivity reaction (Correct answer)
Decrease peripheral neuropathy

Correct answer: Reduce the risk of hypersensitivity reaction

Dexamethasone is used as premedication to reduce the risk of hypersensitivity reactions and infusion-related reactions to certain chemotherapy agents.

Question 102: A child receiving hydroxyurea for sickle cell disease should have which monitoring performed regularly?

Bone density scans
Pulmonary function tests
Liver biopsy
Complete blood count and reticulocyte count (Correct answer)

Correct answer: Complete blood count and reticulocyte count

Hydroxyurea suppresses bone marrow, so CBC and reticulocytes must be monitored regularly to detect myelosuppression and adjust dosing.

Question 103: Stereotactic radiosurgery (SRS) is most commonly used in pediatric oncology for which indication?

Whole-lung irradiation for pulmonary metastases from Wilms tumor
Craniospinal irradiation for high-risk medulloblastoma
Focal treatment of small intracranial tumors or brain metastases (Correct answer)
Total body irradiation prior to bone marrow transplantation

Correct answer: Focal treatment of small intracranial tumors or brain metastases

SRS delivers highly focused, high-dose radiation in one or few fractions to small, well-defined intracranial targets such as brain metastases or small primary tumors.

Question 104: The CPHON nurse is caring for a child with superior vena cava (SVC) syndrome. Which position is MOST appropriate?

High Fowler's (head of bed elevated 60–90°) (Correct answer)
Prone
Left lateral decubitus
Supine with legs elevated

Correct answer: High Fowler's (head of bed elevated 60–90°)

Elevating the head of bed reduces venous pressure in the SVC, decreasing facial/neck swelling and improving venous return.

Question 105: Which sign or symptom in a neutropenic patient indicates possible Clostridium difficile (C. diff) colitis and requires contact precautions?

Blood-streaked stools without diarrhea
Profuse, watery, foul-smelling diarrhea (≥3 loose stools in 24 hours) after antibiotic exposure (Correct answer)
Constipation and abdominal cramping
Bilious vomiting with absent bowel sounds

Correct answer: Profuse, watery, foul-smelling diarrhea (≥3 loose stools in 24 hours) after antibiotic exposure

C. difficile produces toxin-mediated colitis in patients whose gut flora has been disrupted by antibiotics. It presents with profuse watery, foul-smelling diarrhea and is highly contagious via spore transmission, requiring contact precautions and specific hygiene measures.

Question 106: Which personal protective equipment (PPE) is MOST important when administering intravenous vesicant chemotherapy to a pediatric patient?

Standard gloves only
Double gloves and a gown (Correct answer)
Face shield only
Surgical mask only

Correct answer: Double gloves and a gown

Double gloves and a gown are required when handling vesicant chemotherapy agents to protect the nurse from skin exposure.

Question 107: A 9-year-old with Hodgkin lymphoma has a mediastinal mass. Which pre-anesthesia concern is most critical?

Risk of airway compression under anesthesia (Correct answer)
Renal insufficiency
Electrolyte imbalance
Increased bleeding risk

Correct answer: Risk of airway compression under anesthesia

Mediastinal masses can compress the trachea or great vessels, making general anesthesia extremely dangerous due to loss of airway tone.

Question 108: The nurse informs the parent that the child's food should consist of the following for the preceding 12 hours in order to prepare for a PET scan:

low protein.
low carbohydrate. (Correct answer)
high carbohydrate.
low fat.

Correct answer: low carbohydrate.

The youngster should consume low carbohydrate foods over the preceding 12 hours in order to prepare for a PET scan. A high-carbohydrate diet or receiving glucose intravenously (IV) could cause false-positive results. Prior to the test, patients must fast for six hours. Depending on the organ being scanned, the radioactive tracer used in the PET scan may be given orally, intravenously, or both. Because the tracer builds up in regions with a high level of chemical activity, such tumors, PET scans can detect malignancies.

Question 109: In radiation therapy planning, which volume adds a geometric margin around the clinical target volume (CTV) to account for patient setup uncertainties and organ motion?

Gross tumor volume (GTV)
Organ at risk volume (OAR)
Planning target volume (PTV) (Correct answer)
Internal target volume (ITV)

Correct answer: Planning target volume (PTV)

The planning target volume (PTV) adds a margin around the CTV to account for daily setup variations and organ motion, ensuring the tumor consistently receives the prescribed dose.

Question 110: A 14-year-old oncology patient tells the nurse privately that she is deeply depressed and sometimes thinks about not wanting to be alive, though she has no specific plan. The most appropriate immediate action is:

Reassure the patient that these feelings will pass and document in the chart
Immediately tell the parents without explaining the situation to the patient
Maintain confidentiality and not disclose to the care team because the patient asked for privacy
Take the disclosure seriously, ensure patient safety, notify the provider and social worker, and stay with the patient (Correct answer)

Correct answer: Take the disclosure seriously, ensure patient safety, notify the provider and social worker, and stay with the patient

Passive suicidal ideation ('not wanting to be alive') is a psychiatric emergency that supersedes confidentiality. The nurse must take this seriously, ensure immediate safety, notify the provider and social work or psychiatry, and remain with the patient.

Question 111: Which sibling support intervention is most important during a child's cancer treatment?

Focusing all family resources on the sick child exclusively
Providing age-appropriate information about the illness, maintaining school routines, and ensuring the sibling has someone to talk to about their feelings (Correct answer)
Having siblings attend every medical appointment to stay involved
Keeping siblings completely shielded from information to protect them

Correct answer: Providing age-appropriate information about the illness, maintaining school routines, and ensuring the sibling has someone to talk to about their feelings

Siblings of children with cancer experience significant psychological distress including anxiety, depression, fear, jealousy, and social difficulties. Age-appropriate information, maintaining normal routines, and emotional support are the most protective interventions.

Question 112: A child with chronic immune thrombocytopenic purpura (ITP) has a platelet count of 8,000/mm³ and reports a severe headache. What is the most urgent concern?

Intracranial hemorrhage requiring immediate neurological evaluation (Correct answer)
Migraine from stress related to illness
Medication-related headache from IVIG
Sinusitis causing referred headache

Correct answer: Intracranial hemorrhage requiring immediate neurological evaluation

A severe headache with critically low platelets raises urgent concern for intracranial hemorrhage, a rare but life-threatening complication of ITP.

Question 113: Which chemotherapy agent is classified as a topoisomerase II inhibitor and requires cardiac monitoring?

Cytarabine
Busulfan
Vincristine
Etoposide (Correct answer)

Correct answer: Etoposide

Etoposide inhibits topoisomerase II, which can cause secondary leukemia and requires monitoring for hypotension during infusion.

Question 114: A child's morphine dose has been titrated up to 0.2 mg/kg/dose every 4 hours and she now has stable pain but is experiencing constipation. The nurse should anticipate which intervention?

Initiate a scheduled stimulant laxative (senna or bisacodyl) as opioid-induced constipation does not resolve with tolerance and requires active management (Correct answer)
Reduce the opioid dose to treat the constipation
Wait for tolerance to develop as constipation resolves within 1–2 weeks
Recommend increased fluid and fiber intake as the sole intervention

Correct answer: Initiate a scheduled stimulant laxative (senna or bisacodyl) as opioid-induced constipation does not resolve with tolerance and requires active management

Opioid-induced constipation (OIC) is caused by opioid binding to mu receptors in the GI tract, slowing motility. Unlike sedation, OIC does not develop tolerance and requires proactive, ongoing stimulant laxative therapy.

Question 115: Which prophylactic medication is routinely given to pediatric oncology patients receiving intensive chemotherapy to prevent Pneumocystis jirovecii pneumonia (PJP)?

Trimethoprim-sulfamethoxazole (TMP-SMX / co-trimoxazole) (Correct answer)
Vancomycin
Metronidazole
Fluconazole

Correct answer: Trimethoprim-sulfamethoxazole (TMP-SMX / co-trimoxazole)

TMP-SMX is the first-line prophylactic agent for PJP in immunocompromised pediatric oncology patients. It is typically given 2–3 days per week. Alternatives for sulfa-allergic patients include dapsone, atovaquone, or monthly inhaled pentamidine.

Question 116: Which infection is of greatest concern in an asplenic pediatric oncology patient?

Herpes simplex virus
Pneumocystis jirovecii
Candida albicans
Encapsulated bacterial organisms such as Streptococcus pneumoniae (Correct answer)

Correct answer: Encapsulated bacterial organisms such as Streptococcus pneumoniae

The spleen filters encapsulated bacteria; asplenic patients are at high risk for overwhelming sepsis from Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis.

Question 117: A nurse notices swelling and burning at a child's IV site during doxorubicin infusion. The FIRST action should be:

Slow the infusion rate
Apply a warm compress
Flush the line with normal saline
Stop the infusion immediately and disconnect the IV (Correct answer)

Correct answer: Stop the infusion immediately and disconnect the IV

Stopping the infusion immediately and disconnecting the IV prevents further tissue exposure to the vesicant agent.

Question 118: A child with cancer who is in moderate pain rates it 7/10. According to the WHO analgesic ladder, the appropriate step is:

Non-opioid only (acetaminophen/NSAIDs)
Strong opioid (morphine) ± non-opioid (Correct answer)
Topical analgesic alone
Weak opioid (codeine/tramadol) + non-opioid

Correct answer: Strong opioid (morphine) ± non-opioid

Moderate-to-severe pain (6–10/10) corresponds to WHO Step 3, which calls for a strong opioid such as morphine, with or without adjuvants.

Question 119: What is the primary nursing role during a child's end-of-life care transition from curative to palliative focus?

Transfer care entirely to the palliative team without ongoing oncology nursing involvement
Restrict family visitation to provide a calm environment
Focus exclusively on documenting declining vital signs
Provide expert symptom management, emotional support for family, facilitate communication, and advocate for the child's comfort and dignity (Correct answer)

Correct answer: Provide expert symptom management, emotional support for family, facilitate communication, and advocate for the child's comfort and dignity

When transitioning to palliative care, the CPHON nurse remains central to the care team, providing expert symptom control, emotional and spiritual support, family education, communication facilitation, and advocacy for the child's dignity and comfort.

Question 120: A toddler with neuroblastoma has periorbital ecchymosis (raccoon eyes). The nurse documents this as a sign of:

Iron deficiency anemia
Physical abuse only
Orbital metastasis from neuroblastoma (Correct answer)
Normal developmental variant

Correct answer: Orbital metastasis from neuroblastoma

Bilateral periorbital ecchymosis ('raccoon eyes') in children with neuroblastoma indicates orbital metastasis from tumor spread to the skull base.

Question 121: Which of the following is an acute side effect of radiation therapy directed to the head and neck region in a pediatric patient?

Mucositis (Correct answer)
Secondary malignancy
Growth hormone deficiency
Cognitive processing deficits

Correct answer: Mucositis

Mucositis is an acute side effect of head and neck radiation that typically appears within the first 1–2 weeks of treatment due to injury to rapidly dividing mucosal cells.

Question 122: Which blood product is used FIRST-LINE for a child with immune thrombocytopenic purpura (ITP) who has intracranial bleeding?

Platelet transfusion (Correct answer)
Packed red blood cells
Cryoprecipitate
Fresh frozen plasma

Correct answer: Platelet transfusion

Platelet transfusion is given urgently in ITP with life-threatening bleeding such as intracranial hemorrhage to raise the platelet count rapidly.

Question 123: A parent of a newly diagnosed pediatric cancer patient asks the nurse why the child life specialist is visiting their child. Which response best explains the child life specialist's role?

Child life specialists coordinate insurance coverage and financial assistance
Child life specialists manage the child's medication schedule
Child life specialists provide nutritional support and dietary counseling
Child life specialists use therapeutic play, preparation, and coping strategies to help children manage the stress of illness and medical procedures (Correct answer)

Correct answer: Child life specialists use therapeutic play, preparation, and coping strategies to help children manage the stress of illness and medical procedures

Child life specialists are trained professionals who address the psychological and developmental needs of hospitalized children through therapeutic play, procedural preparation, distraction, and coping skill development.

Question 124: A child with a newly placed PICC line develops erythema, warmth, and tenderness along the arm vein pathway 48 hours after insertion. The nurse suspects:

Pneumothorax
Air embolism
Phlebitis or thrombophlebitis of the accessed vein (Correct answer)
Line-associated bloodstream infection (CLABSI)

Correct answer: Phlebitis or thrombophlebitis of the accessed vein

Erythema, warmth, and tenderness tracking along the vein indicate phlebitis or thrombophlebitis — inflammation of the vein wall, a known complication of peripherally inserted central catheters.

Question 125: A nurse is assigned to a 7-year-old who has returned from a bone marrow aspiration under moderate sedation 30 minutes ago. The child's respiratory rate is 11 breaths/minute, SpO2 is 95% on room air, and they are only arousable to voice. The most appropriate nursing action is:

Allow the child to sleep undisturbed as this is expected post-sedation
Administer a dose of acetaminophen for post-procedure pain
Reposition the child to prone for better airway drainage
Apply supplemental oxygen, stimulate the child, notify the provider, and prepare reversal agents per protocol (Correct answer)

Correct answer: Apply supplemental oxygen, stimulate the child, notify the provider, and prepare reversal agents per protocol

SpO2 of 95% and only arousable to voice 30 minutes post-sedation with RR of 11 suggests residual sedation/respiratory depression requiring intervention: supplemental oxygen, stimulation, provider notification, and possible reversal agent (flumazenil for benzodiazepines; naloxone for opioids).

Question 126: A child with neutrophil count of 1,800/mm³ develops fever of 38.5°C. According to CPHON guidelines, this child:

Has febrile neutropenia and requires urgent evaluation
Should receive prophylactic antifungals only
Does not meet criteria for febrile neutropenia (Correct answer)
Can be observed at home for 24 hours

Correct answer: Does not meet criteria for febrile neutropenia

Febrile neutropenia requires ANC below 500/mm³ (or below 1,000/mm³ and falling); an ANC of 1,800/mm³ does not meet the neutropenia threshold.

Question 127: A child with retinoblastoma has a family history of the disease. The nurse understands this is MOST consistent with:

Acquired somatic mutation only
X-linked recessive inheritance
Sporadic unilateral disease
Heritable autosomal dominant germline RB1 mutation (Correct answer)

Correct answer: Heritable autosomal dominant germline RB1 mutation

Heritable retinoblastoma is caused by a germline mutation in the RB1 tumor suppressor gene inherited in an autosomal dominant pattern, often presenting bilaterally.

Question 128: Which action violates best practice when drawing blood cultures from a pediatric central venous catheter?

Disinfecting the needleless connector with chlorhexidine before access
Using the same catheter lumen for blood draw and antibiotic infusion simultaneously (Correct answer)
Discarding the initial 5 mL of blood before collecting the culture sample
Using a sterile syringe to aspirate blood

Correct answer: Using the same catheter lumen for blood draw and antibiotic infusion simultaneously

Drawing blood cultures through a lumen that is simultaneously used for antibiotic infusion risks contaminating the culture with the antibiotic, leading to false-negative cultures and inaccurate pathogen identification.

Question 129: A 10-year-old receiving IV morphine for cancer pain develops increased drowsiness, respiratory rate of 8 breaths/minute, and pinpoint pupils. The priority nursing intervention is:

Hold the next morphine dose and continue monitoring
Notify the provider and wait for orders before acting
Administer naloxone (Narcan) IV per protocol and prepare for airway support (Correct answer)
Administer supplemental oxygen and elevate the head of the bed

Correct answer: Administer naloxone (Narcan) IV per protocol and prepare for airway support

Respiratory rate of 8 breaths/minute with pinpoint pupils and excessive sedation constitutes opioid-induced respiratory depression — a life-threatening emergency requiring immediate naloxone administration and airway readiness.

Question 130: Which pediatric brain tumor is associated with the classic triad of increased intracranial pressure, ataxia, and morning vomiting?

Craniopharyngioma
Medulloblastoma (Correct answer)
DIPG (Diffuse Intrinsic Pontine Glioma)
Pilocytic astrocytoma

Correct answer: Medulloblastoma

Medulloblastoma is a cerebellar tumor causing increased ICP, truncal ataxia, and early-morning vomiting due to posterior fossa location.

Question 131: Which action best demonstrates the nurse's role in pediatric oncology survivorship care?

Focusing education solely on preventing cancer recurrence
Discharging the patient once treatment is complete with no further instructions
Educating families about long-term follow-up needs and potential late effects based on treatment received (Correct answer)
Referring all survivorship concerns to social work only

Correct answer: Educating families about long-term follow-up needs and potential late effects based on treatment received

Survivorship nursing involves comprehensive education about monitoring for late effects of treatment, psychosocial support, and coordination of long-term follow-up care.

Question 132: What does "normalizing" grief mean?

Explaining that grief experiences are normal. (Correct answer)
Providing methods to cope with grief.
Receiving psychotherapy to deal with grief.
Moving past grief to normal functioning.

Correct answer: Explaining that grief experiences are normal.

Since many people start to think there must be something wrong with them because they have trouble functioning during a time of grief, normalizing grief entails reassuring those who are grieving that what they are going through is normal. Grief typically has a variety of emotional effects, such as anger, denial, loneliness, depression, despair, and guilt, as well as cognitive changes, behavioral effects, such as crying, withdrawing, changing one's sex drive, and physical effects, such as insomnia, hypersomnia, anorexia, trembling, palpitations, headaches, chest pain, weakness, and exhaustion.

Question 133: A child with hemophilia A needs factor replacement. Which blood product is most appropriate?

Vitamin K injection
Factor VIII concentrate (Correct answer)
Fresh frozen plasma
Cryoprecipitate alone

Correct answer: Factor VIII concentrate

Factor VIII concentrate directly replaces the deficient clotting factor in hemophilia A and is more effective and precise than FFP.

Question 134: A child with osteosarcoma is most likely to present with which clinical finding?

Painless abdominal mass
Generalized lymphadenopathy
Bilateral lower extremity weakness
Localized bone pain worsened at night with soft tissue swelling (Correct answer)

Correct answer: Localized bone pain worsened at night with soft tissue swelling

Osteosarcoma typically presents as bone pain (often around the knee) that worsens at night, with associated soft tissue swelling.

Question 135: Which of the following might the renal system do in reaction to pain that is not being treated?

Hypokalemia. (Correct answer)
Hyperkalemia.
Hyponatremia.
Hypotension.

Correct answer: Hypokalemia.

Unrelieved pain can cause hypokalemia, which can have an impact on many physiological systems. Hormones that control fluid and electrolyte balance are produced more frequently when pain is not addressed. Increased sodium levels and decreased potassium levels produce fluid retention and overload as well as an increase in heart and respiratory workload, which in turn raises blood pressure. The sympathetic nervous system is activated by pain, which also causes dilated pupils and increased perspiration.

Question 136: What is the primary purpose of the radiation therapy simulation session for a pediatric oncology patient?

To assess tumor response to initial chemotherapy before radiation begins
To define the treatment field, establish reproducible positioning, and create immobilization devices (Correct answer)
To administer the first therapeutic dose of radiation to the tumor
To calculate appropriate chemotherapy dosing for concurrent treatment

Correct answer: To define the treatment field, establish reproducible positioning, and create immobilization devices

Simulation uses imaging to precisely define treatment fields, establish consistent patient positioning, and fabricate immobilization devices to ensure reproducible and accurate radiation delivery.

Question 137: A nurse is educating the family of a child with febrile neutropenia. Which statement by the parent indicates a need for further teaching?

'I will give acetaminophen to mask the fever and monitor at home for 24 hours before calling.' (Correct answer)
'I will not give rectal suppositories to my child during neutropenia.'
'I will avoid crowded places while my child is neutropenic.'
'I will bring my child to the ER immediately if a fever develops.'

Correct answer: 'I will give acetaminophen to mask the fever and monitor at home for 24 hours before calling.'

Parents must not delay seeking care for fever during neutropenia; delaying evaluation can allow a bacterial infection to progress to sepsis rapidly.

Question 138: What is the primary advantage of using a patient-controlled analgesia (PCA) pump for pain management in pediatric oncology patients?

Removes nursing responsibility for pain assessment
Guarantees that the patient will not develop opioid tolerance
Eliminates the need for any scheduled opioid doses
Allows the patient to self-administer small bolus doses on demand, improving pain control and sense of autonomy (Correct answer)

Correct answer: Allows the patient to self-administer small bolus doses on demand, improving pain control and sense of autonomy

PCA gives the patient direct control over administering small demand doses within safety lockout parameters, enabling timely analgesia matched to pain peaks (e.g., procedural pain, movement) while maintaining a sense of agency.

Question 139: A child with sickle cell disease presents with severe bone pain, fever, and chest infiltrates. The nurse recognizes this as:

Vaso-occlusive crisis
Acute chest syndrome (Correct answer)
Aplastic crisis
Splenic sequestration

Correct answer: Acute chest syndrome

Acute chest syndrome in sickle cell disease is defined by a new pulmonary infiltrate with fever, chest pain, and respiratory symptoms.

Question 140: A nurse administering vincristine notices the IV site shows swelling and erythema. What is the priority action?

Stop the infusion immediately and manage as a vesicant extravasation (Correct answer)
Notify the physician and document, then continue at a slower rate
Slow the infusion rate and apply a warm compress
Flush the line with normal saline and continue the infusion

Correct answer: Stop the infusion immediately and manage as a vesicant extravasation

Vincristine is a vesicant; extravasation can cause severe tissue necrosis and requires immediate cessation and specific extravasation management.

Question 141: A child receiving allogeneic HSCT develops sudden weight gain, right upper quadrant pain, and jaundice on day 10 post-transplant. Labs show elevated bilirubin and transaminases. The nurse suspects:

Hepatic veno-occlusive disease (VOD/SOS) (Correct answer)
Cytomegalovirus hepatitis
Drug-induced hepatotoxicity
Acute GVHD of the liver

Correct answer: Hepatic veno-occlusive disease (VOD/SOS)

VOD/SOS typically presents in the first 30 days post-transplant with the classic triad of painful hepatomegaly/right upper quadrant pain, fluid retention/weight gain >2%, and hyperbilirubinemia (>2 mg/dL).

Question 142: A child with AML has been neutropenic for 18 days and develops a new pulmonary infiltrate on chest X-ray. Serum galactomannan test returns positive. The nurse should prepare for which treatment?

Initiation of voriconazole IV as first-line antifungal therapy for invasive aspergillosis (Correct answer)
Chest tube insertion for parapneumonic effusion
High-dose TMP-SMX for Pneumocystis pneumonia
Broad-spectrum antibiotics for community-acquired pneumonia

Correct answer: Initiation of voriconazole IV as first-line antifungal therapy for invasive aspergillosis

A positive galactomannan (a fungal cell wall polysaccharide marker) in a prolonged neutropenic AML patient with new pulmonary infiltrate indicates probable invasive aspergillosis. Voriconazole is the FDA-approved, guideline-recommended first-line agent.

Question 143: A child on high-dose corticosteroids for ALL treatment shows mood swings and increased appetite. The nurse explains these are:

Signs of disease progression
Indicators of opioid toxicity
Symptoms of hypoglycemia
Expected side effects of steroid therapy (Correct answer)

Correct answer: Expected side effects of steroid therapy

Corticosteroids commonly cause mood lability, increased appetite, and weight gain as predictable pharmacologic side effects.

Question 144: A child with newly diagnosed AML is found to have a WBC of 120,000/mm³. The nurse anticipates which emergent complication?

Leukostasis causing pulmonary and CNS symptoms (Correct answer)
Spontaneous tumor regression
Septic shock from neutropenia
Severe anemia requiring transfusion

Correct answer: Leukostasis causing pulmonary and CNS symptoms

Extreme leukocytosis (hyperleukocytosis) in AML causes leukostasis, where blast cells obstruct microvasculature in the lungs and brain.

Question 145: A 15-year-old with osteosarcoma and bone metastases asks the nurse why she needs to take her oral morphine around the clock rather than just when in pain. The most accurate response is:

Around-the-clock dosing is required by law for cancer patients
Cancer pain is often constant; scheduled dosing maintains a steady analgesic blood level to prevent pain from breaking through, while PRN dosing allows painful drug troughs (Correct answer)
Scheduled dosing allows you to use less medication overall by preventing addiction
PRN dosing is actually better for cancer pain but is too difficult for nurses to manage

Correct answer: Cancer pain is often constant; scheduled dosing maintains a steady analgesic blood level to prevent pain from breaking through, while PRN dosing allows painful drug troughs

Chronic cancer pain is best managed with scheduled (around-the-clock) dosing to maintain consistent analgesic blood levels and prevent the pain-analgesic cycle of severe pain before dose and side effects after each PRN dose.

Question 146: Which endocrine late effect is most commonly seen in children who received total body irradiation (TBI) as part of a stem cell transplant conditioning regimen?

Growth hormone deficiency (Correct answer)
Primary hyperaldosteronism
Hyperparathyroidism
Cushing syndrome

Correct answer: Growth hormone deficiency

TBI damages the hypothalamic-pituitary axis, most commonly affecting growth hormone secretion. Growth hormone deficiency is the most frequent endocrine late effect, leading to short stature if untreated.

Question 147: A nurse attempts to flush a tunneled central line and encounters resistance. The patient reports no discomfort and the line flushes partially but aspirates poorly. This presentation is most consistent with:

Line migration into the jugular vein
Fibrin sheath or tip occlusion requiring alteplase (tPA) instillation (Correct answer)
Catheter rupture requiring emergency removal
Air lock requiring vigorous flushing

Correct answer: Fibrin sheath or tip occlusion requiring alteplase (tPA) instillation

Partial resistance to flush with poor aspiration suggests a fibrin sheath or fibrin flap around the catheter tip — a common cause of 'withdrawal occlusion' that responds to alteplase instillation to dissolve the fibrin.

Question 148: A child receiving chemotherapy for ALL is exposed to a sibling at home who develops varicella (chickenpox) the next day. The child is not known to be immune. The most important immediate action is:

Administer prophylactic oral acyclovir without notifying the team
Notify the oncology team immediately for consideration of varicella-zoster immune globulin (VZIG) administration within 96 hours of exposure (Correct answer)
Give the varicella vaccine immediately
Isolate the child at home for 21 days

Correct answer: Notify the oncology team immediately for consideration of varicella-zoster immune globulin (VZIG) administration within 96 hours of exposure

Varicella in an immunocompromised child can be fatal. VZIG (VariZIG) must be administered within 96 hours of exposure to prevent or attenuate disease in immunocompromised varicella-susceptible patients. The team must be notified immediately.

Question 149: What is the first priority action when a nurse suspects a central line-associated bloodstream infection (CLABSI) in a pediatric oncology patient?

Remove the central line immediately
Obtain blood cultures from the central line and a peripheral site before administering antibiotics (Correct answer)
Apply topical antiseptic to the exit site
Start empiric antibiotics immediately without cultures

Correct answer: Obtain blood cultures from the central line and a peripheral site before administering antibiotics

Blood cultures must be drawn from both the central line and a peripheral site before antibiotics are administered to identify the organism, differentiate CLABSI from local infection, and optimize treatment.

Question 150: A child with hemophilia B is bleeding after a fall. The appropriate treatment is replacement with:

Factor VIII concentrate
Factor IX concentrate (Correct answer)
Vitamin K
Fresh frozen plasma alone

Correct answer: Factor IX concentrate

Hemophilia B is caused by deficiency of factor IX ('Christmas disease'); factor IX concentrate is the specific replacement therapy.

Question 151: Which staging classification is used for childhood non-Hodgkin lymphoma?

St. Jude (Murphy) staging system (Correct answer)
FIGO staging
TNM staging
Ann Arbor staging

Correct answer: St. Jude (Murphy) staging system

The St. Jude (Murphy) staging system is specifically designed for pediatric NHL, based on tumor location and extent of disease.

Question 152: The nurse is preparing a family for a bone marrow biopsy in their child. Which statement is accurate?

The procedure is performed via lumbar puncture
The biopsy requires general anesthesia for all children
The posterior iliac crest is the most common site in children (Correct answer)
Results are available within 1 hour

Correct answer: The posterior iliac crest is the most common site in children

The posterior iliac crest is the preferred bone marrow biopsy site in children because it provides good marrow access and avoids vital structures.

Question 153: The nurse is caring for a child who received a bone marrow transplant 3 weeks ago and now develops a skin rash, diarrhea, and elevated bilirubin. These findings are most consistent with:

Engraftment syndrome
Veno-occlusive disease
Cytomegalovirus infection
Acute graft-versus-host disease (aGVHD) (Correct answer)

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

Acute GVHD classically presents with a triad of skin rash, profuse diarrhea, and liver dysfunction (elevated bilirubin) within 100 days of transplant.

Question 154: A 3-year-old with ALL is crying, holding her leg, and refusing to walk. The nurse should use which pain assessment tool?

McGill Pain Questionnaire
Brief Pain Inventory
FLACC scale (Face, Legs, Activity, Cry, Consolability) (Correct answer)
Numeric Rating Scale (NRS) 0–10

Correct answer: FLACC scale (Face, Legs, Activity, Cry, Consolability)

The FLACC scale is validated for assessing pain in preverbal and young children (ages 2 months to 7 years) who cannot self-report, using behavioral and physiologic indicators across 5 domains.

Question 155: Which intervention is MOST effective in preventing chemotherapy-induced nausea and vomiting (CINV) in children?

Pre-medicating with antiemetics before chemotherapy (Correct answer)
Administering acetaminophen 30 minutes prior
Restricting all oral intake during infusion
Administering antiemetics after nausea begins

Correct answer: Pre-medicating with antiemetics before chemotherapy

Antiemetics given before chemotherapy (prophylactically) are far more effective than treating nausea after it begins.

Question 156: A 6-year-old receiving dexamethasone as part of ALL maintenance therapy shows increased appetite, weight gain, and mood changes. The nurse explains to the family that these effects are:

Signs of relapse that require immediate evaluation
Allergic reactions that necessitate stopping the medication
Expected steroid side effects that are monitored and usually resolve when the drug is discontinued (Correct answer)
Permanent changes requiring dietary medication adjustments

Correct answer: Expected steroid side effects that are monitored and usually resolve when the drug is discontinued

Corticosteroids like dexamethasone commonly cause appetite increase, cushingoid features, and behavioral changes that typically resolve after therapy ends.

Question 157: What drug is frequently used to lower elevated intracranial pressure brought on by radiation therapy to the brain?

Dexamethasone. (Correct answer)
Furosemide.
Mannitol.
Phenytoin.

Correct answer: Dexamethasone.

Dexamethasone is frequently used to lower elevated intracranial pressure brought on by brain radiation therapy. Dexamethasone and other glucocorticoids serve to lessen cerebral edema, which in turn lessens headache, nausea, vomiting, and anorexia. However, because glucocorticoids are linked to a number of negative side effects, patients may be given histamine H2 antagonists to lessen GI side effects. Dexamethasone side effects frequently include greater weakness and an increased risk of infection, as well as steroid myopathy.

Question 158: Which statement about von Willebrand disease (vWD) Type 1 is correct?

It is an X-linked recessive disorder
It is characterized by partial quantitative deficiency of vWF (Correct answer)
It requires factor IX replacement
It always presents with hemarthrosis

Correct answer: It is characterized by partial quantitative deficiency of vWF

Type 1 vWD is the most common form and involves a partial reduction in the quantity of von Willebrand factor, inherited in an autosomal dominant pattern.

Question 159: The nurse is reviewing discharge instructions for a child who completed treatment for febrile neutropenia with ANC now 620/µL. The family asks when their child can return to school. The most appropriate response is:

Consult with the oncology team, as the timing depends on the ANC trend, scheduled next chemotherapy cycle, and absence of fever — general guidance is ANC >500 with upward trend (Correct answer)
The child can return immediately since the ANC is now above 500
Return to school is based only on the child feeling well, not the ANC
The child must remain home for 6 weeks regardless of ANC

Correct answer: Consult with the oncology team, as the timing depends on the ANC trend, scheduled next chemotherapy cycle, and absence of fever — general guidance is ANC >500 with upward trend

School return in a pediatric oncology patient requires individualized assessment by the oncology team, considering current and projected ANC, upcoming chemotherapy timing, infection exposure risk at school, and vaccination status of classmates.

Question 160: To prevent oral candidiasis during immunosuppression, children are commonly prescribed:

Oral metronidazole
Oral acyclovir
Topical hydrocortisone
Oral nystatin suspension or fluconazole (Correct answer)

Correct answer: Oral nystatin suspension or fluconazole

Nystatin or fluconazole are antifungal agents used prophylactically to prevent oral candidiasis in immunocompromised pediatric patients.

Question 161: The nurse is preparing to administer a platelet transfusion to a child with acute leukemia who previously had a severe transfusion reaction. Which product modification is most appropriate?

Washed platelets only
CMV-negative platelets only
Standard platelets with premedication
Leukoreduced and irradiated platelets (Correct answer)

Correct answer: Leukoreduced and irradiated platelets

Leukoreduction reduces febrile reactions and CMV transmission, while irradiation prevents transfusion-associated graft-versus-host disease in immunocompromised patients.

Question 162: The family of a child with newly diagnosed cancer refuses a blood transfusion based on religious beliefs. The nurse's most appropriate initial response is:

Immediately seek a court order to override parental authority
Respectfully acknowledge their beliefs, notify the provider and ethics team, and explore all medical alternatives while ensuring the team understands the family's values (Correct answer)
Override the refusal and administer the transfusion without consent
Document the refusal and take no further action

Correct answer: Respectfully acknowledge their beliefs, notify the provider and ethics team, and explore all medical alternatives while ensuring the team understands the family's values

The nurse must respect the family's religious autonomy while ensuring the provider and ethics team are involved to explore alternatives and assess the balance between parental authority and the child's best interest, consistent with legal and ethical frameworks.

Question 163: A pediatric oncology patient has fatigue rated as severe (7/10). Which intervention is MOST evidence-based for cancer-related fatigue?

Complete bed rest throughout treatment
Aerobic exercise tailored to the child's capacity (Correct answer)
High-dose vitamin C supplementation
Caffeine supplementation

Correct answer: Aerobic exercise tailored to the child's capacity

Evidence supports moderate aerobic exercise as effective in reducing cancer-related fatigue in children and adolescents.

Question 164: Which lab value is most important to monitor before administering methotrexate to prevent severe toxicity?

Serum potassium
Serum creatinine and creatinine clearance (Correct answer)
Serum bilirubin
Complete blood count only

Correct answer: Serum creatinine and creatinine clearance

Methotrexate is renally excreted; impaired renal function leads to drug accumulation and severe toxicity including mucositis and myelosuppression.

Question 165: A child with cancer develops delirium on the oncology unit. The nurse's FIRST action is:

Dim lights and leave the child alone
Administer lorazepam immediately
Apply physical restraints
Assess for and correct reversible causes (infection, medications, hypoxia) (Correct answer)

Correct answer: Assess for and correct reversible causes (infection, medications, hypoxia)

Delirium in oncology is often multifactorial; identifying and treating reversible causes (infection, metabolic, medication toxicity) is the priority.

Certified Pediatric Hematology Oncology Nurse (CPHON)

The CPHON certification validates expertise in pediatric hematology and oncology nursing, covering treatment modalities, symptom management, emergencies, and psychosocial care for children with blood disorders and cancer.

165

Questions

180 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