Oncology Nursing Review 6th Edit

A.
HEALTH PROMOTION AND DISEASE

PREVENTION
1. A research study focuses on smoking

cessation among a specific target
population. This group’s research is
focusing on prevention.
1. Primary
2. Secondary
3. Tertiary
4. Integrated
2. You educate Miss Smith about the

prevention of cervical cancer and risk-
reducing behaviors. Which of the
following is a primary preventive
strategy?
1. Use barrier contraceptives.
2. Exercise regularly.
3. Have a Pap test at appropriate intervals.
4. Have human papillomavirus (HPV) testing.
3. Which of the following lifestyle factors is

the most important risk factor of oral
cancer?
1. Poor oral hygiene
2. Habitual use of alcohol and tobacco
3. Vitamin A deficiency
4. Human papillomavirus (HPV)
4. After her father’s death from colon

cancer, Ellen takes the initiative in
preventing colon cancer for herself by
eating less fat and more fruits and
vegetables and by taking up running. She
is engaged in:
1. Illness behavior
2. High-risk behavior
3. Health-protective behavior
4. Information-seeking behavior
5. Which of the following best describes

primary prevention of skin cancers?
1. Removal of a dysplastic nevi
2. Reduce ultraviolet radiation (UVR)
exposure between 10 a.m. and 3 p.m. and
use sunscreens.
3. Annual professional skin examination
4. Practice monthly skin self-examination
6. Which of the following statements

regarding environmental tobacco smoke
or involuntary inhalation of tobacco
smoke is accurate?
1. Environmental tobacco smoke is estimated
to lead to 1,000 deaths of nonsmokers from
lung cancer per year.
2. There is no evidence to support the idea
that involuntary inhalation of tobacco
smoke increases the risk of lung cancer in
nonsmokers.
3. Secondhand smoke does not pose an
elevated risk of lung cancer for smokers.
4. There is a 25% increased risk of lung cancer
in women who have never smoked and are
married to a smoker.
7. According to research, which of the

following statements best describes the
breast health of African American
women of lower socioeconomic status
(SES) compared to age-adjusted
Caucasian women?
1. Breast cancer outcomes in minority women
with a lower SES are worse than those
women with a higher SES.
2. Premature deaths from breast cancer in
African American women are similar to
premature deaths from breast cancer in
non-Hispanic white women.
3. Survival of breast cancer was improved
with higher SES for members of all racial
and ethnic groups.
4. African American women are more
commonly diagnosed with triple-negative
breast cancer.
8. Which of the following scenarios

represents secondary prevention of
cancer?
1. A woman at high risk for breast cancer
decides to have prophylactic bilateral
mastectomies.
2. Referral of women for cervical Pap tests
3. The Great American Smokeout is promoted
to a group of individuals who want to stop
smoking.
4. Celecoxib is prescribed for a patient with
familial adenomatous polyposis for the
reduction of colorectal adenomas.
9. Physical activity is one of the few known

modifiable lifestyle factors for the
development of cancer, and increased
exercise plays a key role in primary
prevention against which of the
following cancers?
1. Colon, breast, endometrial
2. Colon, breast, ovarian
3. Prostate, kidney, colon
4. Pancreatic, endometrial, ovarian
10. Moderate to heavy alcohol intake has

been linked to which of the following
cancers?
1. Prostate, renal, stomach
2. Oral cavity, liver, prostate
3. Stomach, ovarian, esophagus
4. Breast, colorectal, esophagus
11. Ms. Jones recently read a report from the

World Cancer Research Fund and the
American Institute for Cancer Research
(WCRF/AICR) that made
recommendations to decrease cancer
risk. She has decided to modify her
lifestyle and follow their
recommendations. Which of the
following is a recommendation by the
WCRF/AICR?
1. Use supplements to protect against cancer.
2. Increase the consumption of energy-dense
foods.
3. Eat a healthy diet and be physically active
for at least 30 minutes/day.
4. Consume 50% of energy from fat and avoid
sugary drinks.
12. The most important factors that appear

to have a protective effect against the
development of endometrial cancer are:
1. Pregnancy, physical activity, weight
management
2. Physical activity, nulliparous, weight
management
3. Oral contraceptives, cigarette smoking,
pregnancy
4. Nulliparous, oral contraceptives, weight
management
13. Which of the following is the most

successful approach to smoking
cessation in adults?
1. Smoking cessation interventions using
nicotine patches and gum
2. Smoking cessation programs using
multiple recruitment strategies
3. Increased excise taxes for tobacco products,
smoke free laws, and local cessation and
abstinence programs
4. Smoking cessation programs that provide
psychosocial support and life management
skills
14. The Breast Cancer Prevention Trial
tested the ability of which of the
following to prevent breast cancer in
healthy women at high risk for the
disease?
1. Raloxifene
2. Retinoic acid
3. Tamoxifen
4. Beta-carotene
15. Mr. Smith, a heavy smoker, wants to quit

and asks you if vaping with e-cigarettes
will help him quit smoking cigarettes.
The best response to his question is:
1. Vaping with e-cigarettes is a good reduction
tool.
2. Toxic substances in e-cigarettes vapor are
lower than conventional cigarettes so may
be safe for smoking reduction.
3. Manufacturers state that e-cigarettes
decreased smoking-related symptoms and
was more efficacious than nicotine gum.
4. Research is needed to determine health
hazards of e-cigarettes and efficacy in
smoking reduction and cessation.
16. Epidemiology studies have provided

compelling evidence that obesity is
associated with increased risks of:
1. Colon, endometrial, esophageal cancer
2. Thyroid, ovarian, gallbladder cancer
3. Hepatocellular, gallbladder, cervical cancer
4. Prostate, stomach, kidney cancer
17. Successes in the immunologic

approaches to cancer prevention involve
vaccines that prevent cancer. Which of
the following cancer-causing viruses
have vaccines available for prevention?
1. Human papillomavirus (HPV) (type 16),
Helicobacter pylori
2. Hepatitis B, hepatitis C
3. Hepatitis B, HPV (type 16 and 18)
4. HPV (type 16 and 18), Helicobacter pylori
18. Once the elements of a cancer risk

assessment are collected (e.g., personal
medical history, history of exposures to
carcinogens, family history) the risk
must be interpreted to the individual in
understandable terms. This is often
accomplished by using various risk
terms. Which of the following terms is
accurate?
1. Absolute risk measures the occurrence of
cancer (incidence or mortality) in a high-
risk population.
2. Relative risk measures the incidence or
deaths among those with a particular risk
factor.
3. Attributable risk is the amount of disease
within the population that could be
prevented by alteration of a risk factor.
4. Proportional risk factor implicates which
disease an individual will eventually
develop.
19. Chemoprevention focuses on individuals

or subpopulations known to be at
increased risk for developing a
malignancy. Which of the following best
describes chemoprevention?
1. Chemoprevention is the use of natural or
synthetic agents to interrupt the
carcinogenic process.
2. Chemoprevention is the use of
manufactured pills.
3. Chemopreventive agents include food
components ingested as part of a regular
diet.
4. Chemopreventive agents are not derived
from food compounds or supplements.
20. Most chemopreventive agents are

administered through a clinical trial.
Which of the following individuals most
likely would be considered for a
chemoprevention trial?
1. An individual who has smoked for 10 years
2. A 40-year-old female with dense breasts
3. A 55-year-old black male whose father died
of prostate cancer
4. A 63-year-old woman who has a history of
benign breast disease
21. Your patient, Mrs. Smith, who has

ovarian cancer and a BRCA1 gene
mutation, asks you if her 35-year-old
daughter should have risk-reduction
surgery to prevent her from developing
ovarian cancer. Your best advice to her is
which of the following?
1. For your daughter to fully understand her
risk, she should go through a formal risk
assessment and see a genetic health
professional before she makes any
decision.
2. She is at risk for ovarian cancer, and it
would be worthwhile for her to consider a
prophylactic oophorectomy.
3. Your daughter should be followed closely,
and she may want to talk to her physician
about oral contraceptives to suppress
ovulation.
4. Since she is asymptomatic, she should have
a yearly physical examination that includes
a bimanual rectovaginal examination and
discuss tubal ligation with her physician.
22. Which statement is the best reason to

recommend risk-reduction bilateral
mastectomy for a woman with high
genetic risk of breast cancer?
1. Removal of the breasts before cancer
detection lowers risk by 90%.
2. Removal of the breasts before cancer
detection lowers risk by 80%.
3. Removal of the breasts will decrease the
risk of ovarian cancer.
4. Removal of the breasts will decrease the
risk of both ovarian and breast cancer.
23. The American Cancer Society

recommends that all women who are
sexually active or who are 21 years of age
or older have a Pap smear performed:
1. Every 3 years with a conventional or liquid-
based Pap test
2. Every 2 years with a regular Pap test
3. Biannually
4. Annually with a regular Pap test
24. Colorectal surveillance

recommendations for carriers of
hereditary nonpolyposis colon cancer–
associated mutations (Lynch syndrome)
include which of the following?
1. Colonoscopy beginning at age 40; repeat
every 2 years
2. Upper gastrointestinal (GI) endoscopy at
age 50 every 3–5 years
3. Colonoscopy beginning at ages 20–25;
repeat every 1–2 years
4. Screening for gastric, duodenal, and small
bowel cancer
25. The most significant reduction in

prostate cancer risk is in:
1. Men who take nutritional supplements of
selenium and vitamin E
2. Men who take finasteride
3. Men who have an annual digital rectal
examination
4. Men who have a high dietary intake of
antioxidants
26. The most important risk-reduction

behavior for the prevention of cervical
cancer is:
1. Limit the number of lifetime sexual
partners
2. Regular Pap smear testing
3. Take oral contraceptives
4. Annual human papillamovirus (HPV)
testing
B. SCREENING AND EARLY DETECTION
1. Which of the following statements is

accurate regarding prostate-specific
antigen (PSA)?
1. PSA screening for prostate cancer is
controversial.
2. All men with prostate cancer secrete PSA.
3. PSA is the primary screening method for
prostate cancer.
4. A PSA greater than 2 ng/ml is the threshold
for performing biopsies to diagnose
prostate cancer.
2. The most widely used screening

programs have been for the early
detection of:
1. Breast and cervical cancer
2. Breast and colon cancer
3. Colon and cervical cancer
4. Breast and prostate cancer
3. Nurses must communicate to patients

about the accuracy of screening tests.
Which of the following attributes is
correct?
1. The sensitivity of a screening test is its
ability to detect those individuals without
cancer.
2. The specificity of a screening test is its
ability to identify those individuals without
cancer.
3. A true-positive test is a normal test for
cancer in an individual who does not have
cancer.
4. A false-negative test is a normal test in an
individual who does not have cancer.
4. Which of the following tests is

recommended by the American Cancer
Society to screen for polyps and
colorectal cancer in asymptomatic
individuals ages 50 and above?
1. Flexible sigmoidoscopy every 2 years
2. Digital rectal examination
3. Colonoscopy every 10 years
4. Double-contrast barium enema every 10
years
5. You are providing a community

education program on cancer prevention
when a participant asks what is cancer
screening and is it important if you are
healthy and have no problems. Your
most appropriate response is:
1. Screening for genetic abnormalities that
put individuals at high-risk for developing
cancer is a form of cancer screening.
2. Cancer must be measurable and detectable
to be detected on a screening examination.
3. Cancer screening is aimed at individuals
with no symptoms with the goal of finding
disease when it is more easily treated.
4. Screening tests seek to decrease both the
morbidity and mortality associated with
cancer.
6. The single most important factor in

whether an individual has ever had a
screening test is:
1. Recommendation by a nurse
2. Recommendation by a family member
3. Recommendation by a friend who has
cancer
4. Recommendation by their insurance
provider
7. Which of the following models has been

developed for use in women with a risk
for developing breast cancer?
1. Couch
2. Bethesda
3. Gail
4. Family History Assessment Tool
8. Which of the following statements is

most accurate regarding the cancer
screening process?
1. The first step in the cancer screening
process is the risk assessment.
2. A review of past and present medical
history
3. A risk factor does not mean that a person
will develop cancer.
4. Provide a risk assessment tool for the
patient.
9. Research has shown that providing

patients with an individualized risk
estimate, as opposed to providing
general information about risk,
significantly increased the probability
that those individuals would participate
in a screening program. It is best to
explain to patients which of the
following?
1. The predictive value of their chance for
developing cancer
2. Their absolute and relative risk of
developing cancer
3. A model that predicts their risk of
developing cancer
4. Their genetic risk is what is most
important.
10. A nurse asks you which risk model

should be used to calculate a patient’s
risk of having a cancer susceptibility
mutation for colorectal cancer.
1. Gail
2. Tyrer-Cuzick
3. PREMM
4. Claus
11. Which of the following modalities is used

to screen for lung cancer?
1. Chest x-ray
2. Low-dose computed tomography
3. Sputum cytology
4. Magnetic resonance imaging (MRI) of the
chest
12. One of the early signs of ovarian cancer

is:
1. Frequent urinary tract infections
2. Thin, bloody vaginal discharge
3. Heavy and painful menstruation
4. Bloating
13. Physical recognition of cutaneous

melanoma (CM) by practitioners can be
initiated by using the ABCDE rule. In this
rule, C stands for:
1. Change in symmetry
2. Crusting or bleeding
3. Color irregularity
4. Cause
14. Which of the following statements about

dysplastic nevi (DN) is correct?
1. DN occurs in approximately 40% of the
general population.
2. DNs are easy to identify on physical
examination.
3. The total number of DNs is an indicator of
risk for developing malignant melanoma.
4. DNs develop in young adults and especially
in those with sunburns as a child.
15. One way that basal cell carcinoma (BCC)

is distinguished from squamous cell
carcinoma (SCC) is by its:
1. Common occurrence on the head and
hands
2. Lower incidence
3. Less well-demarcated margins
4. Slower growth rate
16. Which of the following is the most likely

presenting symptom in a patient with
Hodgkin lymphoma?
1. Edema in the upper part of the body
2. Enlarged cervical lymph nodes
3. A palpable mass in the axillary or inguinal
lymph nodes
4. An upper respiratory infection
17. Ms. Allison notices a “funny

discoloration” on her arm and comes in
for an examination. She tells you that
her brother died at age 38 from a
common skin cancer. Based on this
information, you should be suspicious
for:
1. Squamous cell carcinoma (SCC)
2. Basal cell carcinoma (BCC)
3. Melanoma
4. Leukoplakia
18. Mr. Eliot, 64 and a smoker for 17 years,
has an undifferentiated neoplasm arising
in the proximal right bronchus. Which
symptom most typically reflects this?
1. Barrel chest
2. Bulges on the thorax
3. Breathlessness
4. Superior vena cava obstruction
19. Mrs. Smith is pregnant and discovers a

mass in the upper outer quadrant of her
left breast. Following her physical exam,
the physician is most likely to order
which of the following tests?
1. Ultrasound
2. Fine-needle aspiration
3. Mammogram (diagnostic)
4. Positron emission tomography (PET) scan
20. Mrs. Blase presents with a continuous

sore throat, and increased difficulty
chewing and swallowing. These
symptoms are possibly an indication of
which type of cancer?
1. Cancer of the larynx
2. Esophageal cancer
3. Cancer of the oral cavity
4. Cancer of the salivary gland
21. The most common presenting symptom

of testicular cancer is:
1. A small, hard mass in the testis
2. A dragging sensation
3. Swelling
4. Dull aching or pain in the scrotal area
22. Early detection of stomach cancer is

difficult because:
1. Symptoms appear in advanced disease.
2. People tend to self-medicate themselves for
gastrointestinal distress.
3. Risk factors for the disease have not yet
been identified.
4. None of the diagnostic tests or procedures
currently available accurately detect gastric
cancer in its early stages.
C. NAVIGATION
1. The primary purpose of patient navigator

programs is:
1. To determine the economic costs of cancer
disparities
2. To provide personal assistance in
eliminating any barriers to patients
obtaining timely and adequate diagnosis
and treatment
3. To identify trusted information sources or
channels in the community
4. To monitor treatment equity according to
established standards of care to diminish
bias in the provision of health care
2. Dr. Harold Freeman, a pioneer in patient

navigation, identified health disparities
for which of the following groups?
1. Racial/ethnic minorities, those with low
socioeconomic status, and rural
populations
2. The “working poor,” and medically
underserved populations
3. Those with low socioeconomic status,
working poor, and rural populations
4. Those with Medicaid or no insurance
3. The best description of a lay navigator is:

1. Individuals who are employed by hospitals
to help patients navigate the healthcare
system
2. Individuals who help identify spiritual and
logistical needs for patients as they
navigate the healthcare system
3. Individuals in the community that help
patients navigate the healthcare system
and identify barriers to care and resources
4. Individuals that are trained to help patients
navigate the healthcare system

patient navigation is most accurate?
1. Navigation is needed only prediagnosis.
2. Navigation can be provided by only
healthcare professionals.
3. Navigators only focus on a specific time
period such as screening to diagnosis or the
treatment period.
4. Navigators provide individualized care to
assist patients as they transition through
the healthcare system.
5. As a newly hired breast care navigator,

your supervisor wants you to conduct a
needs assessment. Your best source of
statistics about screening mammography
in the population you are striving to
serve is:
1. Medicare and Medicaid data regarding the
rate of compliance with annual screening
mammography and demographic data such
as geographic, economic status, and age
groups
2. American Cancer Society statistics by zip
code
3. Tumor registry data regarding numbers of
women diagnosed with cancer, including
age and stage at diagnosis
4. Breast health center data regarding the
number of women screened annually
6. On Jane’s follow-up visit to the breast

health center after a diagnostic
mammogram that reveals a suspicious
mass, the surgeon tells her that he wants
her to meet the patient navigator. The
best explanation of the reason for the
referral is:
1. Since you don’t have insurance, the
navigator must tell you about the costs of
further tests or procedures before we can
continue your care.
2. We are planning surgery for next week and
the navigator will explain the risks of
surgery to you.
3. The navigator will help you schedule some
additional tests and help with
transportation and childcare if needed.
4. The navigator is bilingual and will explain
everything to you in your first language.
7. Measuring the success of breast care

navigation can be challenging. The most
useful metrics to measure success is:
1. Increasing the number and percent of
women having screening mammography
from the defined targeted geographic
region
2. Decreasing the percentage of patients
needing transportation
3. Increasing the number of health
education/outreach programs about breast
cancer and breast health
4. Increasing the number and percentage of
patients having breast cancer treatment
that meets the National Comprehensive
Cancer Network (NCCN) treatment
guidelines
8. A 48-year-old woman had a routine

screening mammogram that revealed a
spiculated mass on the upper outer
quadrant of the left breast measuring 1.3
cm. She was scheduled to return for
additional imaging and referred to the
breast health navigator. The most
important information to give the
woman on the telephone is:
1. Education about the purpose and
importance of additional imaging
2. Preparing the patient for possible surgery
3. Encouraging the woman to bring someone
with her to the appointment
4. Assessing the history of family breast
cancer
9. The breast nurse navigator can identify

opportunities to decrease patient anxiety
and influence system efficiency by
documenting which of the following?
1. Time from biopsy to pathology results
available
2. Time from biopsy results available to time
patient notified
3. Time from patient notified to surgical
consultation
4. Time from biopsy to surgical or medical
intervention
10. A colleague asks you about what

knowledge would she require to be a
breast cancer navigator. Your reply is:
1. Screening, detection, diagnosis, and
treatment of breast cancer
2. Common barriers to care specific to your
facility or region
3. Literacy level and language need of patients
4. Regulatory requirements of the breast
cancer treatment clinical trial sponsors
11. Multiple barriers to breast cancer care

have been identified. The navigator can
assist patients in overcoming these
barriers by which of the following?
1. Referring the patient to the American
Cancer Society
2. Completing an assessment of the resources
and needs of the individual patient
3. Monitoring the progress of the patient
through the healthcare system
4. Assigning a volunteer to meet the woman
at every appointment
D. ADVANCE CARE PLANNING
1. Which of the following statements best

describes advance care planning?
1. Advance care planning is the process of
discussion of end-of-life care at any time
and revised periodically, clarification of
related values and goals, and preferences
through written documents and medical
orders.
2. Advance care planning is the process of
discussion of end-of-life care and life-
sustaining treatments when the patient is
terminally ill and preferences through oral
and written documents.
3. Advance care planning involves
conversations with a person’s healthcare
agent and primary clinician regarding end-
of-life care.
4. Advance care planning involves
conversations with a person’s healthcare
agent regarding end-of-life care and flexible
decisions as health status changes.

concerning advance directives (ADs) is
correct?
1. An AD is a legally binding contract.
2. An AD is a statement that provides very
specific instructions regarding the
preferences for life-sustaining treatments
an individual would want to receive if
unable to express their wishes at a future
date.
3. ADs are required to include a living will.
4. An AD designates a proxy to make
decisions for a terminally ill patient.
3. Which is preferable—the durable power

of attorney or the living will?
1. The living will is preferable because it
states what kind of care an individual
wants under specific conditions.
2. The durable power of attorney is preferable
because it identifies the healthcare agent
who will make medical decisions in case of
patient incapacity.
3. The durable power of attorney is preferable
because it covers not only decisions in a
terminal situation but also any treatment
decisions.
4. The durable power of attorney and the
living will are both preferable. They are
patient-initiated documents (advance
directive).
4. A patient makes some comments about a

living will that leads you to conclude the
patient needs more information. You
know he understands what a living will is
when he says it:
1. Specifies disbursement of assets
2. Addresses all possible medical situations
3. May not always be honored and
implemented
4. Describes the specific types of care to be
used
5. Advance Care Planning (ACP) was a

primary focus of the Institute of
Medicine (IOM) report on “Dying in
America: Improving Quality and
Honoring Individual Preferences Near
the End of Life.” Of the following
recommendations, which is being
followed infrequently?
1. Individuals participate actively in decisions
regarding their health care.
2. Individuals receive medical services that
are consistent with their known values.
3. Clinicians initiate conversations about
ACP.
4. ACP is revisited according to patients’
wishes and when status changes.
E. EPIDEMIOLOGY
1. Eric is a member of a research team that

conducts an epidemiologic study. They
determine, in a given year,
approximately 1 of every 12,000
American men has prostate cancer. This
figure represents:
1. An incidence rate
2. A mortality rate
3. A prevalence rate
4. A survival rate
2. The incidence of bladder cancer is most

common in people with:
1. Exposure to aniline dyes and aromatic
amines
2. Exposure to alkylating agents and
phenacetin
3. Chronic irritation of the urothelial lining
due to infections
4. A history of smoking and/or exposure to
tobacco smoke
3. The highest breast cancer incidence rates

in the United States are found in:
1. Non-Hispanic white women
2. African American women
3. Women who are 80 years or older
4. Premenopausal women
4. The highest overall incidence of cancer

occurs among:
1. Young adult Asian American/Pacific
Islanders
2. Native Americans and Alaska Natives
3. African American men
4. Hispanic/Latino
5. For cervical cancer, the average annual

rate per 100,000 individuals is highest
among which females?
1. Hispanic/Latino
2. Non-Hispanic White
3. Native American
4. African American
6. There are two major histological types of

esophageal cancer: squamous cell
carcinoma (SCC) and adenocarcinoma
(AC). In the United States, the highest
incidence of AC of the esophagus is
found among:
1. Women aged 29–39 years
2. African Americans
3. Caucasians
4. Men aged 30–40 years
7. The highest incidence of cervical cancer

occurs in women who are:
1. 20–34 years of age
4. 70 and older
8. Which of the following is associated with

the development of primary brain
tumors?
1. Inhaled steroids
2. Exposure to chemicals
3. Cellular telephones
4. Radiation to the head and neck area
9. Stomach cancer is the fourth-most-

common cancer in the world. Which
geographical locations have the highest
incidence of stomach cancer?
1. Japan, Korea, and China
2. Western Africa
3. Central and South America
4. North America
10. Race and ethnicity play a role in the risk

of developing lung cancer. Which
individuals are at higher risk of
developing lung cancer?
1. Caucasian Americans
2. African Americans and Native Hawaiians
3. Latinos
4. Japanese Americans
11. Viruses contribute to the development of

cancers. Which of the following cancer
sites are associated with viruses?
1. Cervical cancer, T cell lymphoma, breast
cancer
2. Burkitt’s lymphoma, cervical cancer, lung
cancer
3. Hepatocellular carcinoma (HCC), cervical
cancer, Burkitt’s lymphoma
4. Kaposi sarcoma, T cell lymphoma,
pancreatic cancer
12. Which of the following has been

associated with an increased incidence of
lung cancer in women?
1. Living near high-energy electromagnetic
wires
2. Increased susceptibility to carcinogens and
tobacco-related mutations
3. Exposure to chemicals used in hair dye
4. Hormone replacement therapy
13. Which of the following factors is

associated with a higher incidence of
ovarian cancer?
1. Living in developing countries
2. Lower education and socioeconomic levels
3. The use of oral contraceptives
4. Family history of breast cancer
14. Prostate cancer is the most commonly

diagnosed solid tumor in U.S. males and
is the second-leading cause of cancer-
related deaths. Which of the following
statements best describes the racial and
ethnic group with the highest mortality
rate?
1. African American males
2. Caucasian males
3. Asian American males
4. Hispanic/Latino males
15. Mr. Frank’s cancer has been associated

with occupational exposure to a
carcinogen. He works as a chemical dye
manufacturer. Of the following choices,
which type of cancer is he most likely to
have based on this clue?
1. Bladder cancer
2. Colorectal cancer
3. Testicular cancer
16. The leading cause of liver cancer

throughout the world is:
1. Hepatitis B virus
2. Hepatitis C virus
3. Chronic cirrhosis
4. Chronic hepatitis A virus
17. Which of the following variables appears

to be the best descriptive determinant of
cancer risk?
1. The mortality rates for Japanese Americans
with stomach cancer are significantly
higher than for the white American
population.
2. As more women smoke, more women are
developing lung cancer.
3. A study of medical students found that 55
students who later developed cancer
perceived themselves as more stressed
than their healthy counterparts.
4. Familial aggregates of cancer have been
found to occur.
18. Although the exact etiology of multiple

myeloma is not known, certain factors
increase the risk. Which of the following
is the most recognized and most
common risk factor for multiple
myeloma?
1. Obesity
2. High doses of ionizing radiation
3. Male gender
4. Monoclonal gammopathy of undetermined
significance (MGUS)
19. A primary risk factor for breast cancer is:

1. Age in the 30- to 45-year group
2. Family history of breast cancer
3. Two or more heterosexual relationships
4. Lower socioeconomic status

regarding the BRCA2 gene mutation is
true?
1. The BRCA2 gene mutation is associated
with postmenopausal breast cancer.
2. The BRCA2 gene mutation is only
associated with breast cancer.
3. The BRCA2 gene mutation is genetically
related to the BRCA1 gene.
4. The BRCA2 gene mutation is related to
breast cancer in men.
21. Hepatocellular carcinoma (HCC) is often

associated with:
1. A long history of smoking
2. Obesity
3. Viral hepatitis B and C
4. A bacterial infection

common risk factor associated with the
development of cervical cancer?
1. Being nulliparous
2. Human papillomavirus (HPV 16)
3. Human papillomavirus (HPV 35)
4. Smoking
23. Gastric cancer is associated with

numerous risk factors. Which of the
following is the strongest risk factor for
the development of stomach cancer?
1. Tobacco use
2. Helicobacter pylori infection
3. High intake of smoked or salted meats and
fish
4. Alcohol consumption
24. Which of the following are risk factors

for vaginal carcinoma?
1. Human papillomavirus (HPV), genital
warts, and cervical carcinoma in situ
2. HPV, human immunodeficiency virus
(HIV), and maternal use of
diethylstilbestrol (DES)
3. Cervical carcinoma in situ, HIV, and HPV
4. HIV, genital warts, and number of sex
partners
25. Although the cause has not been

established, certain occupations increase
an individual’s risk of developing a
glioma or a meningioma, including:
1. Exposure to wood dust
2. Exposure to synthetic rubber
3. Exposure to chemicals found in pesticides,
herbicides, and fertilizers
4. Exposure to petrochemical manufacturing

regarding breast cancer risk is accurate?
1. Only 5%–10% of all breast cancers are due
to tumor suppressor genes BRCA1 and
BRCA2.
2. Breast cancers linked to BRCA1/BRCA2
mutations occur more often in older
women.
3. A woman with a strong family history of
breast cancer has a 10% chance that her
cancer is caused by an inherited mutation
in the BRCA1/BRCA2 gene.
4. The number of second-degree relatives
with breast cancer are not a significant risk
factor for development of breast cancer.
27. Which of the following are high-risk

factors for cutaneous melanoma (CM)?
1. Skin pigmentation, ionizing radiation,
congenital nevus
2. Skin pigmentation, actinic keratoses,
dysplastic nevi
3. Dysplastic nevi, smoking, xeroderma
pigmentosum
4. Oral contraceptives, actinic keratoses,
smoking

regarding ovarian cancer risk in families
is most accurate?
1. Women who have two or more first-degree
relatives with a history of breast cancer
have an increased risk for ovarian cancer.
2. The number of family members with
ovarian cancer defines the individual’s
degree of risk.
3. Ovarian cancer is an autosomal dominant
mode of inheritance with variable
penetrance.
4. Ovarian cancer tends to be common among
lower-income groups, especially African
American, Hispanic, and Native American
women.
29. What is the most common risk factor for

non-Hodgkin lymphoma (NHL)?
1. Family history of NHL or leukemia
2. Infections, such as human
immunodeficiency virus (HIV), herpes,
Epstein-Barr virus
3. Immune suppression
4. Exposure to pesticides, arsenic, rubber
production
30. A patient asks, “What are tumor

suppressor genes?” As part of your
answer, you explain that tumor
suppressor genes code for proteins that
growth-promoting factors.
1. Enhance
2. Fuel
3. Inactivate
4. Duplicate
31. The p53 gene is:

1. A potent oncogene
2. The most frequently mutated gene in
human cancer
3. The “guardian of the oncogene”
4. Protected from DNA viruses
32. Mr. Henderson’s cancer is said to have

been induced by familial carcinogenesis.
From this, you can assume that in his
case, certain genes:
1. Caused cancer by functioning to excess
2. Caused cancer by their absence
3. Acted as growth promoters
4. Lost their ability to prevent malignant
growth by their loss of homozygosity
33. The Ras oncogenes:

1. Have a screening usefulness of about 45%
2. Function early in the process of
carcinogenesis as signal transducers
3. Function late in the process of
carcinogenesis
4. Are not effective as targets for early
detection
34. Genes that predispose for the

development of cancer are generally
transmitted in an autosomal dominant
fashion. Which of the following
statements is correct?
1. Individuals who harbor a mutated gene
have a 25% chance of passing the mutated
gene on to their children.
2. The pattern of transmission is usually
vertical, meaning successive generations
are affected.
3. Half of affected persons in a pedigree have
an affected parent.
4. More females than males are affected.

describes the significance of the BRCA1
gene?
1. It is an inherited gene that identifies
women who are ensured of having breast
cancer during their premenopausal years.
2. It is an inherited gene mutation that
identifies families at significant risk for
breast cancer and ovarian cancer.
3. It is an inherited gene mutation that
identifies women likely to have breast
cancer in their postmenopausal years.
4. It is an inherited gene that is present in
over 90% of women with breast cancer.
36. Approximately what percentage of

people with cancer have an increased
risk for cancer due to a hereditary
predisposition?
1. 5%–10%
2. 20%–25%
3. < 5%
4. > 25%

regarding our understanding of the
genetic susceptibility in breast cancer
and ovarian cancer is correct?
with increased susceptibility to only
ovarian cancer.
with an increased susceptibility to both
breast and ovarian cancer.
3. One of the gene mutations is estimated to
be present in approximately 35% of breast
cancer cases.
4. The genes are associated with breast cancer
diagnosed in post-menopausal women.

regarding genetic susceptibility to colon
cancer is correct?
1. Individuals who have a first-degree relative
with colorectal cancer have triple the risk
for developing colon cancer.
2. Adenomatous polyps are precursors to all
gastrointestinal cancers.
3. An inheritable autosomal dominant trait is
found in families with a moderate
incidence of colon cancer.
4. Individuals who have familial
adenomatous polyposis (FAP) syndrome
are at a 100% risk for developing cancer of
the colon.
39. Which of the following cancer-causing

mutations is transmitted to the next
generation at birth?
1. Oncogene mutations
2. Germ cell mutations
3. Somatic mutations
4. Antioncogene mutations
40. During follow-up counseling for your 47-

year-old patient with hereditary breast
cancer, you mention that she should
consider genetic counseling even though
her cancer is not due to BRCA1 or
BRCA2. To clear up her confusion, you
explain which of the following?
1. Women younger than age 50 with
hereditary breast cancer have a significant
risk of developing contralateral breast
cancer in the next 20 years.
2. It is just precautionary to ensure she does
not develop cancer that is due to BRCA1 or
BRCA2.
3. Counseling would help her decide whether
or not she is a candidate for adjuvant
chemotherapy.
4. Counseling would help her decide whether
or not she is a candidate for prophylactic
oophorectomy.
F. SURVIVORSHIP
1. Demographic trends show that the

number of cancer survivors continues to
increase due to:
1. Aging population and improvement in
cancer detection
2. Aging population and improvement in
cancer detection and treatment
3. Aging population and increased number of
breast cancer survivors
4. Aging populations and increased number of
breast and prostate cancer survivors
2. A program that regards rehabilitation in

cancer care as a dynamic rather than a
passive process is most likely to
emphasize both ongoing reassessment
and:
1. Customary convalescence
2. Follow-up home care
3. Redefinition of goals
4. Frequent nursing referrals
3. The overall goal of rehabilitation for the

person with cancer is to:
1. Return to baseline performance before the
cancer
2. Anticipate and prepare physically for future
debilitating effects of cancer
3. Achieve optimal functioning within the
limits of cancer
4. Maintain an active, busy life
4. Which of the following factors have been

found to be most closely related to the
rehabilitation needs of the patient with
cancer?
1. Medical and family history
2. Type of treatment and side effects
experienced
3. Cancer site and stage of disease
4. Severity or duration of disease
5. Which of the following are the major

self-reported concerns and quality-of-life
issues of cancer survivors?
1. Fatigue and fear of pain
2. Fatigue, fear of recurrence, and living with
uncertainty
3. Fatigue, fear of pain, and fear of death
4. Fatigue, fear of death, and living with
uncertainty
6. Survival rates from cancer continue to
improve. Which of the following most
accurately depicts the percentage of
persons surviving 5 years and beyond
after diagnosis?
1. Fifty percent of adults and 60% of children
survive beyond 5 years.
2. Sixty percent of adults and 80% of children
3. Sixty-five percent of adults and 70% of
children survive beyond 5 years.
4. Fifty percent of adults and 83% of children
7. Six months after his surgery, Mr. Fox,

after participating in extensive speech
rehabilitation, learns to speak by
diverting exhaled pulmonary air through
a surgically constructed fistula tract
directly into the esophagus. This method
of speech is produced through:
1. An artificial larynx made available
immediately after surgery
2. Esophageal speech therapy
3. Surgical voice restoration or
tracheoesophageal prosthesis
4. An oral prosthesis
112. After surgery, part of Ms. Eliot’s
rehabilitation process involves restoring
the swallowing function because
aspiration during swallowing is one of
the major complications following
supraglottic laryngectomy. Initially,
will be the most difficult
thing for Ms. Eliot to swallow without
aspirating.
1. Soft mashed foods
2. Dry, crunchy foods
3. Liquids
4. Hard, bulky food boluses (especially meats)
113. Your patient has prostate cancer and is

undergoing leuprolide therapy. He
recently began to complain of pain in his
hip. He underwent a bone scan and was
found to have an isolated lesion that was
thought to be malignant. Biopsy was
done, and a sarcoma was confirmed.
This finding represents which of the
following?
1. This is most likely a metastasis from his
prostate cancer.
2. This is histologically dissimilar from a
prostate cancer and is therefore considered
to be a second primary cancer and
potentially curable.
3. This is most likely a benign condition
because he is receiving treatment for
cancer.
4. This finding represents a guarded
prognosis because his immune system
obviously is failing.
114. Mr. Jones has had treatment for a

primary kidney tumor, which was
eradicated. Now, however, the surgeon
discovers a biopsy-proven metastatic
lesion in the lung. The metastatic site
seems to be solitary, and Mr. Jones is
very healthy otherwise. What method of
treatment will likely be used for his
metastatic lesion?
1. Chemotherapy to provide systemic control
of metastasis
2. Cytoreductive surgery to reduce the mass
so that combination therapy will be
effective
3. Combination radiation and chemotherapy
4. Surgical resection
115. The most common second malignant

neoplasms following radiation therapy
are:
1. Breast and thyroid cancers
2. Gastrointestinal tract cancers
3. Sarcomas of the bone and soft tissue
4. Bladder and lung cancers
116. Your patient is a 5-year survivor of

prostate cancer. Your annual workup is
conducted with the knowledge that he is
most at risk for developing which of the
following second primary cancers?
2. Leukemia
3. Lung cancer
4. Non-Hodgkin lymphoma
117. Judith had Hodgkin disease as a child

and received mantle radiation therapy. It
has been more than 20 years since her
treatment. Which of the following
statements is most accurate concerning
her follow-up care?
1. She needs to continue her annual physical
exams and mammograms because she is
most at risk for secondary malignancies
since it has been 20 years since her
treatment.
2. She can relax more because her risk for
secondary malignancies decreases every
year.
3. Her highest risk for secondary
malignancies was breast cancer and lung
cancer, occurring at 10 years.
4. Eighty percent of secondary solid tumors
are associated with radiation therapy.
118. The major risk of developing a secondary

malignant neoplasm after treatment for
a primary malignancy depends on:
1. The type and dose of treatment received
(e.g., radiation and alkylating agents)
2. A common underlying etiologic factor (e.g.,
smoking)
3. Genetic susceptibility (e.g., genetic
retinoblastoma)
4. The timing of withdrawal of
chemotherapeutic agents, such as
mustargen, oncovin, procarbazine, and
prednisone (MOPP) latency
119. Four years ago, Ms. Smith successfully

completed treatment for breast cancer.
Now she is diagnosed with acute
myelogenous leukemia (AML). Which
drugs most likely contributed to Ms.
Smith’s AML?
1. Alkylating agents
2. Anthracyclines
3. Vinca alkaloids
4. Antimetabolites
120. Mantle radiation for Hodgkin disease is

associated with an increased risk of
which of the following cancers?
1. Breast cancer, especially in those irradiated
before the age of 30
2. Lung cancer
3. Liver cancer
4. Head and neck cancer
121. Which of the following factors regarding

economic disruption in the lives of
family caregivers is correct?
1. The economic burden of caregivers occurs
during the patients’ terminal phase of
illness.
2. Between 20%–70% of family caregivers
miss work or quit jobs to provide care.
3. The Family Medical Leave Act of 1993
provides financial support for family
caregiving.
4. The economic burden of caregivers is
higher for patients with colorectal cancer.
122. Individuals with low annual incomes:

1. Are more likely to die of cancer than those
with high annual incomes
2. Rarely experience a definable difference in
survivorship or treatment
3. Are twice as likely to experience
recurrence, treatment failure, or death as
those with higher incomes
4. Are less likely to receive curative therapy
123. A primary barrier to cancer care for

many of the ethnic minority populations
is:
1. Inability to pay for services
2. Language barrier
3. Cultural differences
4. Access to care
124. Research indicates that survivors and

family caregivers who have more fear of
cancer recurring are:
1. Older
2. Younger
3. Unemployed
4. Less able to cope
125. The primary purpose of the Health

Insurance Portability and Accountability
Act, or HIPAA, is to provide guidelines
for which of the following?
1. Methods to provide health insurance for
the uninsured
2. Measures to ensure each state honors
insurance policies issued in other states
within the United States
3. Methods to describe how patient
documents should be written and
transcribed
4. Measures to provide security for electronic
healthcare transactions and privacy
126. Which statement about socioeconomic

late effects experienced by cancer
survivors is correct?
1. Unemployment rate is higher among
cancer survivors than the general
population.
2. More than 50% of cancer survivors are not
able to return to work.
3. The lowest unemployment rates are among
persons with breast, gastrointestinal, and
gynecologic cancer.
4. The majority of cancer survivors are
depressed and have trouble maintaining
employment.
127. Which statement about the effect of

cancer on the social well-being of
patients and family members is correct?
1. Breast cancer and its treatment course
causes major problems on couples’ marital
relationships.
2. Breast cancer draws most couples closer
together as partners learn to appreciate
each other more.
3. There is a major significant difference in
marital satisfaction of couples coping with
cancer to scores of couples without cancer.
4. The majority of couples separate or divorce
after a partner is diagnosed with cancer.
128. The concept of “protective buffering”

describes problems that occur in the
communication between patients with
cancer and their family caregivers.
Protective buffering is:
1. Hiding cancer-related worries from a
partner and denying concerns in an effort
to avoid disagreement
2. Decreases the emotional distress of both
persons
3. Increases marital satisfaction
4. Decreases distress and improved
relationship satisfaction in partners
129. Patterns of communication among

professionals, patients, and family
members include:
1. Filtered, privileged, and shared
communication
2. Privileged, filtered, and balanced
communication
3. Privileged, balanced, and team
communication
4. Balanced, filtered, and shared
communication
130. Nurses and health professionals can use

a number of strategies to facilitate
communication between patients and
their family members. One of the best
strategies is:
1. To work as a team to manage the effects of
the illness
2. To hide your feelings and not share your
personal feelings in order to protect the
patients
3. Encourage patients to be open with their
feelings and not to have private thoughts of
their own
4. To discuss past problems, which may help
them through the stress of illness
131. The best definition of sexual health is:

1. Acts of a sexual nature such as intercourse
and intimacy
2. Physical functions and physical actions
3. Positive body image and relationships
4. A state of physical, mental, and social well-
being in relation to sexuality
132. Your 55-year-old patient with lung

cancer has completed his treatment,
including three cycles of chemotherapy
and radiation. He expressed some
problems with erectile dysfunction and
states his internist seems reluctant to
address the issue. Which of the following
is the most likely response to his
concerns?
1. Erectile dysfunction is common due to the
paraneoplastic component of his illness.
2. The chemotherapy and radiation are
probably the cause, and it is not likely to
improve.
3. Attention to his erectile dysfunction by his
internist is overshadowed by his history of
cancer and treatment.
4. Sexual dysfunction is to be expected in
someone his age.
133. Mr. Crane is about to undergo a radical

prostatectomy. He is concerned about
his ability to be sexually active after his
surgery. The most important factor that
relates to sexual function after
prostatectomy is:
1. Age less than 50
2. Stage of disease
3. Preservation of neurovascular bundles
4. Hormone therapy postsurgery
134. Two basic nursing interventions for

alterations in sexual health encountered
by cancer patients are:
1. Education and counseling
2. Screening and role-playing
3. Affective therapy and role modeling
4. Enhancing reality surveillance and
reinforcing personal power
135. The primary reason healthcare

providers do not discuss issues related to
sexual concerns with patients is:
1. Personal discomfort and lack of knowledge
2. It may create more problems for the
patient.
3. It is not their responsibility.
4. Lack of time
136. Patients at higher risk for sexual

dysfunction are:
1. Women younger than 30 years of age
2. Women older than 30 years of age
3. Males prepuberty
4. Males over 50 years of age
137. Mrs. Archer has recently had a radical

cystectomy with resection of nearly one-
third of the anterior wall of the vagina
and vaginal reconstruction. She is
approaching discharge and requires
teaching regarding any changes she can
expect in terms of her sexuality. It would
be appropriate to include which of the
following in your discussion?
1. She will be unable to have intercourse and
needs to develop other methods of
intimacy.
2. Sexual interest will be minimal.
3. There will be less lubrication, and she will
need to practice vaginal dilation and liberal
use of lubrication.
4. Orgasm will be diminished due to the
clitoris being compromised.
138. Radiation is commonly used in

conjunction with surgery as treatment
for vaginal cancer. Patient education
before discharge should emphasize that:
1. Vaginal fibrosis and scarring can occur due
to a loss of blood supply; therefore, vaginal
intercourse should be avoided.
2. Vaginal intercourse and the use of a vaginal
dilator are encouraged to prevent
narrowing of the vagina.
3. Prescribed topical estrogen cream may be
used but usually is not effective.
4. She will need to douche daily with diluted
hydrogen peroxide/water mixture for 2 to 3
months.
139. Mr. James is scheduled for a radical

cystectomy with urinary diversion. He is
especially concerned about the
possibility of being impotent and unable
to have sex because of the urinary
diversion following surgery. Your best
response is based on which of the
following?
1. Because the surgery involves removal of
the bladder, attached peritoneum, the
prostate, and seminal vesicles, penile
sensation is altered, and impotence is
unavoidable in many cases.
2. He should be encouraged to talk to his
surgeon because it is possible that the
surgeon will do a potency-sparing
cystectomy.
3. Refer him to an enterostomal therapist for
information about a penile prosthesis and
placement of the urinary diversion.
4. Urinary diversions today result in improved
sexual adjustment due to decreased leakage
and odor control.
140. Treatments for prostate cancer have the

potential to alter sexual function.
Permanent damage to erectile function
with loss of emission and ejaculation is
most likely to occur with:
1. Radical prostatectomy
2. Transurethral resection
3. Bilateral orchiectomy
4. Transabdominal resection
G. TREATMENT-RELATED CONSIDERATIONS
141. The late effects of cancer treatment on

the endocrine system result from damage
to the hypothalamus pituitary axis
and/or:
1. Target organs (e.g., the thyroid, ovaries,
testes)
2. The cortical areas of the brain
3. The chemical structure of key hormones
(e.g., insulin)
4. Epithelial tissue (e.g., blood vessel linings)
142. Growth impairment as a late effect of

treatment for cancer occurs as the result
of:
1. Overproduction of thyroxine by the thyroid
gland
2. Deficient growth hormone release by the
hypothalamus
3. Primary hypothyroidism
4. A disruption in pituitary control of several
target organs
143. A patient who has finished treatment 6

months ago and is considered cured
returns for a follow-up appointment. His
major complaint is that he is distressed
because he continues to experience
symptoms related to his treatment, such
as fatigue and difficulty sleeping. Your
response is based on which of the
following concerning psychosocial late
effects in cancer survivors?
1. The persistence of late and long-term
physiologic symptoms often contributes to
psychologic distress of depression and
anxiety.
2. Fatigue is not normal, and he should be
evaluated for possible recurrence of cancer.
3. Depression is common regardless of the
presence of comorbid conditions.
4. Quality of life before diagnosis is unrelated
to quality of life after cancer treatment.
144. Several years ago, a patient was given

concomitant radiation therapy and
chemotherapy for cancer of the bladder.
Recently, she developed cystitis. If this
condition is a late effect of her cancer
treatment, which agent is most likely to
have been the responsible one involved?
1. Fluorouracil (5-FU)
2. Cyclophosphamide
3. Methotrexate
4. Paclitaxel
145. Patients with human immunodeficiency

virus (HIV) and neutropenia who have
received treatment with corticosteroids
or who have had prolonged
immunosuppression should be
monitored for which of the following?
1. Tuberculosis
2. Second malignancies
3. Pneumocystis jiroveci pneumonia
4. Elevated CD4 lymphocyte count
146. Late effects involving the central nervous

system are most likely to occur in which
of the following individuals?
1. A child treated for Hodgkin disease
2. A child treated for bone sarcoma
3. An adult treated for small cell carcinoma of
the lung
4. An adult treated for primary
hypothyroidism

the late effects of cancer treatment is
most accurate?
1. Late effects are present during treatment.
2. Late effects are long-term physical and
psychosocial changes in cancer survivors
that are not present after treatment for
months or years later.
3. Late effects are severe and clinically subtle.
4. Late effects are the consequence of biologic
cure.
148. Sleeping disturbances can be

problematic long after treatment ends.
Research into the incidence of sleep
disturbances indicates that sleeping
difficulty is reported by approximately
what percentage of patients with cancer?
1. 50%
2. 40%
3. 25%
4. 20%
149. Following four courses of chemotherapy,

Albert shows you that his fingernails
have developed transverse white lines or
grooves. You explain to Albert that this
symptom:
1. Is a response to doxorubicin because
pigmentation has been deposited at the
base of the nail
2. Indicates a reduction or cessation of nail
growth in response to cytotoxic therapy
3. Reflects a cytotoxic reaction to
cyclophosphamide
4. Is a partial separation of the nail plate
called onycholysis and is a reaction to
fluorouracil (5-FU) therapy
150. Secondary malignancies account for

what percentage of all cancers?
1. 10%–15%
2. 16%–20%
3. 20%–25%
4. 25%–30%
151. Hematologic secondary malignancies

usually occur within 10 years from
treatment and the risk increases with:
1. The type of chemotherapy drugs that were
administered
2. The amount of bone marrow exposed to
radiation
3. The age of the patient when treated
4. Higher doses of radiation at the time of
initial treatment
152. Secondary solid tumor malignancies

usually occur 10 or more years after
patient’s initial therapy and are
dependent on
1. The type of chemotherapy drugs that were
administered
2. The amount of bone marrow exposed to
radiation
3. Low doses of radiation therapy
4. Higher doses of radiation therapy
153. Children treated for cancer with

radiation therapy are more likely to
develop:
1. Hodgkin disease
2. Leukemia
3. Breast cancer
4. Bone cancer
154. Chemotherapy treatment places patients

at risk for the development of which
secondary malignancy?
1. Leukemia
2. Breast cancer
3. Bone sarcoma
4. Hodgkin disease
155. A patient who completed her treatment

for breast cancer 6 months ago asks you
about her long-term follow-up care.
Your most appropriate response would
1. You can be transferred to your primary care
provider (PCP) for follow-up care.
2. You should be followed by your oncologist
or PCP for 2 years on a regular basis.
3. Your follow-up care should be performed
by a provider (oncologist or PCP)
experienced in breast cancer surveillance.
4. You should be followed by your oncologist
for the rest of your life.
156. Patients with non-Hodgkin lymphoma

(NHL) have potential late effects due to
radiation therapy and chemotherapy.
Follow-up care should include which of
the following?
1. Blood tests, pulmonary function tests,
electrocardiogram (EKG)
2. Blood tests, cognitive assessment,
pulmonary function tests
3. Blood tests, EKG, dual-energy x-ray
absorptiometry (DXA) scan
4. Blood tests, DXA scan, pulmonary function
tests
157. The majority of women with endometrial
cancer have an excellent prognosis and
compliance to follow-up care is a
challenge. Which of the following factors
is the most important part of your
education to this population?
1. Regular follow-up is important and
involves evaluation of permanent side
effects that may occur in the future.
2. Regular follow-up usually involves regular
pelvic examinations at least quarterly in
the initial years after diagnosis.
3. Education on weight reduction and low-fat
diet
4. Regular screening for other cancers is
important.
158. The recommended follow-up strategy for

men successfully treated for testicular
germ cell tumor is:
1. Close follow-up for 5 years
2. Discontinue cancer surveillance after 5
years
3. Discontinue cancer surveillance after 10
years
4. Follow-up and cancer surveillance for 35
years
159. Opinion varies on which model of follow-
up care for cancer survivors is optimal.
Which model of follow-up care is being
used more frequently?
1. Oncologists maintain care of patient
2. Primary care physician responsible for care
3. Physician-led survivorship clinics
4. Physician assistant– or advanced practice
nurse–led survivorship clinics
H. END-OF-LIFE CARE
160. Which of the following grief reactions of

an elderly woman who has lost her
husband of 40 years to lung cancer
would prompt the hospice nurse to
suggest counseling?
1. She takes out 40 years’ worth of
photograph albums and wants to review
her marriage and life with her deceased
husband with the hospice nurse.
2. She refuses to let her sister and brother-in-
law into her home anymore, blaming them
for buying her husband cigarettes “all those
years.”
3. She plans her husband’s funeral by herself,
listens to all his favorite classical music
pieces, and chooses passages from his
Bible.
4. She delegates all the responsibility for the
funeral and disposition of her husband’s
belongings to the children.
161. While describing her sadness about her

husband’s imminent death, the wife of
your patient says, “I have never been able
to accept the death of our son, and now
my husband is going too.” Which of the
following is the most appropriate
response?
1. “Do you feel your husband is dying soon?”
2. “What was it like for you and your husband
when your son died?”
3. “Losing your son and your husband must
be so difficult for you.”
4. “At least your son and your husband will be
together soon.”
162. Grief is defined as:

1. A normal process of experiencing the
psychological, behavioral, social, and
physical reactions to the perception of loss
2. Outward social expression of loss
3. The time period given to grief and
mourning
4. A process of adapting to the loss governed
by social, cultural, and spiritual beliefs and
rituals
163. Grief needs to be identified as early as

possible for assessment, treatment, and
interventions. The four types of grief are:
1. Anticipatory grief, preparatory grief,
bereavement grief, complicated grief
2. Anticipatory grief, bereavement grief,
complicated grief, prolonged grief
complicated grief, prolonged grief
bereavement grief, complicated grief
164. According to research, the strongest

predictor of preparatory grief in patients
with a terminal diagnosis is:
1. Insomnia
2. Depression
3. Hopelessness
4. Anxiety
165. One year after the death of her husband,

Mrs. Ely still cries, has difficulty
concentrating, avoids activities, and
rarely goes out with friends. As part of
bereavement counseling, you conclude
1. This is a normal grief reaction. She could
benefit from being seen more often.
2. This is an example of a posttraumatic
stress disorder.
3. Acute grief can last beyond a year, but Mrs.
Ely could benefit from a support group.
4. Grieving beyond a year is often associated
with unresolved guilt about the death of a
loved one.
166. Nurses need to prepare family members

for what to expect as death approaches.
This preparation should include:
1. A discussion on the patient’s grief
responses to death
2. How to manage the patient’s symptoms at
the end of life
3. Assessing the family’s coping abilities with
death and providing possible interventions
4. Determine an appropriate postdeath
bereavement plan to help the family
167. Four levels of hospice care exist based on

Medicare Hospice Regulations. Which of
the four levels of care below include
funding by Medicare?
1. Routine home care, day care, inpatient
care, and respite care
2. Continuous home care, routine home care,
residential care, and extended caregiver
services
3. Inpatient care, routine home care, day care,
and residential care
4. Routine home care, continuous home care,
respite care, and inpatient care
168. When a patient and family are cared for

by hospice services, they have:
1. Access to ongoing bereavement support
after the patient’s death
2. Day care services for the patient
3. Home care services for 8 months
4. Access to phase III clinical trials
169. Which of the following most accurately

describes the philosophy of hospice care?
1. Patients can be made comfortable with
alternative and complementary care.
2. Euthanasia is an integral aspect of care if
the patient requests it.
3. Hospice care is an interdisciplinary model
of caring for individuals in the final stages
of an illness.
4. Hospice is specialized care for the dying
that is non-physician-based care.
170. Your patient has failed yet another

treatment regimen and could benefit
significantly from hospice care, but his
wife refuses to consent to hospice care.
Your primary intervention to facilitate
acceptance of hospice care is which of
the following?
1. Provide information to the husband and
wife regarding response to therapy and the
benefits of hospice care.
2. Suggest a “drug holiday” to allow time to
pass so she begins to see that hospice is the
best choice.
3. Point out that she is denying what is
inevitable and that accepting hospice care
is the best thing for everyone.
4. Refer the patient and family to a visiting
nurse service.
171. Which of the following excludes a

patient from meeting criteria for hospice
care?
1. The family prefers that the nurse not talk
about dying around the patient.
2. The patient explains that he wants to
continue to receive the new monoclonal
antibody because he is certain it will be
curative.
3. The doctor orders two units of blood to be
given at home along with pamidronate.
4. The patient explains they are not ready to
look at funeral homes.
172. Which of the instruments below was

developed specifically for assessing
various aspects of the caregiver situation
and quality of life?
1. McGill Quality of Life Questionnaire
2. Hospice Quality of Life Index
3. Missoula-Vitas Quality of Life Index
4. Caregiver Reaction Assessment
173. A potential reaction of an adolescent

whose parent is terminally ill is to:
1. Blame the healthy parent and/or other
family members for the parent’s illness
2. Exhibit signs of anxiety and depression
3. Shield siblings from discussing distressing
feelings
4. Openly share information and feelings with
the healthy parent and other family
members
174. As you plan your interventions for

assisting a family member who is
grieving because a loved one is dying,
you consider the following approach:
1. Encourage the family member to obtain
support from others and shelter their
feelings from the patient, which help
relieve their stress.
2. Encourage the family member to share
his/her concern with a loved one rather
than hide them.
3. Conduct an assessment of the family
member’s coping abilities.
4. Encourage the family member to seek
professional advice.
175. The basic medical and nursing approach

toward patients in a hospice program is:
1. Acute care
2. Curative care
3. Palliative care
4. Euthanasia care
176. The husband of a woman with end-stage

breast cancer is concerned that his wife
is sleeping more and is not even waking
to eat or drink. The hospice nurse would
explain to the husband that:
1. These are signs of approaching death.
2. The pain medication has reached a high
blood level and needs to be reduced.
3. There is no reason to be concerned.
4. Her oncologist should be called to obtain
some direction for her care.
177. In some settings, inpatient palliative care

is provided by consultation from a
palliative care team. A disadvantage to
this model of care is:
1. Resource-intense inpatient care
2. Cannot support family meetings with
complicated dynamics
3. Consults are often requested late, as
patients are approaching the true end-of-
life.
4. Lack of relationships between palliative
care and other disciplines
178. Along with the quantity and quality of

care provided by palliative care settings,
the other important factor that
influences the selection of a care setting
for the patient with cancer is:
1. Its proximity to the acute care hospital
2. Patient’s resources and geographical
location
3. The professional training of its medical
staff
4. Its policies relating to the multidisciplinary
team approach
179. Radiation is indicated for patients

receiving hospice care to:
1. Decrease brain metastases and prevent
seizures
2. Prevent bowel obstruction
3. Decrease pain from bone metastases
4. Stop bleeding from a fungating breast mass
180. During the hospice admission interview

for a patient with recurrent colon cancer
and metastases to the liver, a family
member asks if surgery to remove the
liver lesions would extend the patient’s
life. Your best response is:
1. The doctor would not recommend hospice
care if there was any chance for cure.
2. To remove liver metastases, the surgeon
must be able to completely remove all of
the tumor yet have adequate liver tissue
remaining.
3. Liver resection is not indicated unless the
colon cancer has been cured.
4. There must be no other evidence of
disease.
There are a number of barriers to
181.
providing successful palliative care by
healthcare professionals. Which of the
following barriers is a major problem?
1. Oncology providers believe palliative care
hastens a patient’s death at the end-of-life.
2. Oncologists believe patients lose hope once
palliative care gets involved.
3. Oncologists believe that end-of-life
discussions are the sole responsibility of
the oncologist and do not want other
providers to become involved in decisions-
making.
4. Oncology providers find the term
“palliative care” is not a useful term for
their daily care.
182. The most common models of palliative

care are:
1. Inpatient palliative care unit, intensive care
unit (ICU), home, outpatient/clinic
2. Inpatient consult, ICU, hospice, telehealth
3. Inpatient palliative care unit, inpatient
consult, outpatient/clinic, home-based
4. Inpatient consult, outpatient/clinic,
medical care unit, home-based
183. When a patient at the end-of-life
complains of dyspnea, the nurse should
most appropriately focus on which of
the following?
1. Determine degree of dyspnea by assessing
arterial blood gases and pulmonary
function tests.
2. Monitor pulse oximetry to determine need
for oxygen.
3. Administer opioids to lessen the sensation
of breathlessness.
4. Administer bronchodilators as needed.
184. Delirium is common in the final days of

life. Which of the following nursing
interventions would be
counterproductive in the management of
delirium?
1. Concentrate on orienting the individual to
what is real and what is not.
2. Administer low-dose haloperidol to
decrease anxiety.
3. Discontinue benzodiazepines because they
can worsen delirium.
4. Encourage the individual to speak about a
loved one that has died.
185. As your patient nears death, his daughter
is distressed and believes he is suffering
because he is unable to drink fluids. She
insists you give him intravenous fluids.
To help her understand her father’s
condition and provide optimal end-of-
life care, which of the following is the
most appropriate response?
1. She is right; dying of thirst is painful, and
you will call the doctor for intravenous
hydration.
2. Assure her that he is not suffering or
experiencing any discomfort from
dehydration.
3. Suggest they insert a small nasogastric tube
to administer fluids to prevent dehydration.
4. Suggest that she try to encourage her father
to drink fluids in small amounts.
186. A patient has aspiration pneumonia from

a tracheoesophageal fistula. He is
terminal and in hospice care. The
physician has ordered scopolamine (1.5
mg transdermal patch) and to increase to
two patches after 24 hours. You explain
to the patient and family that the
purpose of the scopolamine patch is
1. To decrease the amount of secretions
2. To manage his pain
3. To decrease anxiety
4. To help manage dyspnea
187. The presence of pain during the final

days of life is often difficult to assess
when the patient is no longer able to
report intensity or presence of pain.
Which of the following would be a pain
cue in this population?
1. Changes in respiration
2. Changes in appetite
3. Changes in sleep
4. Changes in overt behaviors
188. Your patient is in hospice care. One of

his primary complaints is that he cannot
get enough air. Upon examination you
learn he has a normal oxygen saturation,
elevated blood pressure, and minimal
pain, manageable by hydrocodone.
Which of the following treatment
scenarios would best address his chief
complaint?
1. Continuous pulse oximetry, low-dose
oxygen therapy to treat his air hunger, and
a benzodiazepine to treat anxiety
2. Chest x-ray and arterial blood gases with
pulmonary function tests to rule out
pneumonia along with a benzodiazepine for
anxiety
3. Low-dose opioid therapy, a benzodiazepine
for anxiety, position the patient upright,
and provide a cool fan
4. Low-dose oxygen therapy, bronchodilators,
and benzodiazepine for anxiety
189. As the gag reflex and reflexive clearing of

the oropharynx decline, secretions
accumulate in the oropharynx, and
dyspnea becomes complicated. Which of
the following measures is most effective
to manage the accumulation of
secretions often associated with the
“death rattle”?
1. Glucocorticoids to decrease swelling and
secretions
2. Benzodiazepines to sedate the patient and
increase comfort
3. Oral suctioning in the posterior pharynx to
clear secretions
4. Anticholinergic medications to dry
secretions
190. In the weeks before death, many patients
on opioid therapy experience agitation,
confusion, and difficulty sleeping,
especially at night. Which of the
following medications is most
therapeutic for patients experiencing
these symptoms?
1. Amitriptyline, for its anticholinergic effect
2. Lorazepam, for its sedating effect
3. Promethazine, because it potentiates the
analgesic effect of opioids
4. Haloperidol, to combat confusion and
agitation
191. Katrina has end-stage cancer with a

bowel obstruction and is currently in
hospice care. Which of the following
would be an appropriate intervention to
minimize her discomfort?
1. Placement of a nasogastric tube to manage
nausea and vomiting
2. Enemas every other day to promote
evacuation
3. Avoiding the use of opioids, because they
will only make it worse
4. Octreotide acetate to minimize secretions
192. Palliative sedation refers to:

1. The intentional taking of one’s own life
2. Sedation that relieves symptoms to a level
of unresponsiveness
3. Letting a patient who is suffering die by
withdrawing life-sustaining care
4. Assisted suicide
193. The most frequently addressed factors

contributing to palliative sedation are:
1. Pain and other symptom distress
2. Advanced illness and poor prognosis
3. Family history of suicide or personal
suicide history
4. Hopelessness and loss of self-esteem or
control
194. A son whose father is dying of lung

cancer asks you why all of a sudden he
seems to be confused, nervous, and
picking at the bed covers all of the time.
Your best response is
1. He has dementia as a part of delirium,
which is causing him to lose intellectual
function.
2. He may eventually develop hallucinations
due to psychosis as a result of his delirium.
3. He is in a hyperactive state of delirium
causing him to be agitated.
4. He will eventually develop lethargy and
rambling speech.
195. Noisy airway secretions are reported to

occur in 23%–93% of patients in their
last hours of death. Your best
nonpharmacologic intervention for the
management of noisy airway secretions
is:
1. To increase intravenous fluids to dilute
secretions
2. To increase oxygen level
3. To suction the patient’s secretions
4. To reposition the patient onto their side
and slightly elevate the head of the bed
196. Nonpharmacologic interventions have

demonstrated a reduced incidence of
delirium, faster symptom relief, and
improved quality of life. Of the following,
which intervention would you use?
1. Have soft lighting to avoid shadows, and
soothing music.
2. Put on the television and radio as
background noise to help reorient the
patient.
3. Limit visitors and family members to avoid
extraneous stimuli.
4. Confront patient to redirect any delusions
or hallucinations.
197. Assessment over time is critical to

recognize delirium early in its course and
to monitor for response to therapies.
There are numerous assessment tools
available to screen and monitor
delirium. A continuous delirium
assessment instrument to assess patients
over time is:
1. Delirium Rating Scale
2. Nursing Delirium Screening Scale
3. Revised Delirium Rating Scale
4. Mini-Mental State Exam
198. The two most important nursing

considerations as death approaches are:
1. Placing of intravenous lines for hydration
and parenteral nutrition
2. Greater attention to hygiene and activities
of daily living
3. Family preparation and symptom
management
4. Symptom management and palliative
sedation
199. Nurses who care for dying patients and

their families may experience:
1. Anxiety
2. Depression
3. Personal family issues
4. Compassion fatigue
200. Risk factors for compassion fatigue

include:
1. Older age and high levels of empathy
2. Older age and low levels of empathy
3. Younger age and high levels of empathy
4. Younger age and low levels of empathy

regarding palliative sedation is accurate?
1. Palliative sedation does not alter the timing
or mechanism of a patient’s death.
2. Palliative sedation occurs when a physician
prescribes a life-ending medication.
3. Palliative sedation decision-making is
made by the family.
4. Palliative sedation requires the healthcare
team to meet with the institution’s ethics
committee.
202. The prevalence of suicide is higher in

cancer patients. The highest risk for
suicide occurs:
1. During the 1st year of the diagnosis
2. In survivors after successful treatment
3. In survivors after 20 years of treatment
4. In patients diagnosed with metastatic
disease
Answer Rationales
Please note: All page numbers referenced in the
Answer Rationales sections refer to the textbook
Cancer Nursing: Principles and Practice (CNPP),
Eighth Edition, by Connie Henke Yarbro, Debra
Wujcik, and Barbara Holmes Gobel (Jones &
Bartlett Learning, © 2018), Cancer Symptom
Management (CSM), Fourth Edition by Connie
Henke Yarbro, Debra Wujcik, and Barbara Holmes
Gobel (Jones & Bartlett Learning, © 2014), and
Breast Care Certification Review (BCCR) by
Connie Henke Yarbro, Debra Wujcik, and Barbara
Holmes Gobel (Jones & Bartlett Learning, © 2013).
A. HEALTH PROMOTION AND DISEASE
PREVENTION
1. The answer is b.
Secondary prevention is the prevention of
promotion by smoking cessation and
implementation of appropriate screening
measures. Primary prevention is the avoidance
of exposure to carcinogens. Tertiary
prevention consists of arresting, removing, or
reversing a premalignant lesion to prevent
recurrence or progression to cancer. CNPP,
Page 112.
2. The answer is a.
Using barrier contraceptives and practicing
safe sex are primary preventive strategies.
Obtaining a Pap test at appropriate intervals
and HPV testing are secondary prevention and
screening methods. Exercise is not a known
risk factor for cervical cancer. CNPP, Page
1401.
3. The answer is b.
The synergistic use of both alcohol and
tobacco has long been implicated in the
etiology of oral cavity malignancies.
Approximately 75% of patients with oral
cancer drink alcohol, and 90% of patients have
a history of tobacco use. Poor oral hygiene and
mechanical irritation have also been connected
to the development of oral cavity tumors. HPV
has been implicated as a causative agent in a
subset of oral squamous cancers. CNPP, Pages
1578–1580.
4. The answer is c.
Health-protective lifestyle behaviors (primary
prevention) consists of actions taken by people
to protect, promote, or maintain their health.
CNPP, Page 83.
5. The answer is b.
Reducing UVR exposure and using sunscreens
are primary methods of preventions for skin
cancer. The other methods are secondary
prevention. CNPP, Pages 1682–1683.
6. The answer is d.
There is a 25% increase in lung cancer in
women married to a smoker. Environmental
tobacco smoke is estimated to lead to 3,000
deaths per year. Secondhand smoke poses an
elevated risk of lung cancer for both smokers
and never smokers. CNPP, Page 1682.
7. The answer is a.
African American women of lower
socioeconomic status obtain fewer
mammograms, experience premature deaths,
and have a lower survival rate. Research has
shown that African American women are more
commonly diagnosed with triple-negative
breast cancer but does not necessarily relate to
SES. CNPP, Pages 1281–1287.
8. The answer is b.
Although education regarding cervical cancer
is a primary prevention strategy, the use of Pap
test screening is a secondary method of cancer
prevention. A, C, and D are measures of
primary cancer prevention. CNPP, Pages 88,
1401.
9. The answer is a.
Exercise plays a role in primary prevention for
colon, breast, and endometrial cancer. Weaker
evidence suggests increased exercise may be
protective against prostate, kidney, and lung in
nonsmokers and ovarian cancer. CNPP, Page
59.
10. The answer is d.

Moderate to heavy alcohol use has been linked
to cancers of the breast, colorectal, esophagus,
and liver. No evidence of alcohol use and risk
is evident for prostate, renal, or ovarian cancer.
CNPP, Page 61.
11. The answer is c.

A healthy balanced diet is the best source of
nourishment along with physical activity. Ms.
Jones should limit, not increase, the
consumption of energy-dense foods, which are
processed foods with sugar and fat. High-dose
supplements can affect the risk of different
cancers. Energy from fat should be limited
from 20%–35%. Drinks with a high sugar
content should be avoided. CNPP, Pages 58–
60.

The two most important factors that appear to
have a protective effect against the
development of endometrial cancer are oral
contraceptives and cigarette smoking because
they reduce the estrogenic stimulation on the
endometrium. However, risks of developing
lung cancer far outweigh protection against
endometrial cancer. Pregnancy and weight
management also reduces the risk of
endometrial cancer. CNPP, Page 1519.

The most successful approaches are increasing
excise taxes on tobacco products, local
cessation and abstinence programs, and
smoke-free laws. Counseling and behavior
techniques are successful if used as an adjunct
to medical management. Financial incentives
by employers are leading to an increase in
smoking cessation along with phone and web-
based support groups. CNPP, Pages 86, 1686.

The Breast Cancer Prevention Trial tested
tamoxifen as a chemopreventive agent in a
randomized double-blind trial. The STAR trial
compared tamoxifen and raloxifene in
reducing the risk of invasive breast cancer.
Both drugs were equally effective. CNPP, Page
88.

Additional research is essential before any
conclusions can be drawn about the dangers
and efficacy of e-cigarettes. CNPP, Pages 62,
86.
16. The answer is a.

There is compelling evidence that obesity is
associated with colon, endometrial,
esophageal, renal, pancreatic, and
postmenopausal breast cancer. There is
probable or suggestive evidence of obesity and
gallbladder, hepatocellular, ovarian, and
thyroid cancers. CNPP, Page 58.

Vaccines have been developed to prevent
hepatitis B, a major cause of liver cancer, and
for HPV types 16 and 18, which are associated
with cervical, anal, and some head and neck
cancers. CNPP, Pages 97–98.

Attributable risk is the amount of disease
within the population that could be prevented
by alteration of a risk factor. Absolute risk
measures the occurrence of cancer in the
general population, not a high-risk population.
Relative risk compares the incidence or deaths
among those with a particular risk factor and
those without the risk factor. Proportional risk
does not implicate which disease an individual
will develop. CNPP, Pages 116–117.

Chemoprevention is the use of natural or
synthetic agents to interrupt the carcinogenic
process. Chemoprevention refers to
compounds manufactured in pills, but also
capsules and liquid form. Food components
ingested as part of a regular diet are not
considered chemopreventive agents, however,
chemopreventive agents are often derived
from food compounds. CNPP, Page 87.

A black male with a family history of prostate
cancer is at high risk for prostate cancer.
Chemoprevention trials target high-risk
individuals with a personal or family history of
the disease. Unlike population-based lifestyle
interventions, the use of chemopreventive
agents can be recommended only for
individuals and subpopulations known to be at
increased risk for developing a malignancy, to
justify their exposure to potential expected or
unexpected adverse events. Although the
female has dense breasts and is at moderate
risk for breast cancer, she should discuss with
her doctor the benefits of adding MRI
screening to her yearly mammogram. CNPP,
Page 87.

She should have a thorough cancer risk
assessment and genetic counseling, so she will
have the necessary facts about her risk, the
alternatives for dealing with her risk, and
consideration of the options available to her.
Women at high risk may elect to take medicine
to suppress ovulation or consider prophylactic
oophorectomy at the completion of
childbearing. CNPP, Pages 146–149, 1799.

For women at high-risk of hereditary breast
and ovarian cancer (HBOC), risk-reducing
bilateral mastectomy (RRBM)—the removal of
both breasts before a breast cancer is detected
—lowers breast cancer risk by 90%. CNPP,
Page 152.

The American Cancer Society currently
recommends that all who are 21 years of age or
older should have annual Pap tests every 3
years using conventional or liquid-based Pap
test. CNPP, Pages 124, 1404.

Colonoscopy with removal of polyps is
recommended beginning at ages 20–25,
repeating every 1–2 years. Evidence does not
support screening for gastric, duodenal, and
small bowel cancer in Lynch syndrome.
Selected individuals may be advised to have
upper GI endoscopy between 30–35 years of
age every 3–5 years. CNPP, Pages 123, 1433.
25. The answer is b.

Research has shown that men who took
finasteride as part of the Prostate Cancer
Prevention Trial (PCPT) had a 25% lower
incidence of prostate cancer. The selenium and
vitamin E cancer prevention trial (SELECT)
was stopped because there was a higher
incidence of prostate cancer in men taking
vitamin E and increased incidence of diabetes
in men taking selenium. CNPP, Pages 88, 96.

Modifying sexual behavior, thereby limiting a
woman’s exposure to oncogenic human
papillomavirus, will prevent cervical cancer.
This includes barrier contraceptives and
limiting sexual partners. Oral contraceptives,
annual Pap smear, or HPV testing are not risk-
reducing behaviors for prevention of cervical
cancer. CNPP, Page 1401.
B. SCREENING AND EARLY DETECTION

Since the adoption of PSA testing more than
20 years ago, PSA screening for prostate cancer
remains controversial. Not all men with
prostate cancer secrete enough PSA to raise
the level. Digital rectal exam is the most
commonly performed screening exam. PSA
greater than 4 ng/ml is the threshold for
performing biopsies. CNPP, Pages 1850–1851.

The most widely used screening programs
have been for the early detection of breast
and cervical cancer. Prior to screening, cervical
cancer was the leading cause of death among
women. CNPP, Page 100.

The specificity of a test is its ability to identify
those individuals who do not have cancer. The
sensitivity of a screening test is its ability to
detect cancer. A true-positive and a false-
negative are normal tests for cancer in a
patient who has cancer. CNPP, Pages 100, 121–
122.
Colonoscopy is recommended every 10 years;
flexible sigmoidoscopy every 5 years; double
contrast barium enema every 5 years. CNPP,
Page 123.

All the statements are true, but choice c is the
most appropriate response in this situation
because emphasis is on individuals and the
need to screen when asymptomatic. CNPP,
Page 112.

There is a far greater chance that the
individual will actually go have appropriate
screening when a nurse recommends
screening to an individual. CNPP, Page 129.

The Gail Model predicts the risk of developing
breast cancer. The other models have been
developed to calculate the risk of having a
BRCA1/2 genetic mutation. CNPP, Page 117.

The cancer risk assessment is the first step in
the cancer screening process. A review of the
past and present medical history, detailed
family history, risk factors, and use of risk
assessment tools are all a part of the cancer
risk assessment. CNPP, Page 113.

Absolute risk is helpful when patients need to
understand the chances for all persons in a
population of developing a particular disease.
Relative risk refers to a comparison of the
incidence or deaths among those with a
particular risk factor and those without the
risk factor. Thus, individuals can better
understand their personal chance of
developing a specific cancer. CNPP, Pages 115–
116.

The PREMM model predicts risk of hereditary
colorectal cancer mutation. The other models
predict risk of developing breast cancer. CNPP,
Page 117.

Low-dose computed tomography has been
recommended for former smokers ages 55–74
in good health who have 30-pack years or
more of smoking, who currently smoke or
have quit in the last 15 years. Low-dose
computed tomography has demonstrated a
20% reduction in mortality. Chest x-ray or
sputum cytology have failed to demonstrate a
benefit. CNPP, Pages 103, 124, 1687.

Ovarian cancer is typically asymptomatic in its
early stages. As the disease progresses, women
may experience bloating, vague abdominal
discomfort, leading to loss of appetite,
flatulence, or urinary frequency. More often
than not, these symptoms are no more than
annoying and are not taken seriously by the
patient and her physician. By the time a
diagnosis of ovarian cancer is made,
approximately 70% have advanced-stage
ovarian cancer. CNPP, Page 1801.

Physical recognition of CM by practitioners
and those at risk can be initiated by using the
ABCDE rule. In this rule, A = asymmetry, B =
border irregularity, C = color irregularity, D =
diameter greater than 0.6 cm, and E =
elevation or evolving. CNPP, Page 1997.

The total number of DNs is an indicator of risk
for developing malignant melanoma. The
identification of DN is difficult to perform
clinically and occur in approximately 10% of
population, not 40%. DN may develop
throughout life. CNPP, Pages 1901–1902.

BCC is the least aggressive type of skin cancer
and has its origins in either the basal layer of
the epidermis or in the surrounding dermal
structures. It is most commonly found on the
nose, eyelids, cheeks, neck, trunk, and
extremities. It grows slowly by direct extension
and has the capacity to cause major local
destruction. Metastasis is rare. SCC, on the
other hand, may arise in any epithelium. It is
most commonly found on the head and hands.
It is more aggressive than BCC, has a faster
growth rate, less well-demarcated margins,
and a greater metastatic potential. CNPP,
Pages 1918–1920.

The majority (60%–80%) of lymphoma
patients present with enlargement of cervical
or supraclavicular lymph nodes, but enlarged
axillary or inguinal nodes may also be
presenting symptoms. Six percent to 20% of
nodes are characteristically painless, firm,
rubbery in consistency, freely movable, and of
variable size. Weakness, fatigue, and general
malaise may be a part of the presenting
picture. CNPP, Page 1603.

There are three types of skin cancer: BCC, SCC,
and melanoma. However, melanoma is the
most common skin cancer to result in death.
CNPP, Page 1902.

Superior vena cava obstruction is a common
complication of lung cancer; approximately
65% of these cases are caused by
undifferentiated neoplasms arising in
proximal right bronchi. CNPP, Pages 1190,
1691.

Ultrasound is the imaging modality of choice
in a young woman, a pregnant woman, or a
lactating woman, which requires no ionizing
radiation. Fine-needle aspiration is also
appropriate. CNPP, Pages 1301–1303.

Persistent sore throat, difficulty chewing and
swallowing, ongoing weight loss, and airway
obstruction are indications of cancer of the
oral cavity. CNPP, Page 1582.
The most common presenting symptom of
testicular cancer is a hard, painless, pea-sized
swelling or enlargement of the testis.
However, a heavy sensation, swelling, dull
aching, or pain in the scrotal area also may be
a presenting symptom. CNPP, Page 1959.

The earliest symptoms of stomach cancer are
usually nonspecific and vague. Home remedies
and self-medications are often used
successfully, and symptoms are considered to
be related to acid reflux disease. Because of the
elusive nature of gastric disorders, this type of
cancer is usually quite advanced by the time
medical attention is sought. CNPP, Page 1942.
C. NAVIGATION

The major purpose of patient navigator
programs is to provide personal assistance in
eliminating any barriers to patients obtaining
timely and adequate diagnosis and treatment.
BCCR, Page 147.

Racial/ethnic minorities, those with low
socioeconomic status, and rural populations
and members of other medically underserved
populations often do not receive timely
standard cancer care. BCCR, Page 147.

Lay navigators are individuals in the
community that help patients navigate the
complexities of the healthcare system and
identify barriers to care and resources. They
are considered “natural helpers” and are used
in a variety of settings and not only address
spiritual, logistical needs but physical and
psychosocial as well. CNPP, Page 2075.

Navigation services benefit patients during the
period between suspicious finding and
diagnosis, as well as during treatment,
survivorship, and palliative care. CNPP, Page
2075.

Data about the populations you are striving to
serve must include the number of women who
are eligible for screening mammography as
well as the number of women who participate
in annual screening mammography. Other
information such as the number of breast
cancer cases and the stage at diagnosis will
provide information about women receiving
services, but not information about those who
need but are not receiving services. BCCR,
Page 150; CNPP, Page 70.

The priority for the navigator is to assist the
patient with scheduling the next needed tests
and address any barriers to completion such as
transportation and childcare. BCCR, Page 147.

Increasing the number and percent of women
having screening mammography from the
defined targeted geographic region is an
example of outcomes that navigation can
directly influence. Health education/outreach
programs by themselves do not improve the
delivery of standard cancer screening,
detection, and treatment. BCCR, Page 152.

Ensuring that the woman returns for further
testing to rule out or diagnose malignancy is
the most important intervention at this time.
BCCR, Page 152.

The nurse navigator can start by documenting
the time from diagnosis to first treatment. If
that time is within an acceptable standard of
care (< 4 weeks), the navigator can focus on
other aspects of quality improvement. If the
time is not acceptable, further documentation
of the time for individual steps can reveal
opportunities for intervention. BCCR, Page
151.

All answers are important, but knowledge of
screening, detection, diagnosis, and treatment
of breast cancer is most important if the nurse
wants to be a breast cancer navigator. BCCR,
Page 152.
By conducting a comprehensive assessment
that includes the needs and resources of the
woman along with the treatment plan, a
comprehensive plan of care can be developed.
BCCR, Page 152.
D. ADVANCE CARE PLANNING

Advance care planning is the whole process of
discussion of end-of-life care, clarification of
values and goals, and preferences through
written documents (advance directive) and
medical orders. This process can start at any
time and revisited as health status changes.
Dying in America: Improving Quality and
Honoring Individual Preferences Near the End
of Life. Washington DC: The National
Academies Press. Chapter 3.

An AD provides very specific instructions
regarding preferences for life-sustaining
treatments that an individual would want to
receive. It is not a legally binding contract nor
is it required to include a living will. CNPP,
Page 2067.

The durable power of attorney and living will
are both important advance directive
documents that people can complete at any
time and in any state of health that allows
them to do so. Dying in America: Improving
Quality and Honoring Individual Preferences
Near the End of Life. Washington DC: The
National Academies Press. Chapter 3.

A living will describes the kinds of medical
care a person does or does not want under
specific conditions if no longer able to express
those wishes. An advance directive may not
always be honored and implemented. Dying in
America: Improving Quality and Honoring
Individual Preferences Near the End of Life.
Washington DC: The National Academies
Press. Chapter 3.

Despite recommendations and requirements
to complete ACP, conversations initiated by
clinicians are infrequent, especially in the
outpatient setting. A problem may be who is
the healthcare provider that should initiate
ACP. Dying in America: Improving Quality
and Honoring Individual Preferences Near the
End of Life. Washington DC: The National
Academies Press. Chapter 3.
E. EPIDEMIOLOGY

The prevalence rate is the total number of
cases—new and existing—in a given population
during a specific time period (in this case 1
year). It is a function of both incidence and
duration. In other words, the higher the
survival rate (duration) for a type of cancer,
the higher its prevalence rate will be. CNPP,
Page 45.

More than 50% of all bladder cancer cases can
be attributed to smoking. However, all four
factors play some role in the development of
bladder cancer. CNPP, Page 1228.

The highest incidence of breast cancer is in
non-Hispanic white women, less in African
American women, and the lowest in
Asian/Pacific Islander women. The incidence
increases with age. Approximately 79% of
breast cancers occur in women who are 50
years of age or older, with a decrease in
women 80 years of age. CNPP, Page 1281.
The highest overall cancer incidence rates
occur among African American men followed
by Non-Hispanic white, American Indian and
Alaska Native, Hispanic/Latino, and Asian
American/Pacific Islander. CNPP, Page 56.

For cervical cancer, the highest incidence rates
are among Hispanic/Latino females. CNPP,
Page 1399.

Adenocarcinoma of the esophagus is more
prevalent among Caucasians. Squamous cell
carcinoma is more prevalent among Asians
and African Americans. CNPP, Page 1534.

New cervical carcinomas remain highest in
women 35–54 years of age. CNPP, Page 1398.

The only risk factor definitively related to the
development of primary brain tumors is
radiation to the head and neck area. CNPP,
Page 1351.

Japan, Korea, and China have the highest
incidence of stomach cancer in the world. The
lowest incidence rates are found in Western
Africa. CNPP, Pages 1938–1939.

African Americans and Native Hawaiians are at
higher risk of developing lung cancer than
Caucasian Americans, Japanese Americans,
and Latinos. African Americans have higher
cotinine levels than Caucasian and Hispanic
smokers when smoking the same number of
cigarettes. CNPP, Page 1682.

Viruses are a link to approximately 20% of
cancers worldwide. HCC is associated with
hepatitis B virus, cervical cancer with human
papillomavirus (types 16 and 18), and Burkitt’s
lymphoma with the Epstein-Barr virus. CNPP,
Page 67.

Women have an increased susceptibility to
tobacco carcinogens and exhibit more tobacco-
related mutations than men, such as
mutations of the TP53 gene. CNPP, Page 1682.

A family history of breast cancer is associated
with a higher incidence of ovarian cancer. The
use of oral contraceptives provides long-term
protection against ovarian cancer. With the
exception of Japan, industrialized nations have
the highest incidence of ovarian cancer, not
developing countries. Women with higher
educational and socioeconomic levels (not
lower levels) tend to delay childbearing, have
fewer children, and have a higher incidence of
ovarian cancer. CNPP, Page 1794.

The mortality rate of African American males
is twice that for Caucasian males. American
Indian and Alaska Natives have a similar death
rate as Caucasians. Hispanic/Latino men have
the fourth-highest death rate. CNPP, Pages 57,
1848.

One of the strongest risk factors for bladder
cancer involves occupational exposure to
aromatic amines, benzidine, and aniline dyes.
Smoking is also an important exogenous risk
factor. CNPP, Page 1228.

Hepatitis B virus infection is the leading cause
of hepatocellular carcinoma throughout the
world. Hepatis C virus is the leading cause of
hepatocellular carcinoma in the United States,
Europe, and Japan. CNPP, Page 1652.

Data regarding the genetic basis of cancer have
been derived from a number of sources,
including familial patterns. Families with a
hereditary predisposition to cancer often have
multiple cases of cancer at an earlier age than
what would be expected for the general
population. CNPP, Page 114.

The most recognized and common risk factor
for multiple myeloma is MGUS. In addition to
the other risk factors listed, male gender,
increasing age, and African American ethnicity
are factors. CNPP, Page 1755.

The primary risk factors for breast cancer are
family history of breast cancer, increasing age,
genetic proof of BRCA1 or BRCA2, history of
benign breast disease, late age at first live
birth, nulliparity, early age at menarche, late
age at menopause, high socioeconomic status,
being Jewish, estrogen replacement therapy,
exposure to chest radiation, dense breasts, and
having complex fibroadenomas. CNPP, Page
1283.

BRCA2 gene mutation has been identified on
the long arm of chromosome 13 (13q12.13).
This mutation seems to be associated with
male breast cancer and greater risk of early
breast and ovarian cancer. It is not genetically
related to BRCA1, and the BRCA2 gene
mutation has been associated with prostate
cancer, pancreatic cancer, malignant
melanoma, and carcinoma of the fallopian
tube and peritoneum. CNPP, Page 148.

The majority of HCCs cases occur in people
with chronic hepatitis B, hepatitis C, or
cirrhosis. Other risk factors for HCC include
environmental and chemical toxins, alcohol
and smoking, and hereditary factors. CNPP,
Page 1653.

HPVs are members of the family of
deoxyribonucleic acid (DNA) tumor viruses
that can cause cellular hyperproliferation and
a variety of warty infections. HPV 16 is the
most carcinogenic and is associated with
squamous carcinoma. HPV 18 is the second
most common type and associated with
adenocarcinoma of the cervix. HPV 35 has
evidence for cervical cancer but is rare, only
9% as compared to 70% of HPV 16 and 18.
Cervical cancer is rare in women who are
nulliparous or in lifetime monogamous
relationships. Women who smoke are two
times more likely to develop cervical cancer
compared to nonsmokers. CNPP, Pages 1399–
1400.

Helicobacter pylori is the strongest risk factor
for the development of stomach cancer,
accounting for 60% gastric cancer cases
worldwide. The prevalence of H. pylori is
higher in developing countries than
industrialized countries with rates exceeding
80% in some less developed countries. High
intake of excessive salt such as smoked or
salted meats and fish are associated with
increased risk, and smoking continues to be
considered a risk factor. CNPP, Page 1939.

HPV (types 16 and 18), cervical cancer, and
genital warts are risk factors for vaginal
cancer. Maternal use of DES and numerous
sexual partners are also associated with
vaginal cancer. CNPP, Page 1992.

Although many chemicals are carcinogenic in
animals and produce brain tumors, the
substances that have been tested include
chemicals in pesticides, herbicides, and
fertilizers. CNPP, Page 1351.

Approximately 5%–10% of breast cancer cases
are genetically related to BRCA1/BRCA2, and
breast cancers linked to these mutations occur
more often in younger women. A woman with
a strong family history of breast cancer is
generally defined as having four or more
genetically related women affected with the
disease; women who have inherited a
mutation on BRCA1 and BRCA2 have up to an
85% risk of developing breast cancer by age 70.
CNPP, Page 1284.

Multiple etiologic and risk factors are
associated with skin cancers. High-risk factors
for CM include skin color, actinic keratoses,
dysplastic nevi, and congenital. Other possible
risk factors for CM include ultraviolet (UV)
radiation, age, hormonal factors,
immunosuppression, and a previous history of
melanoma. CNPP, Pages 1900–1901.

The number of family members with ovarian
cancer defines the individual’s degree of risk.
If one member has ovarian cancer, there is a 2-
to 3-fold increased risk. If two or more family
members have the disease, the lifetime risk
increases to 70%. Ovarian cancer tends to be
more common among white upper-income
groups in highly industrialized countries.
CNPP, Page 1797.

The risk factors for NHL can be divided into
four groups: immune suppression, toxic
exposure, infectious agents, and familial.
However, the most common risk factor is
immune suppression, both primary and
acquired. CNPP, Page 1723.

Suppressor proteins “turn off” cell growth.
Because the genes coding for these proteins
have an opposite function to that of
oncogenes, they are called antioncogenes.
Because they suppress malignant growth, they
are also called tumor suppressor genes. CNPP,
Page 8.

The p53 gene is one of the most important of
the tumor suppressor genes. Not only is it the
most frequently mutated gene, DNA viruses
produce proteins that inactivate the p53
protein. CNPP, Pages 6, 688, 1229, 1490, 1498,
1536.

Familial carcinogenesis is based on a group of
genes that, when mutated, cause cancer by
their absence; that is, they seem to prevent
cancer when they are functioning normally.
These protective genes are the cancer
suppressor genes. CNPP, Page 7.

The ras oncogenes appear to function early in
the process of carcinogenesis and may be a
good target for early detection. CNPP, Pages
8–9, 20.

Genes that predispose for cancer development
are generally transmitted in an autosomal
dominant fashion, meaning that individuals
who harbor a mutated gene have a 50% chance
of passing the mutated gene on to their
children. Inheritance of the altered gene
confers an increased risk for developing
cancer. The pattern of transmission seen with
cancer susceptibility genes is usually vertical,
meaning successive generations are affected;
depending on the disease, males and females
are generally equally affected. CNPP, Pages
138–139.

Inheritance of the BRCA1 susceptibility gene is
associated with a strong likelihood that the
effect of the mutation will result in the disease
for families with multiple breast and ovarian
cancers as well as for those with breast cancers
diagnosed before the age of 45. CNPP, Pages
146–150, 177, 1284.

Most people believe cancer risk is increased
simply because someone in the family has
cancer, which is not true. Only 5%–10% of all
cancers are hereditary. CNPP, Page 138.
The BRCA2 gene is associated with an
increased susceptibility to both breast and
ovarian cancer. CNPP, Pages 146–153, 2084.

Persons who have a FAP have 100% risk of
developing colorectal cancer. Individuals who
have a first-degree relative with colorectal
cancer have double the risk for developing
adenomatous polyps, which are precursors of
colorectal carcinoma. CNPP, Pages 1206–1208.

Germ cell mutations are transmitted to the
next generation at birth and are responsible
for hereditary (familial) cancer. Most human
cancers result from a combination of acquired
and inherited mutations with alterations of
both oncogenes and antioncogenes. CNPP,
Page 137.

After 20 years, the probability of developing
contralateral breast cancer is approximately
27% among women with hereditary breast
cancer compared to 5% among women with
breast cancer in the general population. The
risk of contralateral breast cancer is highest
among women with hereditary breast cancer
that is diagnosed before the age of 50. More
than 40% of women in this group develop
contralateral breast cancer during the 20 years
after their initial breast cancer diagnosis.
Adjuvant hormone therapy reduces the risk of
contralateral breast cancer. CNPP, Pages 149–
153, 1317–1318.
F. SURVIVORSHIP

The actual cancer incidence has decreased but
the number of cancer survivors continues to
climb due to population growth, aging
population, and improvements in cancer
detection and treatment. Breast cancer
survivors are the largest group followed by
prostate and colorectal survivors, but there are
other groups of survivors as well. CNPP, Page
2030.

The success of any cancer survival program
depends on the commitment of the healthcare
team to provide ongoing evaluation and
planning for change in the lives of survivors.
Under such a dynamic program, preventive
and restorative goal setting (redefinition of
goals) become critical to a long-term
survivorship trajectory that is characterized by
minimal debilitation and a wellness
orientation. Particular attention is also paid to
the ongoing and long-range implications of
financial burden imposed by cancer. CNPP,
Pages 2006–2007.
Rehabilitation refers to the process by which
individuals, within their environments, are
assisted to achieve optimal functioning within
the limits imposed by cancer. The goals are to
improve the quality of life for those
experiencing cancer and to help the individual
regain wholeness. CNPP, Pages 2007, 2041.

Severity or duration of disease is the factor
most closely related to the cancer patient’s
rehabilitation needs. The physical needs
frequently occurring with a variety of cancers
include general weakness, limited activities of
daily living, and issues related to limited
morbidity. CNPP, Pages 2041–2042.

A cross-sectional study of 377 cancer survivors
reported that fatigue, fear of recurrence, and
living with uncertainty were identified as the
highest-ranking concerns. CNPP, Page 70.

The population of cancer survivors is
increasing with 50% of adults and 83% of
children surviving beyond 5 years after their
diagnosis. CNPP, Page 2006.
Tracheoesophageal prosthesis enables the
patient to divert exhaled pulmonary air
through a surgically constructed fistula tract
directly into the esophagus. CNPP, Page 1588.

Liquids are the most difficult thing for the
patient to swallow without aspirating.
Thickening agents can be used. Swallowing
rehabilitation with a speech-language
pathologist is essential. CSM, Pages 392–393.

A second primary lesion refers to a
histologically separate malignant neoplasm in
the same patient. A general rule is always to
biopsy the first recurrence, because it may
represent a new, curable, or treatable
malignancy. Bladder, colorectal, and
melanoma are associated with secondary
malignancies of bladder cancer. CNPP, Page
2036.

Surgery may be used to resect a metastatic
lesion if the primary tumor is believed to be
eradicated, if the metastatic site is solitary, and
if the patient can undergo surgery without
significant morbidity. CNPP, Page 1663.

The most common second malignant
neoplasms following radiation therapy are
breast and thyroid cancers. Other common
solid tumor cancers seen after radiation
therapy include lung cancer, bone sarcoma,
and gastrointestinal tumors. CNPP, Page 2035.

In patients with prostate cancer, there is an
increased risk of the development of colorectal
cancer, bladder cancer, and melanoma. CNPP,
Page 2036.

In a study of survivors of Hodgkin disease, a
risk of secondary cancers was noted 20 years
posttreatment. Eighty percent of secondary
solid tumors are associated with radiation
therapy. CNPP, Page 2035.

Adults and children who have received
chemotherapy or radiation therapy, or both,
for a primary malignancy are at increased risk
for the development of a second malignant
neoplasm. Alkylating agents and ionizing
radiation are the treatments most closely
linked to a second malignant neoplasm. CNPP,
Page 2035.

Alkylating agents have a demonstrated
causative relationship to AML. AML is the
most frequently reported secondary cancer
following aggressive chemotherapy for
Hodgkin disease, non-Hodgkin lymphoma,
multiple myeloma, ovarian cancer, and breast

The risk of breast cancer correlates with
increased radiation dosage, especially if a
woman is exposed to radiation in the period of
young adulthood. CNPP, Page 371.

Estimates indicate that 20%–70% of family
caregivers miss work or quit their jobs. The
highest economic burden is during the
patients’ continuing phase of treatment and
for patients with lung cancer. The Family
Medical Leave Act guarantees only unpaid
leave to care for a seriously ill spouse. CNPP,
Page 2053.

Individuals with low annual incomes are more
likely to die of cancer than those with high
annual incomes. CNPP, Page 55.

A primary barrier to cancer care for many
ethnic minority populations is access to health
care, especially among the socioeconomically
disadvantaged. CNPP, Page 55.

Research indicates that survivors and family
caregivers who have more fear of cancer
recurrence are younger. Fear of recurrence is
not a sign of poor coping as it is a natural
response to having a life-threatening illness.
CNPP, Page 2049.

HIPAA mandates security and privacy
regulations for electronic health information.
CNPP, Page 2121.

The unemployment rate is higher among
cancer survivors versus the general
population. Thirty percent of cancer survivors
are unable to return to work. Unemployment
rates are the highest among survivors of
breast, gastrointestinal (GI), and gynecological
(GYN) cancers and the majority of cancer
survivors are not depressed. CNPP, Page 2037.

The illness draws most couples closer together
as the partners learn to appreciate each other
more and to value their time together. There is
NO significant difference in marital
satisfaction of couples coping with cancer.
CNPP, Page 2050.

Protective buffering is hiding cancer-related
worries from a partner and denying concerns
in an effort to avoid disagreement. Protective
buffering increases emotional distress of both
persons and decreases marital satisfaction.
CNPP, Page 2050.

Three patterns of communication have been
noted to occur among professionals, patients,
and family members: privileged, filtered, and
balanced. CNPP, Pages 2054–2055.

A major strategy that professionals can use to
promote patient-family communication is to
encourage patients and family members to
work as a team to manage the effects of the
illness. CNPP, Page 2056.

All answers relate to the definition of sexual
health, but the World Health Organization
(WHO) provides the global definition of sexual
health as a state of physical, mental, and social
well-being in relation to sexuality. CSM, Page
507.

Managing sexuality issues in adults with
cancer is fraught with the complexities of
cancer diagnosis, treatment, and
comorbidities. Healthcare providers must
remember that sexuality, physical, and
emotional intimacy are lifelong needs of
individuals and need to be addressed as a
component of cancer care. CNPP, Pages 1036–
1037.

Preservation of the cavernous nerves is the
most important factor for post-prostatectomy
erectile function recovery. Cavernous nerve
reconstruction can be undertaken to preserve
spontaneous erectile function. PDE5 inhibitors
have also been used to manage erectile
dysfunction in men who have had a radical
prostatectomy. CNPP, Page 1016.

Education and counseling are basic
interventions for alterations in sexual health.
It may be difficult for patient and family to
adapt to role playing. Another problem is that
patients are generally not screened for
participation. Screening increases the
probability of identifying patients and partners
with preexisting problems that may require
more intensive therapy. CNPP, Pages 1029–
1030.

Primary reasons healthcare providers do not
discuss issues related to sexual concerns is
personal discomfort, lack of knowledge and
training, and fear of embarrassing themselves
and patients. Lack of time is another reason
and some nurses believe it is not their
responsibility. CNPP, Page 1026.

While all patients should be assessed for
alterations in sexuality, it is important to
recognize those who may be at higher risk for
sexual dysfunction, which includes women
older than age 30, and postpuberty men.
CNPP, Pages 1026–1027.

If more than the anterior third of the vaginal
wall is removed, the diameter of the introitus
and the vaginal barrel can be severely
compromised, and intercourse may be
restricted. She needs instruction on vaginal
dilation and to use liberal lubrication. Orgasm
is not diminished. CNPP, Page 1017.

For women receiving radiation therapy to the
vagina, vaginal fibrosis and scarring with a loss
of blood supply and elasticity is a major
adverse effect. Frequent intercourse can
minimize these effects. For patients who are
not sexually active, the use of a vaginal dilator
with water-soluble lubricants or prescribed
estrogen cream starting 2 weeks after
treatment are effective prophylactic measures
to minimize functional loss. CNPP, Page 1997.

The new urinary diversions and neobladder
have resulted in improved quality of life,
decreased alterations in sexual function, and
decreased odor and urine leakage. A radical
cystectomy with urinary diversion can affect
many aspects of sexual functioning; however,
penile sensation is not altered. CNPP, Page
1014.

Permanent damage to erectile function with
loss of emission and ejaculation may occur
with perineal resection or radical
prostatectomy. Retrograde ejaculation is
common with transurethral and
transabdominal resection and erectile
dysfunction with transabdominal resection.
Bilateral orchiectomy causes sexual
dysfunction through gradual diminution of
libido, impotence, gynecomastia, and penile
atrophy. CNPP, Page 1016.
G. TREATMENT-RELATED CONSIDERATIONS

The target organs most commonly affected are
the thyroid, ovaries, and testes. Late effects
can include alterations in metabolism, growth,
secondary sexual characteristics, and
reproduction. CNPP, Page 2031.

High doses of radiation to the hypothalamic
pituitary axis can damage the hypothalamus
and disrupt the production of growth
hormone. Growth hormone deficiency with
short stature is one of the most common long-
term endocrine consequences of radiation to
the central nervous system in children. CNPP,
Pages 363–364, 1501.

Fatigue is normal for many months following
treatment and often occurs with other
symptoms. CNPP, Pages 804, 2014. CSM,
Pages 27–29.

Nephritis and cystitis are the major long-term
renal toxicities that result from cancer
treatment. Damage to the nephrons and
bladder has been documented in patients
treated with cyclophosphamide, ifosfamide,
and cisplatin. Treatment for late effects on the
bladder may include drug therapy to reduce
cystitis. CNPP, Pages 369, 546–547.

Patients with HIV and neutropenia, who have
had prolonged treatment with corticosteroids,
immunosuppression, should be assessed for
the development of Pneumocystis jiroveci.
Because symptoms are insidious, a prolonged
fever that is unresponsive to antibiotics and
associated with a nonproductive cough and
dyspnea on exertion may indicate infection.
CNPP, Page 593.

The late effects of central nervous system
treatment, including neuropsychological,
neuroanatomic, neurophysiologic changes and
cognitive impairment, have been observed
most commonly in children with acute
lymphoblastic leukemia and brain tumors and
in small cell carcinoma of adult lung patients,
all of whom received central nervous system
treatment for the primary tumor. CNPP, Pages
1379, 2032. CSM, Pages 637–641.

The late effects after cancer treatment result
from physiologic changes related to particular
treatments or to the interactions among the
treatment, the individual, and the disease.
Unlike the acute side effects of chemotherapy
and radiation, however, late effects are
believed to progress over time and by different
mechanisms. They can appear months to years
after treatment; can be mild, severe, or life
threatening; and can be clinically obvious,
clinically subtle, or subclinical. Their impact
appears to depend on the age and development
stage of the patient. CNPP, Page 2030.

One-third to one-half of cancer survivors
experience sleep disturbances of some kind.
CNPP, Page 1053.

Beau’s lines indicate a reduction in or
cessation of nail growth in response to
cytotoxic therapy. Drugs that are implicated
include bleomycin, cisplatin, docetaxel,
melphalan, and doxorubicin. CNPP, Page 601.

Secondary malignancies account for 16%–20%
of all cancers and include both hematologic
and solid tumor malignancies. CNPP, Page
2035.

Hematologic secondary malignancies usually
occur within 10 years from treatment and the
risk increases with the amount of bone
marrow exposed, yet the risk is generally not
elevated with increased dosage of radiation

Approximately 80% of secondary solid tumor
malignancies are associated with radiation
therapy and is dependent on radiation dose,
area treated, and age of patient. In contrast to
hematologic secondary malignancies, higher
doses are associated with increased risk for
development of secondary solid tumor
malignancies. CNPP, Page 2035.

Children treated for cancer with radiation
therapy are more likely to develop breast

Chemotherapy carries a higher risk than
radiation therapy of causing leukemia.
Generally, individuals develop myelodysplastic
syndrome that progresses to leukemia. CNPP,
Page 2035.

Breast cancer recurrence is possible 15 years or
even longer after the initial diagnosis; thus, it
is important to be followed by an oncologist or
PCP experienced in breast cancer survivor
surveillance. If the patient has early stage
breast cancer, she can be transferred to her
PCP 1 year after the initial diagnosis. CNPP,
Page 2039.

Follow-up care for potential late effects of the
patient with NHL should include Blood tests,
electrocardiogram for cardiac assessment, and
a DXA scan for potential bone loss. Cognitive
assessment is also important but pulmonary
function tests are not necessary. CNPP, Page
2033.

Regular follow-up should be the focus of their
care and usually involves quarterly pelvic
examinations in the initial years after
diagnosis because most recurrences will take
place in the first 3 years following initial
treatment. Education about a healthy lifestyle
and regular screening for other cancer is also
important. CNPP, Page 1529.

Most institutions now propose 35 years of
follow-up be conducted given that secondary
malignancies can occur up to this point and
have become the leading cause of death in
testicular cancer survivors. CNPP, Page 1972.

There is increased momentum for utilization
of the advanced practice provider model, in
part due to the strain on the healthcare system
associated with the growing survivorship
populations and shortage of physician
providers. CNPP, Page 2041.
H. END-OF-LIFE CARE

She may be suffering prolonged grief distress,
which is a severe reaction to loss and may
manifest itself as psychopathologic bitterness
toward the loss. The nurse should be able to
identify and recommend referrals for
abnormal types of grief. It is therapeutic to
review a person’s life with a loved one.
Listening to a family member share stories of
their life with the loved one honors the
meaning of their relationship and their life
together. Funeral planning can be therapeutic
and facilitate someone’s loss as they do one
last thing in a special way for their loved one.
Delegating responsibilities that can be
overwhelming or too painful might actually be
an indicator of the grieving party being aware
of their limitations and calling on their
resources and support systems. CSM, Pages
674–675.

It is helpful to explore previous losses and
coping mechanisms used in an individual
experiencing anticipatory loss. CSM, Page 674.
Grief is a normal process of experiencing the
psychological, behavioral, social, and physical
reactions to the perception of loss. The
outward expression of lost and process of
adapting is “mourning.” The time period given
to grief and mourning is “bereavement.” CSM,
Page 674.

Four types of grief are distinguished as 1)
anticipatory grief, 2) preparatory grief, 3)
complicated grief, and 4) prolonged grief. CSM,
Page 674.

A study of patients with a terminal diagnosis
of cancer reported that anxiety was the
strongest predictor of preparatory grief
followed by depression and hopelessness.
CSM, Page 674.

Persistent avoidance of activities and friends
after the death of her husband and symptom
duration more than 1 month is indication of a
posttraumatic stress disorder. She should be
referred to an appropriate professional. CNPP,
Page 220.
According to Domain 7 of the National
Consensus Guidelines for Palliative Care, a
post-death bereavement plan should be
activated when an interdisciplinary team
member is assigned to the family in the post-
death period to help with religious practices,
funeral arrangements, and burial planning.
CSM, Pages 699–700.

Routine home care provided by hospice staff,
continuous home care with skilled nursing,
respite care to caregivers, and break and
inpatient care with limitations on days are the
four levels of hospice care. Funding is not
provided by Medicare for residential care, day
care, and extended caregiver services. CNPP,
Pages 2067–2068.

Families of patients dying without hospice
care may not have been made aware of
bereavement support which is available as a
part of hospice care. They are not eligible for
clinical trials with curative intent and day care
is not a service of hospice care. CSM, Page 713.

Hospice care is a medically directed,
interdisciplinary team-managed program of
services that focuses on the patient and family
as the unit of service. Hospice services provide
medical care, pain management, and
emotional and spiritual support. CNPP, Page
2068.

Families often believe the information they
receive from healthcare professionals
regarding coping is insufficient. The family
begins to prepare for the unavoidable pain of
loss and the necessary adjustments that must
be made (hospice care) if sufficient
information is presented to them. Families
desire honest communication, despite the use
of denial, as well as appropriate referrals.
Denial is viewed as a healthy coping
mechanism that with appropriate information
will help the wife gradually accept the next
level of care. CNPP, Pages 2054–2057.

The patient must desire palliative, not
curative, treatment. Patients can receive
treatments that are aimed at palliation, not
cure. Blood is generally not given but can be
for palliative reasons, as can pamidronate.

The Caregiver Reaction Assessment was
developed for family members to provide
information. The other instruments have been
developed expressly to capture the elements
that are important to patients at the end of life.
CNPP, Page 220.

Most children and adolescents whose parent is
ill are well adjusted, but a significant number
are at risk for moderate to high levels of
emotional distress and behavioral problems.
Researchers have found that children’s
responses vary by developmental age.
Compared to younger children, adolescents
report more problems with anxiety and
depression. CNPP, Pages 2049–2050.

The family member should not deny their
feelings but communicate openly with the
patient. Interventions include promoting
optimism and hope, providing support, and
facilitating communication between the
patient and family. CNPP, Page 2056.
Hospice care pivots around the idea of
palliative medical management. Palliative
management involves a shift in treatment
goals from curative toward providing relief
from suffering. CNPP, Pages 2067–2069.

The hospice team’s goal is to help the family
prepare for their loved one’s death. Families
need to be prepared for the actual time of the
patient’s death and what universal signs they
can anticipate. Increasing sleep, a gradual
decrease in need for food and drink, increased
confusion or restlessness, decreasing
temperature of extremities, and irregular
breathing patterns may occur. CNPP, Pages
2077–2081; CSM, Pages 712–713.

A disadvantage to this model of care is that
consults are often requested late when
patients are near the end-of-life. CNPP, Page
2071.

The evaluation and selection of palliative care
arrangements requires individual attention to
the needs and goals of the patient. Two
important considerations in this selection
process are the patient’s resources and
geographical location. CNPP, Page 2070.

The most common indication for radiation
therapy at the end-of-life is to control pain
from bone metastases. CNPP, Pages 327, 1263.

National Comprehensive Cancer Network
(NCCN) guidelines to remove liver metastases
in patients with colon cancer indicate that the
surgeon must be able to completely remove all
tumor and yet have adequate liver tissue
remaining. CNPP, Page 1445.

A barrier is that some oncologists believe that
end-of-life discussions are the sole
responsibility of the oncologist and do not
want other providers to become involved in
decision-making. Research has shown that
patients do not lose hope once palliative care is
initiated. The term “palliative care” was a
barrier to referral, not daily care, as reported
by a study done at MD Anderson Cancer
Center. Oncology providers preferred the term
“supportive care” instead when providing
inpatient and outpatient referrals. CNPP, Page
2070.

The four primary models of palliative care are
inpatient palliative care unit, inpatient consult,
outpatient/clinic, and home-based (palliative
care, hospice, telehealth). CNPP, Page 2071.

Although continuous pulse oximetry is used
widely, patients and family members often
focus on the monitor, which can increase
anxiety and fear. Opioids are the first-line
therapy in relieving dyspnea without causing
respiratory depression. Bronchodilators can
relieve bronchospasm but can also increase
anxiety. CNPP, Page 2078.

Reality orientation is not considered beneficial
in actively hallucinating patients. In fact,
correcting the patient’s perceptions may only
increase anxiety and agitation. Be open to
comments by dying patients about “going
home” or seeing loved ones who have
previously died. These are common behaviors
seen during the dying process. CNPP, Page
2079; CSM, Pages 702–704.
Research demonstrates that patients do not
suffer or experience discomfort due to
dehydration. Tube feedings may actually
contribute to decreased survival due to
aspiration and abdominal distention. Family
members may inadvertently try to force
patients to eat or drink, leading to aspiration
or simply to decrease discomfort for the
patient. CNPP, Pages 2080–2081.

Scopolamine is used to manage excessive
salivation and respiratory tract secretions.
CNPP, Pages 2078–2079; CSM, Page 705.

Pain cues include changes in overt behaviors
(aggressiveness, restlessness, and agitation),
sounds (increases or decreases in verbalization
or vocalization), or appearances (facial
expressions or body language). CNPP, Page
2077.

Room air directed at the person’s face can
provide some relief of the feeling of
breathlessness. Opioids are the first-line
therapy in relieving dyspnea. Opioids decrease
the intensity of dyspnea regardless of the
underlying pathophysiology without causing
respiratory depression. Low doses of an opioid
administered on an as-needed basis are
generally very effective in patients with mild to
moderate dyspnea who have not previously
been taking opioids. CNPP, Page 2078.

Anticholinergic medications, including
scopolamine or glycopyrrolate, are effective for
decreasing oral secretions once the patient is
unable to mobilize them himself. Although
suctioning visible pooled secretions in the
posterior oral cavity may be effective,
suctioning is usually ineffective. It may be
contraindicated because of the associated
discomfort and because the site of the
accumulated secretions is generally
inaccessible. Glucocorticoids are ineffective in
managing fluid in the oral pharynx, and
benzodiazepines only sedate the patient.
CNPP, Pages 2078–2079; CSM, Pages 704–
706.

Haloperidol can be used to treat opioid-
induced acute confusion states (e.g.,
hallucinations, agitation, from delirium).
CNPP, Page 2079; CSM, Pages 703–704.

Octreotide or somatostatin is used to minimize
intestinal secretions. CNPP, Page 1457.

Palliative sedation is use of medicines to
provide decreased consciousness and to relieve
intractable symptoms and suffering in the
final hours and days of life. CNPP, Page 2081;

The most frequently addressed factors for the
use of palliative sedation are pain, delirium,
and other symptom distress that is intolerable
for the patient. CNPP, Page 2081.

Delirium is distinct from dementia and
psychoses. Delirium at the end-of-life presents
in one of three ways: 1) as a hyperactive state
with agitated behavior such as picking at bed
covers; 2) as a hypoactive state with lethargy,
anxiety, incoherent speech; or 3) a
combination of hyperactive and hypoactive
states. CSM, Pages 700–701.
Repositioning the patient to the side and
slightly elevating the head of the bed is
helpful. Intravenous fluids should be
decreased or stopped. Suctioning is usually not
recommended as it is thought to cause more
discomfort and agitation. CSM, Page 706.

A restful environment, such as soft lighting
and soothing music, decreases extraneous
stimuli. The presence of a family member or
familiar person may be calming. Reality
orientation is not beneficial in hallucinating
patients and correcting patient’s perceptions
can increase anxiety and agitation. CNPP, Page
2079; CMS, Page 704.

The Nursing Delirium Screening Scale is an
observational scale that can be completed
quickly and was created to assess patients for
delirium over time that is easy to use and time
efficient. The Revised Delirium Rating Scale is
the most widely used to measure delirium
symptom severity. CSM, Pages 702–703.

The two most important nursing
considerations as death approaches are expert
symptom management and family preparation.

Nurses caring for dying patients may
experience compassion fatigue or “burnout,”
leading to difficulty coping. It can also be an
extremely meaningful and rewarding
experience for some nurses. CSM, Pages 713–
715.

Risk factors for compassion fatigue are
younger age, high levels of empathy,
unresolved personal trauma or loss, lack of
professional or institutional supports, and
frequent exposure to trauma or loss. CSM,
Pages 713–715.

Palliative sedation does not alter the timing or
the mechanism of a patient’s death, as
refractory symptoms are most often associated
with very advanced terminal illness. Assisted
death is when a physician prescribes a life-
ending medication. Palliative decision-making
needs to involve the interdisciplinary team
with the patient and family. There is no
requirement that the team meets with the
ethics committee. CNPP, Page 2081.

Research has shown that of 5,875 patients who
committed suicide, 2,111 (36%) did so within
the first year of diagnosis, and 1 in 3 of those
did so within one month of diagnosis.
However, suicide risk remains high among
some survivors after successful treatment.
CSM, Page 658.
CHAPTER 2
Oncology Nursing Practice

A. SCIENTIFIC BASIS
Carcinogenesis
1. The two most commonly recognized
models of cancer development are:
1. Cancer stem cell model and clonal model
2. Inflammation theory and plasticity model
of cancer stem cells
3. Clonal model and inflammation theory
4. Cancer stem cell model and the genetic
predisposition model
2. Mutations are deoxyribonucleic acid

(DNA) changes caused by a variety of
reasons. Mutations caused by disease
occur in:
1. Germline and stem cells
2. Stem cells and ribonucleic acid (RNA)
3. Somatic and germline cells
4. Transfer RNA
3. Mutations can occur in normal genes

that direct cell growth. These genes can
be activated into:
1. Cancer-causing mutations
2. Genes such as ras that promote invasion of
cancer cells
3. Cancer-causing genes called oncogenes
4. Tumor suppressor genes such as p53
4. Telomerase, an enzyme that prevents the

destruction of telomeres, is associated
with limitless replication. Telomeres are
important because:
1. Telomeres protect chromosomes, enabling
longer cellular life.
2. Shortened telomeres are associated with
more aggressive cancers.
3. Telomeres allow apoptosis, the natural
progression to cellular death.
4. Shortened telomeres are a hallmark of
cancer stem cells.
5. In clonal selection:
1. Mutation in the genome of a cell may
confer a survival advantage on that cell.
2. A cell becomes weaker with each mutation.
3. Oncogenes are destroyed.
4. Telomeres develop, which are completely
duplicated during cell division.
6. A patient asks you to describe the “types

of things that cause cancer.” Because of
her interest in “types” of causes, you
might begin by explaining that cancer is
ordinarily classified as being caused by a
combination of factors that include:
1. Biological, physical, or chemical
2. Viral, dietary, or familial
3. Genetic, dietary, and environmental
4. Genetic, familial, and environmental
7. One encouraging aspect of research into

tumor-associated viruses is the discovery
of:
1. Their direct tumor causation
2. Their promise for prevention through
development of vaccines from animal
forms of the viruses
3. Their promise for prevention through
attenuated (inactivated) viruses
4. Similar viruses in animals that have been
eliminated by vaccines made from
attenuated viruses
8. Fat and fiber are two dietary factors that

appear to be correlated with the
occurrence of colorectal cancer. It is
thought that they operate by affecting, in
opposite ways, the:
1. Conversion of ionized bile salts into
insoluble compounds
2. Rate of uptake of calcium by the
gastrointestinal tract
3. Breakdown of carcinogenic compounds by
digestive enzymes
4. Exposure of the gastrointestinal tract to
promoters of carcinogenesis
9. Mrs. Harris has hepatocellular

carcinoma and states she never drank
alcohol in her life and cannot
understand how she could have liver
cancer. You explain that although the
cause is not really known, hepatocellular
carcinoma is associated with which of
the following?
1. Chronic viral infection
2. Obesity
3. Aging
4. Drug use
Immunology
10. The macrophage
1. Manufactures interleukin-3, -4, and -6 and
alpha- and gamma-interferon to aid in its
ultimate function of target cell wall damage
2. Is a precursor to the monocyte
3. Is a primary initiator to an inflammatory
immune response
4. Is a short-lived white blood cell that
responds to bacterial invasion
11. Diseases such as acquired immune

deficiency syndrome (AIDS)–related
lymphoma are referred to as
opportunistic because they:
1. Affect any or all organs and tissues in the
body
2. Normally occur in a benign state in most
individuals
3. Occur in patients with preexisting
immunodeficiency
4. Affect only human immunodeficiency
virus–infected individuals who have other
diseases

what cytokines do?
1. They bind to surface receptors of target
cells and act as regulators of cell growth or
as mediators of defense functions.
2. They are capable of nonspecific tumor cell
killing.
3. They are sedentary cells located in the
spleen.
4. They facilitate the attachment of a natural
killer cell and other cytotoxic cells.
13. The primary function of the immune

system is to:
1. Protect the body against viruses and
bacteria
2. Preserve bone marrow function
3. Provide support and nourishment to the
body’s genetic machinery
4. Prevent or limit infection and malignant
disease
14. The body can generally respond to a non-

self-invader cell more quickly and
powerfully the second time it encounters
such a cell than it did the first time, even
if months have passed between
invasions. Which of the following cells is
most closely related to this ability?
1. Polymorphonuclear granulocytes
2. Memory B lymphocytes
3. Natural killer cells
4. Mononuclear phagocyte
15. The immune system is comprised of
primary and secondary organs and
tissues based on their role in defending
the host. Examples of primary organs
and tissues are:
1. Bone marrow, spleen, and lymph nodes
2. Bone marrow and thymus
3. B cells and T cells
4. Spleen, tonsils, lymph nodes
16. Myeloid and lymphoid cells arise from

multipotent progenitor cells. Examples
of myeloid cells are:
1. Erythrocytes, granulocytes,
megakaryocytes
2. B cells and T cells
3. Basophils, eosinophils, natural killer cells
4. Interleukins, colony stimulating factors,
erythropoietin
17. Innate immunity is also known as

natural immunity. Some of the
components of natural immunity are:
1. Dendritic cells, natural killer (NK) cells
2. Leukocytes, plasma proteins
3. Antibodies, effector CD4+ cells
4. Dendritic cells, plasma proteins
18. The immune response is affected by:
1. Free radicals that strengthen the immune
response
2. Activation of the hypothalamic-pituitary-
adrenal (HPA) axis during periods of acute
stress
3. Increased levels of estrogen and lower
levels of progesterone and testosterone
4. Sleep that restores immune function
Clinical Trials
19. A major barrier for both patients and
institutions to participation in clinical
trials is which of the following?
1. Trials sponsored by drug companies pose a
financial burden for most oncology
programs.
2. The National Cancer Institute rarely is
committed to research to prevent cancer
because success is limited; thus, it only
consistently supports research to improve
the quality of life for those who develop
cancer.
3. Third-party payers often do not cover
experimental treatment, which includes all
research trials.
4. Standard-of-care treatments are covered by
the research sponsor.
20. The reliability of a measure can be said to

depend on:
1. The heterogeneity or consistency of the
items on the measurement scale
2. The extent to which the measure produces
the same score when applied at multiple
times in the same patient
3. Test–retest or alternative form and
interrater repeatability
4. Publication in a peer-reviewed journal
21. Content validity:

1. Need not depend on the degree to which
the scale superficially appears to measure
the construct
2. Includes the degree to which the items
represent the range of significant attributes
3. Includes statistical evidence to support
inferences
4. Must include the physical and
psychological domains but not the social
one (which is covered under construct
validity)
22. The Quality of Life Index (QLI):

1. Was originally a patient-rated scale of five
areas of functioning (activity, daily living,
health, support, and outlook)
2. Can distinguish cancer patients with
terminal illness from those with recent
disease or active treatment
3. Is probably the best example of a “cancer-
specific” scale that in reality measures
generic health concepts
4. Is used in clinical trials sponsored by the
National Cancer Institute
23. Evelyn uses the FACT G scale to assess a

group of patients to determine the
impact of cancer on daily issues. The
degree to which this scale superficially
appears to measure the construct in
question is referred to as:
1. Face validity
2. True content validity
3. Construct validity
4. Criterion validity
24. In a research study, four basic elements

are required to be included in the
informed consent document. Which of
the following are the four essential
elements?
1. Understanding, comprehension,
voluntariness, and competence
2. Understanding, comprehension,
compensation, and assent
3. Comprehension, competence,
voluntariness, and literacy
4. Competence, compensation,
reimbursement, and voluntariness
25. The primary ethical struggle in clinical

research is which of the following?
1. Accurate documentation
2. Patient participation
3. Construct and execution of the study
4. Institutional review boards
26. A phase IV clinical trial is designed:

1. To address the use of drugs, usually in
combination, with cure as the goal of
therapy
2. To determine maximum tolerated dose
3. To offer new information regarding risks
and toxicities
4. To compare to standard therapy
27. The main purpose of a phase I trial is to

determine:
1. The long-term safety of a new agent
2. The safe dose of the agent
3. The comparison of efficacy and toxicity
with standard of care drugs
4. Which cancers are affected by the agent
28. The usual number of participants in a

phase III clinical trial are:
1. 15–30
2. Fewer than 100 people
3. From 100 to 1,000 people
4. Several hundred to several thousand
29. Additional blood, tumor, or tissue are

analyzed to measure the biological
effects on target molecules in what type
of studies?
1. Clinical trials
2. Correlative studies
3. Phase I/II studies
4. Ancillary studies
B. SITE-SPECIFIC CANCER CONSIDERATIONS
lymphomas is correct?
1. Non-Hodgkin lymphoma (NHL) is
distinguished from Hodgkin disease (HD)
primarily based on its different clinical
manifestations.
2. Lymphomas are predominantly a
malignancy of the lymphocyte.
3. There seems to be a single malignancy for
all stages in the developmental sequence
from primitive to mature lymphocyte.
4. In general, B-lymphocyte malignancies are
more aggressive than T-lymphocyte
malignancies.
2. The most common form of skin cancer

is:
1. Basal cell carcinoma (BCC)
2. Squamous cell carcinoma (SCC)
3. Malignant melanoma
4. Superficial spreading melanoma
3. You are a new oncology nurse in a large

hospital. On your first day, you meet Mr.
Jackson. His physician neglects to tell
you what type of leukemia Mr. Jackson
has, but he says to you, “I still have the
Philadelphia chromosome, so I will need
more treatment.” From this you can
discern that Mr. Jackson has:
1. Acute lymphocytic leukemia
2. Acute myelogenous leukemia
3. Chronic lymphocytic leukemia
4. Chronic myelogenous leukemia
4. Glioblastoma multiforme (GM) is

separated into two subtypes: primary and
secondary. Primary GM:
1. Is more common in younger patients
2. Is characterized by platelet-derived growth
factor (PDGFR) over expression
3. Is characterized by estimated glomerular
filtration rate (EGFR) amplification
4. Is characterized by p53 mutations
5. Multiple myeloma is a cancer of which of

the following cell types?
1. T lymphocyte
2. Granulocytes
3. Monoclonal lymphocyte
4. Plasma cells
6. In determining the progression of
bladder cancer, the most important
feature is the:
1. Degree of hematuria present
2. Presence of bladder neck obstruction
3. Depth of penetration into the bladder wall
4. Presence of pain in the suprapubic region
7. Mrs. Carry asks you to explain the

relationship among tumor size, node
involvement, and prognosis. Which of
the following statements is most
accurate?
1. Smaller tumors with positive node
involvement have the best prognosis.
2. Larger tumors with negative node
involvement have the best prognosis.
3. Smaller tumors with negative node
involvement have the worst prognosis.
4. Larger tumors with positive node
involvement have the worst prognosis.
8. The prognosis for a patient with Hodgkin

disease is most closely related to:
1. Elevated lactic dehydrogenase level
2. Histologic type
3. Abdominal lymph node involvement
4. Stage at presentation
9. Of the following factors related to

cutaneous melanoma (CM) prognosis,
the one most closely correlated with
decreased survival rates in patients with
stage I CM is:
1. Anatomic level of tumor invasion
2. Tumor location
3. Clark level
4. Tumor thickness
10. Mr. James has been told by his physician

that he has a high-grade seminoma of the
testis. His doctor seemed encouraged by
this, but your patient is concerned that a
high-grade tumor might be associated
with a poor prognosis. Which of the
following statements might help to
clarify the issue for Mr. James?
1. High-grade seminomas respond poorly to
radiation and surgery but are curable with
chemotherapy.
2. High-grade tumors have a brief tumor cell
doubling time, which means they are more
susceptible to the cell kill effects of
chemotherapy.
3. High-grade seminomas tend to be more
like the cell of origin and therefore
metastasize infrequently.
4. A high-grade seminoma is curable by
surgery, whereas chemotherapy is used for
palliation only.
11. The most favorable prognostic factor for

a patient with small cell lung cancer
(SCLC) is:
1. Female gender
2. Normal serum lactic dehydrogenase
3. Limited-stage disease
4. Good performance status
12. Alicia is diagnosed with breast cancer

and is confused about prognostic
indicators and how tests on her tumor
will determine the type of treatment she
should receive. Which of the following
would be appropriate points to clarify for
this patient regarding what the test
results mean for her treatment and
prognosis?
1. The hormone receptor analysis is used to
determine the likelihood of metastases.
2. The hormone receptor analysis and
assessment for the presence or absence of
the human growth factor receptor (HER2)
gene are used to decide what type of
treatment is needed for metastatic disease.
3. The hormone receptor analysis and
assessment for the presence or absence of
the human growth factor receptor (HER2)
gene are used to determine treatment
strategies and prognosis for both local and
advanced disease.
4. Women who have tumors that are positive
for the hormone receptor do not require
further treatment beyond surgery.
13. The prognosis for a patient with

colorectal cancer is probably poorest if
which of the following exists?
1. Venous and lymph node invasion
2. High blood pressure
3. Location of the tumor above the peritoneal
reflection
4. Squamous cell involvement
14. Mr. Black presents to the physician’s

office with complaints of fatigue, loss of
appetite, and generalized itching. Which
of the following diagnoses is most likely
to be associated with these presenting
symptoms?
1. Lymphoma
2. Prostate cancer
3. Pancreatic cancer
4. Gallbladder cancer
15. The most common sites of occurrence

for chondrosarcoma are the:
1. Femur, tibia, patella, and metatarsal
2. Vertebrae and shoulder girdle
3. Shoulder girdle, hip girdle, and trunk
4. Mandible and maxilla
16. The anemia associated with multiple

myeloma is believed to be caused by:
1. The effects of radiation
2. A normochromic iron deficiency
3. The replacement of erythrocyte precursors
with plasma cells
4. Erythrocyte destruction by white blood
cells
17. Ms. Drake has myelodysplastic syndrome

(MDS). She reports being asymptomatic
for a prolonged time and asks you why
she still must endure ongoing
monitoring. The best explanation you
can offer is that:
1. T-cell abnormalities increase the risk of
opportunistic infections.
2. Compliance with the prescribed treatment
delays or prevents the onset of symptoms.
3. All patients with MDS eventually develop
anemia, thrombocytopenia, and/or
neutropenia.
4. All patients with MDS eventually develop
acute leukemia.
18. A 60-year-old woman reports a flesh-

colored, raised, firm papule on the top of
her nose. It is examined and found to be
a squamous cell carcinoma (SCC). How
do SCCs differ from most basal cell
carcinomas (BCCs)?
1. They tend to be less aggressive than BCCs,
even though they have faster growth rates.
2. Their margins are well demarcated, as
compared with those of the BCCs.
3. They tend to have greater metastatic
potential.
4. They tend to bleed easily.

dysplastic nevi (DN) is correct?
1. DNs are familial only.
2. Most persons affected by DN have about
25–75 abnormal nevi.
3. DNs develop from precursor lesions of
cutaneous melanoma.
4. DNs have a “scrambled egg” appearance
with a deeply pigmented papular area
surrounded by an area of lighter
pigmentation.
20. The phase of cutaneous melanoma

tumor growth that is characterized by
tumor growth parallel to the skin surface
is the:
1. Radial phase
2. Vertical growth phase
3. Nodular phase
4. Acral lentiginous phase
21. Which is the best description of Burkitt’s

lymphoma?
1. An aggressive lymphoma that accounts for
one-third of pediatric lymphomas
2. More common in women than men
3. Common sites of involvement are
abdomen, bowel, and stomach
4. Is associated with BCL-2 expression
22. A common manifestation of central
nervous system lymphoma is:
1. A change in personality
2. Syndrome of inappropriate antidiuretic
hormone (SIADH)
3. Frontal headache
4. Spinal cord compression
23. The occurrence of non-Hodgkin

lymphoma (NHL) in persons infected
with human immunodeficiency virus
(HIV) appears to be related to:
1. The destruction of helper T cells because of
infection by cytomegalovirus
2. Decreased levels of serum protein/albumin
because of internal coalesced lesions
3. Opportunistic infections of the central
nervous system related to toxoplasmosis
4. The proliferation of B lymphocytes because
of Epstein-Barr virus (EBV) and HIV
infection
24. Common symptoms of carcinoma of the

nasal cavity and paranasal sinuses
include:
1. Diplopia, headache, hyperesthesia of the
cheek
2. Hyperesthesia of the nasal cavity and
paranasal sinuses
3. Taste changes, diplopia, and headache
4. Diplopia, migraine headaches
25. The three classic signs of a pancreatic

tumor located in the head of the
pancreas are progressive jaundice, pain,
and:
1. Profound weight loss
2. Projectile vomiting
3. Confusion
4. Hyperkalemia
26. The cancer most often associated with

malignant ascites is:
1. Ovarian cancer
3. Breast cancer
27. A liver tumor may be suspected if

laboratory tests reveal elevated levels of:
1. Gastrin
2. Cholesterol
3. Alpha-fetoprotein
4. Amylase
28. Which of the following clinical
manifestations typically occur in patients
with a cancer of the sigmoid colon?
1. Anemia and a vague, dull, persistent pain in
the upper-right quadrant
2. Abdominal pain and melena
3. Sensations of incomplete evacuation and
tenesmus
4. Bright red bleeding through the rectum
29. Assessments completed on a patient with

cancer of the right colon usually find
1. A palpable mass
2. Polyps in the rectum
3. Anemia
4. High levels of carcinoembryonic antigen
30. The most common clinical symptom

associated with esophageal cancer is:
1. Other gastrointestinal cancers
2. Superior vena cava syndrome
3. Dysphagia and weight loss
4. Xerostomia
31. Stan has a well-differentiated tumor on

his true vocal folds that seems to be
growing slowly. Stan’s tumor is most
likely to be which kind of tumor?
1. Subglottic
2. Supraglottic
3. Glottic
4. Periglottic
32. Most small cell lung cancer (SCLC)

tumors:
1. Are not associated with necrosis
2. Are responsible for 55% of all lung cancers
3. Are centrally located, developing around a
main bronchus, and eventually
compressing the bronchi externally
4. Have a longer doubling time than that of
any other lung cancer type
33. The best method to establish a

histopathological diagnosis of
chemotherapy-induced pulmonary
toxicity is:
1. A sputum specimen
2. Fiber-optic bronchoscopy
3. Thoracotomy
4. Needle biopsy
34. Mrs. Mura has chronic myeloma and has
recently begun to complain of blurred
vision, headache, drowsiness, and
occasional confusion. These symptoms
may be caused by:
1. A low concentration of proteins that
decreases serum viscosity
2. Overmedication with opioids
3. Hyperviscosity syndrome
4. Chronic effects of steroid use
35. The prognosis for persons with renal cell

carcinoma is determined by:
1. Grade, histology, and staging
2. The four stratification groups in the UCLA
Integrated Staging System (UISS)
3. Nuclear grade and tumor necrosis score
4. Preoperative nomograms
36. The phase of cutaneous melanoma

tumor growth that is characterized by
focal deep penetration of atypical
melanocytes into the dermis and
subcutaneous tissue is the:
1. Radial phase
2. Vertical growth phase
3. Nodular phase
4. Acral lentiginous phase
37. What percentage of women with ovarian

carcinoma eventually develop ascites?
1. 90%
2. 80%
3. 60%
4. 30%
38. One important feature of the tumor

classification system is to:
1. Allow for tumors to be classified by their
metastatic behavior
2. Allow for tumors to be classified by their
biological behavior and tissue of origin
3. Provide clinical symptom information
4. Provides information about who will
benefit from chemotherapy
39. Cervical intraepithelial neoplasia (CIN)

stage III is characterized by neoplastic
changes involving up to full thickness of
the epithelium with no areas of stromal
invasion or metastases. CIN III is also
known as:
1. Preclinical invasive carcinoma
2. Carcinoma in situ
3. Adenocarcinoma
4. Verrucous carcinoma
40. Two patients have been diagnosed with

bronchogenic cancer. You know this
does not mean that both patients will
necessarily have a similar
symptomatology or course of treatment
because bronchogenic cancers are
grouped into what two broad categories?
1. Small cell lung cancer and non-small cell
lung cancers
2. Adenocarcinoma and large cell carcinoma
3. Heterogeneous and histologic
4. Hyperplasia and carcinoma in situ
41. The primary objective of classification

and staging of malignant tumors is to do
1. To provide the information necessary for
treatment planning
2. To identify individuals who might be
candidates for research studies
3. To recommend the best cancer center for
treatment
4. To determine what insurance will cover
42. In the TNM staging system:

1. cTNM indicates that assessment has been
obtained clinically.
2. cTNM indicates whether carcinogenesis
has occurred.
3. rTNM indicates that remission of the
cancer is occurring.
4. aTNM indicates that the cancer has been
detected on first assessment.
43. Stage groupings involve:

1. Combining the various classification
elements of tumor site, regional lymph
node involvement, and the presence or
absence of metastasis
2. Two main staging periods: pretreatment
and posttreatment
3. Two main staging periods: clinical
diagnostic staging and pretreatment staging
4. Combining the various classification
elements of tumor site, regional lymph
node involvement, and the presence or
absence of metastasis posttreatment
44. After a course of treatment, Ms. Trent’s

treatment response is evaluated. This
reevaluation or restaging:
1. Makes possible the redesignation of a more
appropriate stage to be referenced
throughout the remaining course of the
illness, replacing the stage ascribed at the
time of diagnosis
2. Focuses attention on the disease
parameters that were positive at diagnosis
3. Determines whether the patient is eligible
to participate in a clinical trial
4. Helps the physician plan for maintenance
therapy
45. Tumors of unknown origin occur in 2%–

3% of patients diagnosed with cancer
each year. Which of the following
statements about tumors of unknown
origin is true?
1. Most tumors of unknown origin are
neuroendocrine tumors.
2. The prognosis is generally poor, from 9–12
months.
3. Prognosis is predicted by serum albumin
levels and performance status.
4. Most tumors of unknown origin are
adenocarcinomas, followed by
neuroendocrine tumors.
46. The American Joint Committee on

Cancer (AJCC) staging system for lung
cancer uses:
1. Eight stages, each of which is distinct
relative to treatment and 5-year survival
statistics
2. The Tumor, Nodes, Metastases (TNM)
letters
3. The simple two-stage system
4. Two defining terms—limited-stage disease
and extensive-stage disease—to stage lung
cancers

the staging of Hodgkin disease (HD) is
correct?
1. Stage II malignancy is determined by a
positive bone marrow biopsy.
2. Stage determination is important because it
influences what treatment option will be
used.
3. Stage II presentation is usually indicative
of a more aggressive HD type.
4. HD rarely presents as stage II.
48. Standard tests for the staging of a patient

with Hodgkin disease include?
1. A chest radiograph, blood chemistries, and
a complete blood count
2. A chest radiograph and computerized
tomography of the chest and abdomen
3. Exploratory laparotomy
4. Liver biopsy
49. The most important objective of solid

tumor staging is which of the following?
1. Provide information regarding risk factors.
2. Determine performance status and
eligibility for research protocols.
3. Identify individuals at high risk for disease
recurrence.
4. Provide the necessary information for
individual treatment planning.
50. A primary tumor is one that is

histologically confirmed to arise from a
specific site of tumorigenesis, whereas a
secondary tumor refers to:
1. A tumor that arises in another site after the
primary tumor has been discovered
2. A tumor of unknown origin
3. A metastatic tumor resembling the primary
tumor histologically
4. A second primary cancer that is
histologically different from the primary
tumor
80. Grading a malignant neoplasm is a
method of classification based on
histopathologic characteristics of the
tissue. Grading is the primary
determinant of stage of disease and
prognosis for which cancer type?
1. Melanoma
2. Sarcoma
3. Testicular cancer
4. Thyroid cancer
81. Mr. Fleischman’s cancer is given an

American Joint Committee on Cancer
(AJCC) classification of G2. This means
his cancer is:
1. Undifferentiated
2. Well differentiated
3. Poorly differentiated
4. Moderately well differentiated
82. Histopathologic type refers to:

1. A qualitative assignment given to a lesion
at a site other than the original site that is
of the same cell type as the original; this is
used to determine metastatic tumors
2. A quantitative assessment of the extent to
which the tumor resembles the tissue of
origin
3. A qualitative assessment whereby a
neoplasm is categorized in terms of the
tissue or cell type from which it has
originated
4. A qualitative assignment that indicates that
a lesion at a site other than the original site
is of a different cell type than the original
tumor; this is used to indicate a second
primary cancer
83. The least life-threatening prostate

cancers are those that:
1. Feature large tumor volume
2. Have a Gleason grade of 3–5
3. Originate in the peripheral zone
4. Are indolent
84. The primary application of flow

cytometry analysis in solid tumors is
1. Determine deoxyribonucleic acid (DNA)
content (ploidy) and the percentage of cells
synthesizing DNA (the S-phase fraction)
2. Determine the presence of metastases
3. Is more useful in blood tumors than solid
tumors
4. Determine which chemotherapy agent will
be the most effective
85. The most common site of metastasis for

tumors of the bone is the:
1. Gastrointestinal tract
2. Central nervous system
3. Liver
4. Lungs
86. The most common metastatic site for

breast cancer at initial presentation is
the:
1. Brain
2. Liver
3. Bone
4. Gastrointestinal tract
87. During the initial workup, Mr. Smith,

who has testicular cancer, complains of
low back pain that has been present for
about 1 month. This may indicate:
1. Metastatic disease to the lumbar spine
2. That the cancer has spread to the prostate
3. That the cancer has spread into the
retroperitoneal lymph nodes
4. That the pain is unrelated to testicular
cancer and other causes should be explored
88. One of the mechanisms that tumors

spread from the primary site to bone is:
1. Direct extension to adjacent bone
2. Venous embolization
3. Direct arterial spread
4. Surgical seeding
89. Andrea has ovarian cancer and

complains of abdominal fullness. In this
patient, the presence of shifting dullness
during percussion would be indicative of
1. Abdominal carcinomatosis
2. Liver enlargement
3. Ascites
4. Recurrent cancer
90. The most common cause of ascites fluid

buildup is:
1. Obstruction of abdominal lymphatics
2. Tumor seeding of the peritoneum
3. Humoral factors that cause decreased
capillary leakage of proteins
4. Perforation of the bowel
91. Your patient with ascites had a
paracentesis and removal of 1–2 liters
repeatedly in the past and is calling now
with a request for another tap because
the fluid has come back, and she is
uncomfortable. Your response to the
patient is based on knowledge of which
of the following?
1. Sclerosis with instillation of chemotherapy
is the most effective treatment.
2. Repeated paracentesis often makes fluid
reaccumulate faster and can lead to severe
protein depletion.
3. Repeated paracentesis can lead infection.
4. Paracentesis can lead to tumor seeding.
92. In the presence of a known bone tumor,

symptoms such as hemoptysis, cough,
fever, weight loss, and malaise may
indicate:
1. Pulmonary metastases
2. Pernicious anemia
3. Radiotherapy toxicity
4. Infection
93. Mr. Svensen has had treatment for a

primary kidney tumor, which was
completely eradicated. Now, however,
the surgeon discovers a biopsy-proven
metastatic lesion in the lung. The
metastatic site seems to be solitary, and
Mr. Svensen is very healthy otherwise.
Given these limited clues, what method
of treatment will be used for his
metastatic lesion?
1. Chemotherapy to provide systemic control
of metastasis
2. Cytoreductive surgery to reduce the mass
so combination therapy will be effective
3. Combination radiation and chemotherapy
94. Ms. Edwards, a patient with cancer, is

being assessed for abnormal bleeding.
She is to receive a prothrombin time test.
This test is a measure of:
1. Coagulation deficiencies in the intrinsic
pathways
2. The concentration of functional factors in
plasma
3. Platelet plug formation
4. Diminished or absent coagulation factors
95. The individual who has recently had an

ultrasound-guided percutaneous needle
biopsy of the liver must be monitored
closely for symptoms of:
2. Hematemesis
3. Hemorrhage
4. Headache
96. A patient with a brain tumor is suspected

of having possible hemorrhage. The test
most likely needed to determine this is:
1. Computed tomography (CT)
2. Positron emission tomography (PET)
3. Magnetic resonance imaging (MRI)
4. Cerebral angiography
97. During the physical exam of a new

patient, you notice that he has small red
eruptions on his upper and lower
extremities. He appears pale and states
that his gums bleed when he brushes his
teeth. A diagnostic test will be suspicious
1. Severe anemia and bleeding
2. Disseminated intravascular coagulopathy
3. Thrombocytopenia
4. Leukemia
Tumor markers are most often used as
98. adjuncts to a diagnosis for several
cancers or used to monitor disease
progression and response to treatment.
Of the following markers and associated
malignancy, which is true?
1. Elevated CA-125 may increase the level of
suspicion of liver cancer.
2. Elevated CA 27-29 may indicate recurrent
disease.
3. Elevated carcinoembryonic antigen (CEA)
may indicate recurrent colon cancer.
4. Elevated alpha-fetoprotein (AFP) may
indicate prostate cancer.
99. Mr. Jones reports frequent episodes of

hematuria. His doctor assesses him for
possible bladder cancer. Of the following
tests, which is the most definitive to
diagnose bladder cancer?
1. Urine cytology
2. Cystoscopy with biopsy
3. Intravenous pyelogram
4. Computed tomography (CT) scan
100. Magnetic resonance imaging (MRI) is the

preferred imaging study when
diagnosing:
1. Brain tumors
2. Non-hodgkin lymphoma
4. Breast cancer
101. When providing instructions for patients

undergoing positron emission
tomography, what will you emphasize?
1. Patients must fast for at least 8 hours prior
to the procedure.
2. Fasting glucose is tested before the exam.
3. Patients are to fast, but they can chew gum.
4. The radiotracer is given to the patient the
night before the exam.
102. Ms. Anderson presents to her physician

with the complaints of recurrent
infections and chest pain. Her physician
orders numerous laboratory tests and
does a bone marrow biopsy aspirate that
shows more than 30% plasma cells. This
is indicative of what disease?
2. Acute myelogenous leukemia
3. Multiple myeloma
4. Metastatic lung cancer
103. What is the most important evaluation
for the diagnosis of gallbladder cancer?
2. CA 19-9
3. Carcinoembryonic antigen (CEA)
4. Liver function test and MRI
104. What laboratory test(s) is helpful in the

diagnosis of hepatocellular carcinoma
(HCC)?
1. Liver function tests
2. Elevated bilirubin
3. Alpha-fetoprotein (AFP)
4. Carcinoembryonic antigen (CEA)
C. SCOPE, STANDARDS, AND RELATED
ISSUES
105. The recognized professional authority

for oncology nursing practice is:
1. American Nursing Association
2. American Academy of Nursing
3. Oncology Nursing Society
4. National Institute of Oncology Nursing
106. What defines the functions of specific

nursing roles?
1. Role education
2. Role competencies
3. Role experience
4. Role name
107. The Clinical Nurse Specialist (CNS) role

is based on which model of practice?
1. Medical/nursing model
2. Nursing model
3. Medical model
4. Advanced nursing model
108. Recognized professional nurse roles are:

1. Nurse administrator, nurse educator,
certified nurse practitioner
2. Nurse educator, clinical research nurse,
nurse navigator
3. Informatics nurse, nurse navigator, nurse
administrator
4. Chief nursing officer, clinical nurse
specialist, certified nurse midwife
109. The proportion of states that recognize

the Oncology Nursing Certification
Corporation’s three advanced oncology
certified nursing roles is:
1. All states
2. Some states
3. Many states
4. None
110. What was created to address the

licensure inconsistencies among the
states?
1. State nursing boards
2. Nurse Licensure Compact
3. Professional Nurse License Board
4. National Registered Nurse Registry
111. Characteristics of certification are:

1. Voluntary and awarded by a
nongovernmental agency
2. Awarded by both governmental and
nongovernmental agencies
3. Required to work in specialty areas
4. Endorsed by the state nursing license board
112. Professional nursing certification

assures , that a nurse has met
eligibility criteria for a specific credential
and has earned recognition by
demonstrating minimum competency in
the specialty.
1. Other nurses
2. Hospital administration
3. The public
4. Physicians
113. Professional nurses occasionally

question why it is important to be
recertified on a regular basis by the
Oncology Nursing Certification
Corporation. Which of the following
would be the best response to this issue?
1. Certification guarantees that the nurse is
qualified to provide competent care.
2. Certification is a requirement for receiving
Magnet Hospital status through the
American Nurses Credentialing Center.
3. All employers recognize certification
through pay differentials.
4. Certification validates that you know the
most current oncology nursing practices.
114. Which of the following best describes the

difference between the nurse generalist
and the nurse specialist?
1. A baccalaureate degree
2. A broader scope of practice
3. Clinical experience
4. Conceptual knowledge and skills
115. The mission of the Oncology Nursing

Certification Corporation is to advance
oncology nursing through the
certification process. To be eligible for
the certification examination, a nurse
must have accomplished which of the
following?
1. Have a current registered nurse license, 1
year of experience as a registered nurse
over the 3-year period before application,
and at least 1,000 hours of oncology
nursing practice within 2.5 years of
application
2. Have a minimum of 50 continuing
education units in oncology nursing
practice
3. Have 1 year of experience as a registered
nurse over the 3-year period before
application, a current license, and sufficient
experience in oncology nursing
4. Have at least 1,000 hours of oncology
nursing practice within 2.5 years of
application and have a minimum of 50
continuing education units in oncology
nursing practice
116. The following organizations have

developed safety standards for the
prescription, preparation, and
administration of antineoplastic agents:
1. American Society of Clinical Oncology,
Oncology Nursing Society
2. Oncology Nursing Society, Joint
Commission for Accreditation of Hospitals
3. Oncology Nursing Society, American
Commission for Nursing Safety
4. American Pharmacy Association, Oncology
Nursing Society
117. Recent literature reviews note
chemotherapy errors range from 4% to
19%. One risk factor for chemotherapy
errors is:
1. Complex regimens
2. Multimodality treatment
3. Wide dosing ranges
4. Multiple drug indications
118. Oncology nurses are at risk for litigation

if:
1. Their patient has a hypersensitivity
reaction.
2. The nurse fails to administer
premedication before administering an
agent with known hypersensitivity
potential.
3. The nurse administers an agent with
known hypersensitivity potential after
giving the test dose.
4. The patient has a hypersensitivity reaction
after receiving both a test dose and
premedication.
119. Best practice for risk reduction when

administering agents with
hypersensitivity potential includes:
1. Administration of the right drug to the
right patient at the right time
2. Two nurses monitor the patient
3. Preparation for emergencies
4. Instruct the patient to call if they begin to
feel itchy.
120. The best reason patients should receive

vesicants through a central venous
access device is to:
1. Reduce the risk of extravasation.
2. Avoid discomfort for the patient.
3. Allow fluids or other medications to be
given through a peripheral intravenous
line.
4. Follow institutional policy.
121. To avoid litigation due to negligence

during vesicant administration, the
oncology nurse should:
1. Always have a second nurse witness venous
patency.
2. Instruct the patient to report any redness
or swelling.
3. Only use an implanted port for vesicant
administration.
4. Know and follow all institutional policies
regarding safe administration of vesicants.
122. In instances where the advanced practice

nurse (APN) is employed by a physician,
the physician can bill 100% of the
Medicare fee schedule for the services
provided by the APN if which
requirement is met:
1. The physician must be available by phone
at the time of the patient’s visit.
2. The patient is being seen for a preexisting
problem.
3. The physician must countersign the
patient’s chart.
4. There is a nursing plan of care.
123. The authority for the advanced practice

nurse (APN) to prescribe drugs is
regulated at the state level but also
involves the Drug Enforcement
Administration. Whether the nurse has
dependent prescriptive authority or
independent prescriptive authority is
based primarily on which of the
following?
1. Dependent prescriptive authority requires
the APN be under the supervision of a
physician when performing this task.
2. Dependent prescriptive authority permits
the APN to prescribe only non-narcotic
medications independent of the physician.
3. Independent prescriptive authority is given
only when the APN is certified at the
doctoral level.
4. Independent prescriptive authority
requires the APN to be prepared at the
doctoral level, attend pharmacology
courses, and to be under the direct
supervision of the responsible physician.
124. If Ann is guilty of misappropriation

during conducting her research, she has
most likely:
1. Misused the research funds entrusted to
her through a grant
2. Committed plagiarism
3. Tagged her study onto an existing protocol
rather than initiating a new project
4. Deliberately omitted facts or fabricated
data and findings
125. A patient with metastatic cancer is

admitted to a unit with uncontrolled
pain. The physician has ordered
morphine as the primary pain
medication. The patient frequently
requests more pain medication. You
suspect he is a drug abuser and has an
addiction problem. The most
appropriate nursing action would be to
do which of the following?
1. Substitute other medications in the place of
narcotics.
2. Refer him to a drug addiction program.
3. Call the physician to increase his pain
medication.
4. Administer less potent analgesics along
with the morphine to stretch the effect of
the narcotic.
126. As safety and efficacy of gene therapy is

established, legal issues arise such as:
1. Treatment costs that make therapy
available only in clinical trials where the
therapy is provided
2. Treatments available only in large medical
centers for those with insurance
3. Gene therapy on those with terminal
illnesses
4. Discrimination by health insurers to
require higher premiums for those with
known genetic mutations
127. One of the four ethical principles guiding
clinical practice is nonmaleficence. To
what does this term refer?
1. Helping the patient to balance the benefits
against the risks
2. Distributing the resources in a fair and
reasonable way
3. Helping the patient make decisions that are
right for themselves
4. Avoiding practices that will do harm to the
individual
128. The two most important ethical

considerations within the realm of
genetic testing and genetic information
are:
1. Nonmaleficence and beneficence
2. Informed consent and confidentiality
3. Informed consent and full disclosure
4. Nonmaleficence and confidentiality
129. The Joint Commission’s National Patient

Safety Goals and Recommendations
1. Improve safety when using oxygen.
2. Provide alarm systems for all patients 70
years or older.
3. Limit the number and type of infusion
pumps available.
4. Improve safety when stocking, ordering,
and dispensing medications.
130. Which national organization issues

national patient safety goals and
recommendations that are updated
annually and are delineated by practice
setting?
1. Institute of Medicine
2. The Joint Commission
3. Occupational and Safety Health
Administration
4. National Institutes of Health
131. Which event is categorized by the Joint

Commission as a sentinel event?
1. Assisted suicide
2. Transfusion reaction
3. Radiation dosing error
4. Death while hospitalized
132. The Joint Commission’s National Safety

Goals and Recommendations published
in 2016 include:
1. Reducing transmittable infections,
medication reconciliation, and holding
patients more accountable
2. Use of evidence-based practices to prevent
blood-borne infection
3. Setting procedures to prevent disabling
clinical safety alarms
4. Improving patient identification, staff
communication, and medication safety
processes
133. The Joint Commission recommendation

to meet the goal of improved medication
safety processes is to:
1. Compare current and newly ordered
medications to provide reconciled lists to
the next provider.
2. Manage look-alike and sound-alike
medications.
3. Relabel medications so labeling is
consistent.
4. Develop a system for patient reporting of
all medications.
134. The mandate to assess for spiritual

beliefs and practices is from:
1. The National Society for Pastoral Care
2. The Oncology Nursing Society
3. The American Nurses Association
4. The Joint Commission
135. You are concerned that your colleague

may be experiencing compassion fatigue.
You have noticed:
1. Increased irritability and a lack of flexibility
2. Decreased sense of self-competence
3. Feeling of helplessness
4. Difficulty sleeping
136. As the nurse manager on an inpatient

oncology unit, you want to avoid staff
turnover due to compassion fatigue. You
have learned that which of the following
is a risk factor for compassion fatigue?
1. Older nurses without degrees
2. Nurses with family or friends that have
experienced cancer
3. Nurses with a high level of empathy
4. Nurses who prefer to work alone rather
than in teams
137. To avoid compassion fatigue, nurses

should practice strategies to develop:
1. Resilience
2. Meditation practices
3. A sense of humor
4. A personal philosophy of nursing care
D. STANDARDS OF PROFESSIONAL
PERFORMANCE
138. The four-accepted fundamental ethical

principles that guide medical decision-
making are:
1. Autonomy, maleficence, beneficence, and
justice
2. Autonomy, maleficence, beneficence, and
judgment
3. Autonomy, nonmaleficence, beneficence,
and judgment
4. Autonomy, nonmaleficence, beneficence,
and justice
139. The patient has the right to make

medical decisions regarding their care
even when medical professionals
disagree with that decision. In the field
of genetics, it is especially important to
ensure informed consent. Informed
consent is a central focus of which
fundamental ethical principle that
guides medical decision-making?
1. Autonomy
2. Nonmaleficence
3. Beneficence
4. Justice
140. The patient had a biopsy with negative

results. However, the team knows that
the biopsy material can be negative while
another part of the tumor mass may be
positive for cancer. Which fundamental
ethical principle that guides medical
decision-making serves as an ethical
principle in determining what to tell the
patient?
1. Autonomy
2. Nonmaleficence
3. Beneficence
4. Justice
141. The ethical principle of justice is applied

in which section of the informed consent
document?
1. Eligibility
2. Risks/benefits
3. Cost to the patient
4. Procedures
142. Following World War II, the Nuremberg

Code was established to delineate legal
responsibility for patient education in
informed consent. Content central to this
code includes which of the following?
1. The use of voluntary consent to protect
human subjects in experimentation
2. The use of coercion as deemed necessary to
provide quality care
3. The individual or their spouse can provide
consent.
4. An understanding of what costs are covered
by the study
143. The first step a nurse should take when

addressing someone from another
culture is:
1. Addressing the person formally, such as
using “Mr.” or “Mrs.”
2. Direct them to the educational kiosk in
your center.
3. Determine the preferred language and
learning process.
4. Determine the decision-making patterns.
144. When providing education for patients

who do not speak English, you should
use which of the following?
1. Over-the-telephone interpretation service
or professional interpreters of the same
tribe, state, region, or nation
2. Nonfamily members of the same age and
gender
3. Family members
4. Only staff members who are bilingual
145. The most important information to

include when providing education for
patients receiving radiation is:
1. Treatment plan and expected outcomes
2. Sensory and procedural information
3. Myths and misinformation that family
members may provide
4. Side effect management
146. In planning a smoking cessation

program, the nurse knows that the most
successful strategy for tobacco cessation
is:
1. Increased taxes on tobacco products
2. The smoker’s desire and readiness to quit
3. Pharmaceutical interventions
4. Nonpharmaceutical interventions
147. The nurse practitioner (NP) is a

registered nurse who has advanced
education and clinical training in a
specialty area. The primary difference
between an adult, family, pediatric, or
acute care NP is which of the following?
1. Educational requirements are essentially
the same.
2. A family NP is more general and not
considered “advanced” compared to the
other practitioner roles.
3. A family NP requires a clinical doctorate in
nursing.
4. A master’s degree is common but not a
baseline requirement for an adult NP.
148. The three interacting domains of

competencies of the Oncology Clinical
Nurse Specialist (OCNS) practice are
1. Patient/client, nurses and nursing practice,
and organizations/systems
2. Patient/family, professional nursing
practice, and institutional practice
3. Patient/client, evidence-based practice, and
organizational quality initiatives
4. Patient/family, nurses and nursing
practice, and institutional practice
149. According to the Oncology Nursing

Society (ONS) the primary difference
between an Oncology Clinical Nurse
Specialist (OCNS) and a nurse
practitioner (NP) is which of the
following?
1. There is no significant difference between
these terms.
2. An NP is a nurse who has completed an NP
program at the master’s or doctorate level.
3. OCNSs deliver direct care to patients,
whereas NPs are more like doctor’s
assistants.
4. All OCNSs are NPs, whereas not all NPs are
considered OCNSs.
150. Specialty certification among healthcare

providers has concentrated on which of
the following avenues of inquiry?
1. Education characteristics that differentiate
certified and noncertified providers
2. Describing similarities in practice between
certified and noncertified providers
3. Describing the role of labor unions and
demands for certification among healthcare
providers
4. Linking provider certification to patient
outcomes
151. Terrence is an oncology advanced

practice nurse (OAPN) who chooses to
work as a consultant rather than as a
direct care provider. The OAPN in
secondary care may be most helpful in:
1. Discussing the treatment plan and expected
outcomes with the patients and family
2. Planning and implementing initiatives
aimed at preventing provider compassion
fatigue
3. Triaging patient calls for symptom support
4. Establishing standards for oncology
practice and developing critical pathways
152. Which of the following is required for

use of the designation “oncology
certified nurse”?
1. A minimum of 1-year experience as a
registered nurse within the last 3 years
2. A baccalaureate degree with credits toward
a master’s degree
3. A minimum of 2,000 hours of cancer
nursing practice within the last 2.5 years
4. A score of 90% or higher on the Oncology
Nursing Certification Corporation
certification examination
153. Karen is a nurse practitioner (NP)

working in a collaborative practice. In
general, in a collaborative practice:
1. NPs function independently in caring for a
caseload of patients in the ambulatory
setting only.
2. NPs function independently in caring for a
caseload of patients in the ambulatory or
acute care setting.
3. The skills of the NP are matched with those
of the MD partner patient.
4. The physician ultimately makes the final
decision regarding patient management.
154. The Oncology Nursing Society (ONS)

Putting Evidence into Practice Weight of
Evidence Rules use:
1. 6 levels of effectiveness for grading nursing
and medical interventions
2. 4 categories from low- to high-level
evidence
3. 6 levels of higher or lower strength
4. 4 grades of recommendations from very
low to high
155. When reviewing a research survey, it is

important to ensure whether the survey
has been validated for reliability. Which
of the following is a type of research
reliability measure?
1. Question and answer format
2. Test and control reliability
3. Internal consistency testing
4. Connect–disconnect analysis
156. One of the statistical methods used to

determine reliability is Cronbach’s
coefficient alpha. Which of the following
best describes what this statistical
measure refers to?
1. It is a measure of the strength of the
internal consistency of a set of survey
questions.
2. It is a measure of the likeness of
individuals being surveyed.
3. It is a predictive measure of the sameness
of the findings as they relate to similar
research findings.
4. It is a measure of whether two observers
agree.
157. Pilot studies are best used to:

1. Compare a new intervention with an
existing intervention
2. Assess the feasibility of a research design
and pretest an instrument
3. Evaluate the side effects and management
of a new treatment toxicity
4. Determining effectiveness of an
intervention
158. In the process of evidence-based

practice, the PICOT acronym is useful to
clarify the specific question/problem. In
the acronym, P stands for:
1. Practice
2. Population
3. Patient
4. Patient or population
159. In the process of evidence-based

practice, the PICOT acronym is useful to
clarify the specific question/problem. In
the acronym, C stands for:
1. Comparison intervention or group
2. Context
3. Cancer
4. Complex
160. When assessing evidence for practice,

the strongest evidence useful for practice
is:
1. Level IV
2. Level II
3. Level III
4. Level I
161. The Oncology Nursing Society Putting

Evidence into Practice (PEP) rating
system has six levels that are color coded
for easy interpretation. Interventions for
which effectiveness has been
demonstrated from a single rigorously
conducted controlled trial, consistent
supportive evidence from well-designed
controlled trials using small samples, or
guidelines developed from evidence and
support by expert opinion would be
considered:
1. Green, likely to be effective
2. Yellow, effectiveness not established
3. Green, recommended for practice
4. Yellow, benefits balanced with harm
162. You recently attended a program on

nutritional supplements presented by
nationally known oncology specialists
and heard about a recommendation that
you wanted to share with your patient.
You discussed it with the advanced
practice nurse on your unit who asked
you to provide some evidence to support
the option. Even though you could not
find a randomized controlled study that
supported the use of the recommended
nutrient, you did find this practice
supported by an expert in a peer reviewed
publication. You agreed that this was a
low-risk intervention with which level of
recommendation?
1. Effectiveness unlikely
2. Not recommended for practice
3. Effectiveness not established
4. Expert opinion
163. The Oncology Nursing Society (ONS)

Putting Evidence into Practice (PEP) is
used for evaluating evidence-based
research. Which of the following is the
best description of the process for
evaluating the evidence?
1. Teams review all literature on 20
symptoms annually to ensure the
recommendations are current and accurate.
2. Teams search for relevant literature, create
summaries of the intervention research,
and rank each intervention.
3. Teams of nurses, physicians, and
pharmacists review the literature on 20
symptoms to ensure a comprehensive
approach.
4. ONS staff select nurse experts to develop
the PEP summaries then turn them into
practical PEP cards.
164. Failure mode and effect analysis (FMEA)

is a risk analysis technique that is used to
examine which of the following?
1. Root-cause analysis
2. Pharmacy errors in drug dispensing
3. Risk analysis technique to examine the
chemotherapy administration process
4. Errors in drug administration as it relates
to method of administration
165. The major difference between root-cause

analysis and failure mode and effect
analysis (FMEA) as it relates to
chemotherapy administration is which of
the following?
1. They are the same process where root-
cause analysis follows FMEA.
2. FMEA is designed to prevent chemotherapy
errors.
3. Root-cause analysis is a prospective risk
analysis.
4. Both FMEA and root-cause analysis
provide a “fail-safe” process in drug
administration.
166. Which of the following

chemotherapeutic agents is lethal if
injected intrathecally, and to assure
patient safety it has special United States
Pharmacopeia (USP) labeling and
packaging that must be removed before
administration?
1. Cytarabine
2. Methotrexate
3. Vincristine
4. Interferon
167. You are caring for a patient who was

recently diagnosed with acute leukemia.
The patient begins asking you questions
regarding his prognosis and is
expressing difficulty in deciding about
being evaluated for transplantation.
Which of the following statements is the
best example of effective
communication?
1. I know you are feeling afraid to make a
decision regarding transplantation? Did
your doctor tell you that you will likely be
cured with transplantation?
2. Your disease is progressing rapidly, so you
should make a decision soon.
3. It sounds like you are concerned about how
to make this decision. Would it be ok if we
discussed some of the goals you have for
care?
4. I will refer you to the social worker to
discuss your concerns.
168. When the nurse is assessing the spouse’s

response to the death of his wife, which
of the following factors can influence the
grieving process?
1. History of previous loss
2. Number of children
3. Length of the illness of the spouse
4. Health of the surviving spouse
169. To demonstrate therapeutic

understanding at the time of diagnosis,
the nurse may ask the patient “how are
you feeling.” If the patient states that he
is not sleeping well, the best response
would be:
1. Asking the patient what measures they
have tried followed by attentive listening
2. Telling the patient you will request a
sleeping medication be ordered
3. Asking the patient if he is anxious about
his diagnosis
4. Asking the patient if he has ever been
treated for anxiety
170. Cognitive techniques may help patients

reduce anxiety, manage symptoms, and
increase feelings of self-control. Which
are cognitive techniques?
1. Hypnosis, cognitive distraction, passive
relaxation
2. Biofeedback, music therapy, cognitive
focusing
3. Progressive muscle relaxation, systematic
desensitization
4. Mindfulness-based stress reduction,
hypnosis, therapeutic touch
171. Behavioral techniques may help patients

reduce anxiety, manage symptoms, and
increase feelings of self-control. Which
are behavioral techniques?
1. Passive relaxation, progressive muscle
relaxation, and systematic desensitization
2. Biofeedback, music therapy, cognitive
focusing
3. Mindfulness-based stress reduction,
hypnosis
4. Self-monitoring and biofeedback
172. What nursing interventions are useful

when patients use information seeking to
cope with their cancer:
1. Shared decision-making interventions
2. Psychoeducational interventions
3. Adult learning interventions
4. Multimedia interventions including web
resources, videos, and print materials
173. Cognitive rehabilitation is used for

patients with mild cognitive
impairments. Which of the following
best describes a cognitive rehabilitation
technique?
1. Teaching compensatory mechanisms to
develop alternative ways to achieve
behavioral tasks
2. Retraining to create new cognitive abilities
that may have been lost
3. Holistic methods to address social,
emotional, and functional issues related to
cognitive impairment
4. A combination of medications, physical
therapy, and cognitive challenges
174. The most important reason for

multidisciplinary collaboration in
determining cancer risk is:
1. Individual healthcare providers always
include family history in the patient
assessment.
2. Individual and family risk are the same and
should be shared among the care providers.
3. Although preliminary risk assessment can
be done by all healthcare providers, full
assessment and testing should be provided
by trained genetic counselors.
4. Only physicians can refer patients and
families for genetic risk assessment.
175. Professional barriers to successful

palliative care have been identified as
inadequate knowledge, lack of cultural
awareness and sensitivity, difficulty with
issues related to death and dying, and
delays in referral for hospice services. To
best overcome these barriers, palliative
care should be:
1. Provided only in dedicated inpatient
palliative care units
2. Provided only in combined
hospital/palliative care units with or
without a community-based hospice
program
3. Provided by trained providers both in
inpatient and outpatient settings
4. Provided by trained providers in the setting
that is most appropriate for the patient and
family
176. Patients with head and neck cancer

receive multimodality therapy.
Coordination of therapy may be
complicated by which of the following?
1. Timing of consultations with radiation,
surgery, and medical oncologists; dentists;
and nutritionists
2. Timing of consultations with radiation,
surgery, and medical oncologists;
nutritionists; and financial counselors
3. Presence of side effects from various
therapies
4. Inability to swallow oral targeted therapies
and/or liquids and solids
177. Guidelines for handling antineoplastic

agents have been established by:
1. The U.S. Food and Drug Administration,
the Occupational Safety and Health
Administration, and the Oncology Nursing
Society
2. The Occupational Safety and Health
Administration, the Oncology Nursing
Society, American Society of Clinical
Oncology, and the American Society of
Hospital Pharmacists
3. The National Cancer Institute, the
Oncology Nursing Society, and the
American Society of Clinical Oncology
4. The Oncology Nursing Society, the U.S.
Food and Drug Administration, and the
Occupational Safety and Health
Administration
178. Examples of useful cancer-related

websites recommended for patients and
families include:
1. http://www.cancer.org;
http://www.ons.org
2. http://www.livestrong.org;
http://www.cancercare.org
3. http://www.canceranswers.org;
http://www.cancercaregivers.org
4. http://www.cancercare.org;
http://www.nccn.org
179. Which of the following does the federal

government insist on before a drug can
be marketed?
1. The safety of the drug only
2. The efficacy of the drug only
3. The safety and the efficacy of the drug only
4. The safety, efficacy, and long-term value of
the drug
180. Safe delivery of patient care is supported

by oncology nurses who are aware of
1. Professional licensing requirements, use of
medical equipment, institutional
procedures, personal practices, use of
personal protective equipment
2. Accreditation requirements, use of medical
equipment, institutional safety committees
3. Staffing ratios, professional licensing
requirements, market value of nurses
4. Use of medical equipment, institutional
procedures, amount of liability insurance
carried by the institution
181. Oncology nurses work in high-risk
environments. Which response best
describes the challenges oncology nurses
face:
1. Inadequate staffing to care for increasing
numbers of patients at risk for falls
2. Increased documentation requirements,
individualized treatment dosing
3. Inadequate staffing to support safe
administration of vesicants
4. Medication errors, patients at risk for falls,
infusion reactions, or extravasation
182. The best strategy to decrease risk of

exposure to hazardous drugs is:
1. Limit the nurse’s daily assignment to two
patients receiving treatment.
2. Provide personal protective equipment
3. Education and use of personal protective
equipment
4. Mandatory education on safe
administration on an annual basis
183. Medical surveillance of workers who

handle hazardous drugs recommended
by the National Institute for Safety and
Health includes which of the following?
1. Observation of the nurse administering
chemotherapy
2. Hazard identification program with
baseline assessment and annual
monitoring
3. Semi-annual monitoring of health status
including laboratory studies
4. Regular review of medical history and
biological monitoring
184. In addition to occupational exposure to

hazardous drugs, oncology nurses are at
risk for which of the following safety
hazards?
1. Back injury and respiratory infection
2. Back and neck injury when lifting patients
3. Influenza and other infections
4. Violent patients
185. According to the groundbreaking 2000

Institute of Medicine report, To Err is
Human: Building a Safer Health System,
medical errors caused 44,000 to 98,000
deaths per year. An updated estimate
from 2008 to 2011 estimates which of the
following is the number of preventable
deaths per year?
1. 50,000
2. 100,000
3. 200,000
4. 400,000
186. An adverse event is described as a

sentinel event only if:
1. Patient death occurs.
2. Serious injury or death occurs.
3. Staff were negligent.
4. The event causes psychological injury.
187. The definition of a sentinel event was

expanded in 2013 to include:
1. Visitors
2. Staff, family, and vendors
3. Anyone in the institution at the time of an
event
4. Staff, family, and volunteers
188. The American Society of Clinical

Oncology and the Oncology Nursing
Society have developed safety standards
for:
1. The prescription, preparation, and
administration of antineoplastic agents
2. Staffing ratios to ensure safe care for
oncology patients
3. Assessment and management of cancer
treatment side effects
4. The preparation and administration of
antineoplastic agents
189. In recent years, what condition has

prompted litigation for nurses?
1. Medication errors
2. Inadequate pain management
3. Violations of the Health Insurance
Portability and Accountability Act
4. Hypersensitivity reactions
190. To avoid litigation when using electronic

communication with patients, which
response describes best practice?
1. Electronic communication for nonurgent
matters, a set turnaround time for
responses, and following Health Insurance
Portability and Accountability Act (HIPAA)
regulations
2. Delineating which types of requests will be
permitted such as appointments and
narcotic refills
3. Use of phones with cameras to assist in
assessment of patients
4. Use protocol-driven, and computer-
supported telephone systems
191. Which of the following is true about the

Health Insurance Portability and
Accountability Act (HIPAA)?
1. HIPAA provides comprehensive protection
against inappropriate or unintended
disclosure of personal health information.
2. Patients have control over who can see
their health information but not the use of
their health information.
3. The Privacy Rule became effective 10 years
after HIPAA.
4. The Privacy Rule preempts state laws
regarding privacy.
Answer Rationales
Cancer Nursing: Principles and Practice, Eighth
Edition, by Connie Henke Yarbro, Debra Wujcik,
and Barbara Holmes Gobel (Jones & Bartlett
Learning, © 2018) and Cancer Symptom
Gobel (Jones & Bartlett Learning, © 2014).
A. SCIENTIFIC BASIS
Carcinogenesis
1. The answer is a.
The two most commonly recognized models of
cancer development; clonal evolution and
development of the cancer stem cell suggest a
path to metastatic disease. The plasticity
model proposed that plasticity exists between
the non-cancer stem cell and cancer stem cell
compartments such that there is bidirectional
conversion to malignancy. The inflammation
theory proposes that inflammation is
associated with the development of cancer.
CNPP, Page 4.
2. The answer is c.
Disease-causing mutations can occur in the
germline, inherited DNA originally from the
egg and sperm, or in the somatic cells. DNA is
found in every cell in the body except the
sperm and the egg. CNPP, Page 6.
3. The answer is c.
Mutations can occur in normal genes that
direct cell growth. These are proto-oncogenes
that can be activated into cancer-causing genes
or oncogenes, which have the trait of ongoing
cell proliferation. Tumor suppressor genes are
anti-oncogenes, protecting a cell from turning
malignant. CNPP, Page 6.
4. The answer is a.
Cells with increased telomerase are known to
be associated with longer telomeres and
greater longevity of cell life. Shorter telomeres
are associated with a shortened cell lifespan.
Cancer stem cells are known to have increased
levels of telomerase, with their extended life
span being enhanced by the protective
telomere at the chromosome ends. Telomerase
also assists in protecting the cells from
apoptosis, thereby preventing the death of
malignant cells. CNPP, Page 11.
5. The answer is a.
In clonal selection, mutation in the genome of
a cell may confer a survival advantage on that
cell. The cell grows stronger, not weaker, with
each mutation. The cancer cell is immortal
because it seems to lack the “biologic clocks”
like telomeres, which are not completely
duplicated during cell division and thus grow
progressively shorter until the chromosome
can no longer replicate. In cancer, the final
common path of action is through oncogenes,
the growth-promoting genes: Oncogenes must
be mutated or relocated to be activated. CNPP,
Page 4.
6. The answer is c.
Carcinogenesis is influenced by genetic,
dietary, and environmental factors, even
though it is likely that human carcinogenesis
involves a combination of factors. CNPP, Page
96.
7. The answer is c.
Tumor-associated viruses probably are
necessary but not sufficient for tumor
causation. The discovery of cancer-causing
viruses in humans shows some promise for
cancer prevention in that similar viruses in
animals have been eliminated by vaccines
made from the attenuated (inactivated)
viruses. CNPP, Page 50.
8. The answer is d.
It is believed that dietary factors affect the
exposure of the gastrointestinal tract to
promoters of carcinogenesis. Fats increase the
production, and change the composition, of
bile salts. These altered bile salts are converted
into potential carcinogens. Fiber decreases the
effects of fatty acids and may protect against
the disease, even in the presence of a high-fat
diet. Fiber may limit the time the colon is
exposed to cancer promoters by speeding
intestinal transit time. CNPP, Pages 58, 1427–
1428.
9. The answer is a.
Common risk factors for hepatocellular cancer
are chronic viral hepatitis, underlying liver
disease in the form of cirrhosis, environment
and chemical toxins, hormones, alcohol, and
smoking, and nonalcoholic fatty liver disease.
CNPP, Page 1653.
Immunology
The macrophage is a primary initiator to an
inflammatory immune response. It originates
in the bone marrow, circulates as a monocyte,
and becomes a macrophage when it enters a
tissue at a site of infection. The macrophage is
also a secretory cell manufacturing key
pyrogenic cytokines such as interleukin-1,
tumor necrosis factor, and interleukin-6.
CNPP, Page 28.

AIDS-related diseases such as non-Hodgkin
lymphoma, Kaposi sarcoma, and primary
central nervous system lymphoma are referred
to as opportunistic because they occur in
patients with preexisting immunodeficiency.
This immunodeficiency can be the result of
HIV infection (which destroys the immune
system), therapeutic immunosuppression
(e.g., chemotherapeutic agents used in organ
transplantation), or primary
immunodeficiency (e.g., as the result of a
genetic defect). CNPP, Page 1733.

Cytokines are glycoprotein products of
immune cells. They bind to surface receptors
of target cells and act as regulators of cell
growth or as mediators of defense functions.
Natural killer cells can kill transformed cells.
Lymphokine-activated killer cells are a special
population of cytotoxic cells used in cancer
therapy that comprise primarily natural killer
cells, which are capable of nonspecific tumor
cell killing. B lymphocytes are sedentary cells
located in the lymph nodes and spleen. CNPP,
Pages 31–32.

The primary function of the immune system is
to prevent or limit infection and malignant
disease CNPP, Pages 31–32.
B memory cells (memory B lymphocytes),
along with T memory cells (memory T
lymphocytes), make up the recall component
of the immune system. They have memory of
antigens previously recognized by the body
and deal with an antigen each time it is
encountered. CNPP, Page 31.

The bone marrow and thymus represent the
primary lymphoid in the immune system. B
cells mature in the bone marrow and T cells
mature in the thymus. Systemic secondary
organs include the spleen and lymph nodes.
The tonsils are secondary tissue. CNPP, Page
31.

Erythrocytes, granulocytes, and
megakaryocytes are myeloid cells. Basophils
and eosinophils are also myeloid cells, but
natural killer cells are lymphoid. Both B and T
cells are lymphocytes. Interleukins, colony
stimulating factors, and erythropoietin
regulate the myeloid and lymphoid cells.
CNPP, Page 31.

Physical and chemical barriers, phagocytic
cells, dendritic cells, NK cells, blood proteins,
and cytokines are all part of the innate
immune system. Leukocytes, plasma proteins,
antibodies, effector CD4+, and plasma proteins
are part of the acquired immune system.

Sleep restores the immune function while
prolonged sleep deprivation increases cytokine
production and proinflammatory cytokines.
Environmental factors affect the immune
system through the formation of free radicals.
Free radicals provide a protective function for
the immune system. Periods of chronic stress
lead to activation of the HPA axis, causing an
inability to turn of the stress response. This
ultimately leads to molecular damage and
increased risk of disease. Higher levels of
estrogen favor immune processes involving
CD4+ and B cells and higher levels of
androgens support activities of CD4+ and
CD8+ levels. CNPP, Pages 40–41.
Clinical Trials
A major barrier for both patients and
institutions to participation in national studies
is that third-party payers often do not cover
experimental treatment, which includes all
research trials. Trials sponsored by drug
companies generally do not pose a financial
concern for oncology programs. The NCI
clearly is committed to research to prevent
cancer, as well as to improve the quality of life
for those who develop cancer. CNPP, Pages
237–238.

Two synonyms for reliability are repeatability
and consistency. Repeatability is the extent to
which a measure, applied two different times
(test–retest) or in two different ways
(alternative form and interrater), produces the
same score. Consistency is the homogeneity of
the items of a scale. Reliability is not a fixed
property of measure, and it cannot be assumed
to be generalizable. CNPP, Page 45.

Content validity includes both face validity
(the degree to which the scale superficially
appears to measure the construct in question)
and true content validity (the degree to which
the items accurately represent the range of
attributes covered by the construct). Content
validity does not include statistical evidence to
support inferences made from tests, but it
should cut across at least three broad domains
(e.g., the physical, psychological, and social) to
be considered valid from the perspective of
item content. CNPP, Pages 45, 52.

The QLI is probably the best example of a
“cancer-specific” scale that in reality measures
generic health concepts. It was originally a
physician-rated scale of five areas of
functioning (activity, daily living, health,
support, and outlook). It has been shown to
distinguish cancer patients with terminal
illness from those with recent disease or active
treatment, as was once popularly assumed.
CNPP, Page 211.

The degree to which a scale superficially
appears to measure the construct in question
is referred to as face validity. The degree to
which the items accurately represent the range
of attributes covered by the construct is called
true content validity. Criterion validity
includes both concurrent and predictive
validity. Data collected simultaneously with
the scale data provide evidence of concurrent
validity; data collected after the scale data
provide evidence for predictive validity.
Construct validity extends criterion validity to
test the scale in question against a theoretical
model and adjusts it according to results to
help refine theory. CNPP, Pages 45, 52.

Legal, regulatory, medical, and ethical groups
have described the process of informed
consent to contain four essential elements:
understanding, comprehension, voluntariness,
and competence. CNPP, Page 235.

The primary ethical struggle in clinical
research is that comparatively few individuals
accept the risk of being research subjects in
order to benefit others and society. Ethicists
raise the point that asking subjects to bear the
risk of harm for the good of others creates the
potential for maltreatment or misuse. CNPP,
Pages 237–238.

Post marketing or phase IV studies are usually
designed to answer questions regarding other
uses, doses, and schedules as well as new
information regarding risks and toxicity of a
new treatment. CNPP, Pages 231.
The purpose of phase I studies is to determine
the maximum tolerated or safe dose of the
drug. CNPP, Page 229.

A phase III trial requires 100 to 1,000 people
to compare the agent or intervention with the
standard of care. CNPP, Page 220.

An increasing number of correlative studies
have been conducted in cancer research.
Blood, tumor, or tissue specimens are obtained
before, during, or after treatment to measure
an effect on the target molecules or
intracellular pathways. CNPP, Pages 231–232.
B. SITE-SPECIFIC CANCER CONSIDERATIONS

Lymphomas are preeminently a malignancy of
the lymphocyte. However, there seems to be a
separate malignancy for each sequential stage
in the developmental sequence from primitive
to mature lymphocyte. At each stage of
development, the potential exists for the
normal maturing lymphocyte to be
transformed into a cancer cell. Once
transformed, the new clone of malignant cells
follows the behavioral pattern of the stage of
the lymphocyte at which the transformation
occurred. For example, if the function of the
maturing cell at the time it is transformed is
secretion of an antibody, the tumor cells
continue to secrete that normal protein in
abnormal quantities. HD and NHL are
distinguished based on the Reed-Sternberg
giant cells in NHL. The information in choice d
is reversed. CNPP, Pages 1459–1462.

BCC is the most common form of skin cancer
in whites and outnumbers SCC by a ratio of
3:1. Nonmelanoma skin cancers, including
BCC, have a higher incidence but a lower
metastatic potential and mortality rate than
malignant melanoma. Malignant melanoma
has a much lower incidence but a mortality
rate that is triple that of the nonmelanoma
cancers. Increased mortality is directly related
to its high potential for metastasis. CNPP,
Pages 1666–1667.

Approximately 90% of patients with chronic
myelogenous leukemia have the diagnostic
marker Philadelphia chromosome. CNPP, Page
690.

GM is the most common adult primary brain
tumor. It is most common in individuals who
are aged 50 or older. GM is characterized by
EGFR amplification. CNPP, Pages 1148, 1161–
1162.

In multiple myeloma, the malignant cell is the
plasma cell, the functional mature cell that
differentiates and develops from the B
lymphocytes. CNPP, Pages 1756–1757.

Although gross hematuria, bladder neck
obstruction, and pain in the suprapubic region
can all be clinical manifestations of bladder
cancer, the most important indicator of disease
progression is the depth of tumor penetration
into the bladder wall. CNPP, Page 1232.

The larger the tumor and the more positive
nodes involved, the worse the prognosis is.

For Hodgkin disease, prognosis is most closely
related to stage of disease. Age and the total
number of lymph node groups involved
(independent of stage) are other prognostic
factors, whereas for non-Hodgkin lymphoma,
prognosis is most closely related to histologic
type. CNPP, Pages 1604–1605.

Microstaging describes the level of invasion of
the CM and maximum tumor thickness. The
two parameters that are used in assessing the
depth of invasion are the anatomic level of
invasion, or the Clark level, and the thickness
of tumor tissue, or the Breslow level. The
prognosis for patients with metastatic disease
at the time of diagnosis is poor, with most
dying within 5 years. As CM thickness
increases, survival rates decrease. Thus, the
Breslow level has consistently proved to be a
significant prognostic variable in stage I CM.
CNPP, Pages 195, 1917, 1926.

Ninety percent of patients with seminoma are
curable by radiation and chemotherapy.
Because they are extremely sensitive to
radiation and chemotherapy, the stage of the
disease at diagnosis is insignificant. High-
grade tumors are known to undergo rapid cell
division; they double their tumor volume
quickly. Because most drugs are active against
cells that are undergoing cell division,
seminomas are more susceptible to the cell kill
effects of chemotherapy. CNPP, Pages 1965–
1967.

Limited-stage disease is the most favorable
prognostic factor in SCLC. A good ambulatory
performance status, female gender, and
normal lactate dehydrogenase are also
favorable prognostic factors for SCLC. Poor
prognostic factors include weight loss,
impaired immunocompetence as measured by
delayed hypersensitivity skin testing, and
Cushing’s syndrome. CNPP, Pages 1697–1698.

Hormone receptor analysis reveals whether a
tumor is positive for the estrogen and
progesterone receptor. If the tumor is positive
for hormone receptors, then hormonal
manipulation can be used for treatment.
Patients with hormone receptor-negative
tumors tend to have a poorer prognosis.
Women whose tumors are positive for the
HER2 receptor gene are candidates for
trastuzumab (Herceptin) therapy whether they
have local or metastatic disease. Presence of
the gene indicates a poorer prognosis. CNPP,
Page 1307.

Poor prognosis has been associated with
venous and lymph node invasion, obstructing
or perforating carcinomas, occurrence in
young people, location of the tumor below the
peritoneal reflection, hepatic metastasis, and
invasion of the bowel wall. CNPP, Page 1463.

The diagnoses commonly associated with
generalized itching are Hodgkin disease, non-
Hodgkin lymphoma, multiple myeloma, small
cell lung cancer, leukemia, vulvar cancer,
gastric adenocarcinoma, and central nervous
system tumors. CNPP, Page 1462.

Chondrosarcoma is a tumor arising from
either the interior medullary cavity of the
cartilage (central chondrosarcoma) or from the
bone through malignant changes in benign
cartilage tumors (peripheral chondrosarcoma).
The most frequent sites for this cancer are the
shoulder girdle, hip girdle, and trunk. Less
common sites include the bones of the hands
and feet. CNPP, Pages 1268–1270.

A multifactorial model for multiple myeloma-
associated anemia has been postulated,
including the replacement of erythrocyte
precursors with plasma cells. CNPP, Pages
1518–1519.

All patients with MDS eventually develop life-
threatening anemia, thrombocytopenia, and/or
neutropenia. Regular evaluation of patients
with MDS is important to monitor the need for
supportive therapy with red blood cells,
platelets, or antibiotics. MDS can transform to
acute leukemia; however, this does not occur
in all patients with MDS. CNPP, Page 1622.

SCC is more aggressive than BCC because it
has a faster growth rate, less well-demarcated
margins, and a greater metastatic potential.
SCC appears as a flesh-colored or
erythematous raised firm papule. It is usually
confined to areas exposed to ultraviolet
radiation. CNPP, Page 1918.

DN may develop throughout life and one-third
arise from preexisting nevi. They may be
familial or nonfamilial. DN are often larger
than 5 mm and most persons have about 25–
75. They appear typically on sun-exposed
areas, especially on the back, but also may be
seen on the scalp, breasts, and buttocks.
Pigmentation is irregular, with mixtures of
tan, brown, and black or red and pink. CNPP,
Page 1901.

Melanoma has two growth phases. In the
radial phase tumor growth is parallel to the
skin surface, risk of metastasis is slight, and
surgical excision is usually curative. The
vertical growth phase is marked by deep
penetration into the dermis and subcutaneous
tissue. Penetration occurs rapidly, increasing
the risk of metastasis. CNPP, Pages 1980–
1981.

Burkitt’s lymphoma is an aggressive
lymphoma that accounts for one-third of
pediatric lymphomas. BL is more common in
men than women and common sites of
involvement are abdomen, bowel, pleura, and
pharynx. c-Myc translocation is a hallmark of
BL. CNPP, Pages 1732–1733.

Central nervous system lymphoma commonly
causes neurologic dysfunction, apathy,
confusion, and/or personality changes. It does
not typically cause the headaches that are
common to brain tumors, spinal cord
compression, or SIADH. CNPP, Pages 1932,
1745–1746.

AIDS-associated NHLs are typically
intermediate- to high-grade B-cell
malignancies. They appear to be associated
with a rise in polygonal B-cell
lymphoproliferation that results from EBV and
HIV infection. AIDS-NHL has been associated
with persistent generalized lymphadenopathy,
suggesting polyclonal B-cell activation. One
possibility is that once HIV infection occurs,
EBV may trigger lymphocyte proliferation that
remains unchecked as a result of HIV-induced
immune dysfunction. This proliferation, in
turn, may allow the expression of two
oncogenes, resulting in a polygonal or
monoclonal NHL. CNPP, Pages 1746–1747.

Diplopia, headache, hyperesthesia of the cheek
along with excessive lacrimation and swelling
of the cheeks or orbit, are all clinical
manifestations of carcinoma of the nasal
cavity and paranasal sinus. CNPP, Page 1582.

A classic triad is apparent with cancer of the
head of the pancreas: progressive jaundice,
profound weight loss, and pain. Jaundice,
which is precipitated by common bile duct
obstruction, is the presenting symptom in 80%
of all cases of cancer of the head of the
pancreas and is the symptom that inevitably
leads individuals to seek medical attention.

Malignant peritoneal effusion (ascites) is most
common in patients with ovarian cancer.

Alpha-fetoprotein is a tumor marker that is
elevated in the serum of 70%–90% of
individuals with primary hepatocellular
carcinoma, but because levels of alpha-
fetoprotein are not specific for liver cancer,
histologic diagnosis is required. CNPP, Page
1405.

Cancers of the sigmoid colon are most often
manifested by abdominal pain and melena.
The manifestations in choice a are those of a
tumor of the right colon; manifestations in
choices c and d are those of rectal cancer.
CNPP, Page 1440.

Because the transverse colon is the most
anterior and movable part of the colon, tumors
here are more accessible to detection by
palpation. Other possible symptoms that
might have been determined by inspection,
auscultation, palpation, and percussion of the
abdomen include distention of the abdomen,
enlarged and visible abdominal veins, occult
blood in the stool, and enlarged lymph nodes
or organs (especially the liver). Diagnostic
examination by fiber-optic colonoscopy
confirms the presence of the tumor. Anemia is
more likely to occur with cancer of the right
colon. Polyps in the rectum may be present
and may indicate the patient was at high risk
for colorectal cancer. Carcinoembryonic
antigen, although useful in evaluating the
efficacy of treatment, is of limited value in the
detection of colon cancer. CNPP, Pages 1440–
1441.

An esophageal tumor gets so large that it can
interfere with the ability to swallow saliva,
food, and liquids. Weight loss occurs along
with a potential for aspiration pneumonia.
Nutrition support, pulmonary hygiene, and
aspiration precautions should be a focus of
nursing care for the person with esophageal
cancer. CNPP, Pages 1538–1539.

The glottic area includes the true vocal folds
and the anterior and posterior glottic
commissures. Tumors in this area tend to be
well differentiated, grow slowly, and
metastasize late. Lesions that lie superior to a
horizontal plane passing through the floor of
the ventricles and including the epiglottis,
aryepiglottic folds, arytenoids, and ventricular
bands (false cords) are classified as
supraglottic. CNPP, Page 1583.

Most SCLC tumors are centrally located,
developing around a main bronchus as a
whitish-gray growth that invades surrounding
structures, eventually compressing the bronchi
externally. Necrosis is frequently seen, and
SCLC is responsible for 25% of all lung
cancers, not 55%. Its doubling time is shorter,
not longer, than that of any other lung cancer
type. CNPP, Pages 1697–1698.

The best method to establish a histopathologic
diagnosis is to obtain involved tissues by
means of an open-lung biopsy or a fiber-optic
bronchoscopy. CNPP, Page 541.

The patient’s symptoms could be caused by
hyperviscosity syndrome, a rare occurrence in
myeloma patients caused by a high
concentration of proteins that increases the
serum viscosity and vascular sludging. CNPP,
Page 1781.

The most accepted factors to determine
prognosis for persons with renal cell
carcinoma are grade, histology, and staging.
The UISS, with five stratification groups along
with relevant clinical information, is an
emerging tool to determine prognosis. Other
criteria being used include nuclear grade,
tumor necrosis score, and preoperative and
postoperative nomograms. CNPP, Page 1878.

Melanoma has been classified into several
types, including lentigo maligna, superficial
spreading, nodular, and acral lentiginous. Each
type is characterized by a radial and/or vertical
growth phase. In the radial phase, tumor
growth is parallel to the skin surface, risk of
metastasis is slight, and surgical excision is
usually curative. The vertical growth phase is
marked by focal deep penetration of atypical
melanocytes into the dermis and
subcutaneous tissue. Penetration occurs
rapidly, increasing the risk of metastasis.

Approximately 60% of women with ovarian
cancer develop ascites at some time before
death. The appearance of ascites in patients
with advanced disease is a poor prognostic sign
and palliation is usually all that can be offered.
Life expectancy is a few months. CNPP, Pages
1814–1815.

Tumors are classified by their biological
behavior (benign versus malignant) and by
their tissue of origin. CNPP, Pages 185–187.

The term “carcinoma in situ” describes a lesion
characterized by full-thickness neoplastic
change with no evidence of stromal invasion
or metastases. CNPP, Pages 194–198, 1400.

Bronchogenic cancers are grouped into small
cell lung cancer and non-small cell lung
cancers, which include squamous cell
carcinoma, adenocarcinoma, and large cell
carcinoma. Many tumors are heterogeneous,
containing cells from more than one histologic
type. In both types of cancer, both hyperplasia
and carcinoma in situ occur. CNPP, Pages 1697–
1698.

There are multiple objectives of solid tumor
staging, but the most important is to provide
the necessary information for individual
treatment planning. Other reasons for using a
uniform staging system are to give prognostic
information, to assist in treatment evaluation,
to facilitate the exchange of information and
comparative statistics among the treatment
centers, and to stratify individuals who may be
eligible for clinical trials. CNPP, Pages 194–
295.

In the TNM system, the extent of the primary
tumor (T) is evaluated on the basis of depth of
invasion, surface spread, and tumor size. The
absence or presence and extent of regional
lymph node (N) metastasis are considered, and
the presence of distant metastasis (M) is
assessed. The system is further classified by
whether the assessment is obtained clinically
(cTNM or TNM), after pathologic review
(pTNM), at the time of retreatment (rTNM), or
on autopsy (aTNM). CNPP, Pages 194–195.

Stage groupings involve combining the various
classification elements of tumor site, regional
lymph node involvement, and the presence or
absence of metastasis. It involves two main
staging periods: pretreatment and retreatment.
The two aspects of pretreatment staging of a
previously undiagnosed cancer are clinical
diagnostic staging, for patients who have had a
biopsy, and postsurgical resection-pathologic
staging, which includes a complete evaluation
of the surgical specimen by a pathologist.

Restaging focuses attention on the disease
parameters that were positive at diagnosis, to
signal a search for any remaining evidence that
treatment should continue. Restaging does not
imply that if a remission is obtained the
patient reverts to a lesser disease stage. The
stage ascribed at the time of diagnosis is the
one referenced throughout the illness. CNPP,
Pages 194–195.

Most tumors of unknown origin are
adenocarcinomas and have a poor prognosis.
Patients with neuroendocrine carcinomas of
unknown origin have a higher median survival
time (33 months) than those with
adenocarcinomas (9 months). CNPP, Page 189.

The AJCC staging system for lung cancer uses
the letters T, N, and M. T designates primary
tumor and is divided into categories relative to
size, location, and invasion. N, with three
categories, represents regional lymph node
status. M designates the absence or presence
of distant metastases. Lung cancer is also
divided into eight stages, each of which is
distinctive relative to treatment and 5-year
survival statistics. Small cell lung cancer is
usually staged using a simple two-stage
system. Because most small cell lung cancer
patients have metastatic disease at the time of
diagnosis, this system describes the extent of
disease as either “limited” or “extensive.”

Determination of the stage of disease in HD is
important because it influences which
treatment option (radiation therapy or
combination therapy) is used. Radiation is
very effective for localized HD and is therefore
used in early-stage disease. Chemotherapy is
more effective than radiation for late-stage
disease, when the number of lymph node
groups involved is greater, but it also is as
effective as radiation in early-stage disease.
Non-Hodgkin lymphoma, on the other hand, is
almost always treated with chemotherapy
because it usually presents at an advanced
stage. A positive bone marrow biopsy indicates
a stage IV tumor. A stage II presentation for
HD is more likely to indicate a slow-growing
malignancy; it is not at all uncommon. CNPP,
Pages 1463–1464.

A chest radiograph and computerized
tomography of the chest and abdomen are
standard tests for staging of Hodgkin disease.
Other procedures, including a computed
tomography of the chest and abdomen, a bone
marrow biopsy, a percutaneous liver biopsy, a
lower limb lymphangiogram, and an
exploratory laparotomy, may be done if there
is evidence of lymph node involvement below
the diaphragm, hepatomegaly or abnormal
liver function, extension of the lymphoma to
mediastinal lymph nodes, or splenomegaly.
Positive results on these tests often indicate a
stage IV disease. CNPP, Pages 1465–1468.

There are multiple objectives of solid tumor
staging, but the most important is to provide
the necessary information for individual
treatment planning. CNPP, Pages 189–192.

A secondary or metastatic tumor resembles
the primary tumor histologically. A second
primary lesion refers to an additional
histologically separate malignant neoplasm in
the same patient. CNPP, Page 192.

For selected tumors, the grade is considered
more significant than anatomic staging in
terms of prognostic value and treatment. In
soft tissue sarcomas, the grade is the primary
determinant of stage of disease and of
prognosis. In other tumors, such as
melanoma, testicular cancer, and thyroid
cancer, histologic grading has no useful
application. CNPP, Pages 194–196.

A G2 rating means the tumor is moderately
well differentiated. The AJCC recommends the
following grading classification:
GX = grade cannot be assessed; G1 = well

differentiated; G2 = moderately well
differentiated; G3 = poorly differentiated; G4
= undifferentiated. CNPP, Page 194.

Histopathologic type is a qualitative
assessment whereby a neoplasm is categorized
in terms of the tissue or cell type from which it
has originated. Histopathologic grade is a
quantitative assessment of the extent to which
the tumor resembles the tissue of origin. A
lesion with the same cell type but at a site
other than the original site indicates a
metastatic tumor; a different cell type
originating from another lesion anywhere in
the body indicates a second primary cancer.

The vast majority of prostate cancers do not
threaten the patient’s life and are termed
indolent. Clinically important cancers include
features such as large tumor volume, Gleason
grades 3–5, an invasive proliferative pattern of
growth, elevated PSA, and origination in the
peripheral zone. These cancers threaten the
patient’s life because they progress to fatal
metastatic cancers. CNPP, Pages 1856–1857.

The primary application of flow cytometry
analysis in solid tumors has been to determine
DNA content and the percentage of cells
synthesizing DNA. Normal DNA is
characterized as diploid and contrasts with
abnormal disorganized DNA that is aneuploid.
CNPP, Page 176.

Most of the more common bone tumors
metastasize to the lungs. Although some bone
tumors metastasize to the lymph nodes (e.g.,
Ewing’s sarcoma), few, if any, seem to
metastasize to the central nervous system or
liver. Whether or not these metastases develop
and when depends on the stage and
aggressiveness of the disease process. CNPP,
Pages 1273–1276.

The most common site at presentation is bone,
followed by lungs, liver, pleura, and brain.
CNPP, Page 1337.

A complaint of low back pain frequently
indicates that the cancer has spread into the
retroperitoneal lymph nodes. CNPP, Pages
1959–1960.

Direct extension to adjacent bone is the only
correct answer. Other mechanisms by which a
tumor spreads from the primary site to bone
are arterial embolization, and direct venous
spread through the pelvic and vertebral veins.

Ascites can become severe in advanced
disease. Palliative measures to control ascites
include fluid and sodium restriction, diuretic
therapy, paracentesis, and albumin
administration. CNPP, Pages 1666–1668.

The most common cause of ascitic fluid
buildup is tumor seeding of the peritoneum,
resulting in obstruction of the diaphragmatic
and abdominal lymphatics. The tumor itself
may secrete humoral factors that cause
increased capillary leakage of proteins and
fluids into the peritoneum. CNPP, Page 1814.

Repeated paracentesis often makes fluid
reaccumulate faster and can lead to severe
protein depletion. CNPP, Page 1814.

Metastatic spread in bone cancer occurs
primarily to the lungs by the hematogenous
route. Symptoms of pulmonary metastases
include weight loss, malaise, hemoptysis,
cough, chest pain, and fever. CNPP, Pages
1273–1274.

Surgery may be used to resect a metastatic
lesion if the primary tumor is believed to be
eradicated, if the metastatic site is solitary, and
if the patient can undergo surgery without
significant morbidity. CNPP, Page 237.

The prothrombin time test is a measure of
diminished or absent coagulation factors.
Choice a is the activated partial
prothromboplastin test, choice b is the specific
factor assays test, and choice c is the bleeding
time test. CNPP, Pages 862–868.

Because most liver tumors are highly vascular,
the person having an ultrasound-guided
percutaneous needle biopsy of the liver must
be monitored closely for intra-abdominal
hemorrhage. In general, this procedure is
rapid, safe, and commonly used; however,
some clinicians strongly believe that needle
biopsies should be avoided at all costs if there
is any potential for curative resection, because
of the potential for seeding and spreading the
cancer during the procedure. CNPP, Page 1659.

CT allows differentiation between bone, brain
tissue, and cerebral spinal fluid. It is highly
sensitive to blood within the brain and is the
technique of choice for evaluating the
presence of acute hemorrhage. MRI is the
more definitive and preferred imaging study
for the individual with a central nervous
system tumor. Cerebral angiography may be
used to confirm that the lesion in question is a
vascular malformation or an aneurysm rather
than a neoplasm. PET provides information on
cerebral perfusion and metabolism. CNPP,
Page 1363.

Manifestations of thrombocytopenia are easy
bruising; bleeding from gums, nose, or other
orifices; and petechiae on the upper and lower
extremities. CNPP, Pages 862–864.

CEA level may become elevated with recurrent
colorectal cancer prior to any clinical
indications of disease. CA-125 is elevated in
ovarian cancer, not liver cancer. CA 27-29 is
not recommend for early detection of cancer
recurrence. Alpha-fetoprotein (AFP) is
elevated in 80% of hepatocellular cancer and
60% of non-seminomatous germ cell cancer,
but not prostate cancer. CNPP, Page 173.

Cystoscopy with biopsy is the test of choice for
a definitive diagnosis. A CT scan is used for
staging and follow-up. Sensitivity is low with
urine cytology, and intravenous pyelogram
evaluates the entire genitourinary system.
CNPP, Pages 177, 1231.

MRI is used to diagnose brain tumors, is
useful in staging colorectal cancer, and screens
for breast cancer. CNPP, Pages 177–179.

Patients fast the night before and their fasting
glucose must be within normal range. The
radiotracer is injected, inhaled, or swallowed at
the time of the test and will take 30–60
minutes for absorption. Vigorous exercise and
chewing gum must be avoided before the
exam. CNPP, Pages 177–178.

Bone marrow plasmacytosis with >30%
plasma cells and bone pain in back or chest are
indications for multiple myeloma. CNPP,
Pages 1758–1764.

Liver function test and MRI evaluate the
potential for surgical resection to look for
metastases. CA 19-9 and CEA are not lab tests
specific for gallbladder cancer. CNPP, Page
1567.

AFP is helpful in the diagnosis and
management of HCC. Liver function tests may
be normal in the early stages of liver cancer.
Due to its lack of specificity, CEA is not used
as a diagnostic or screening test. CNPP, Page
1658.
C. SCOPE, STANDARDS, AND RELATED
ISSUES

The recognized professional authority for
oncology nursing practice is the Oncology
Nursing Society. CNPP, Page 2091.

Role competencies define the expectations for
each role in nursing, guiding curricula
development and communicating role
expectations to the public. CNPP, Page 2090.
107. The answer b.

The CNS practices using the nursing model.
The CNS assesses symptoms and interacts
with patients and families. CNPP, Page 2091.

The recognized professional nurse roles are
nurse administrator, nurse educator, and
certified nurse practitioner. CNPP, Page 2009.

Certification is recognized by some states but
in general, certification is voluntary and
granted by non-governmental organizations.
CNPP, 2097–2098.

The Nurse Licensure Compact was established
to allow nurses to obtain a single license and
practice in other states subject to each state’s
practice laws and regulations. CNPP, Page
2096.

Certification is a voluntary process and unlike
licensure, specialty certification is awarded by
nongovernmental agencies. CNPP, Pages 2096–
2098.

Professional nursing certification assures the
public that a nurse has met eligibility criteria
for a specific credential and has earned
recognition by demonstrating minimum
competency in the specialty. CNPP, Pages
2096–2098.

An increasing number of employers want
certified nurses as employees. Although
certification does not validate who we are as
nurses or as people, certification does validate
that nurses have met stringent requirements
for knowledge and experience and are
qualified to provide competent care. Nurses
who are not certified may provide competent
care but earning oncology certification
provides strong evidence beyond a person’s
claim. CNPP, Pages 2096–2097.

Cancer nursing is practiced by both nursing
generalists and nursing specialists. Nursing
generalists have conceptual knowledge and
skills acquired through basic nursing
education, clinical experience, and
professional development and updated
through continuing education. They meet the
concerns of individuals with cancer and
provide care in a variety of healthcare settings.
Nursing specialists have substantial
theoretical knowledge gained through
preparation from a master’s degree. They meet
diversified concerns of cancer patients and
their families and function in a broader scope
of practice. CNPP, Pages 2096–2097.

Have a current registered nurse license, 1 year
of experience as a registered nurse over the 3-
year period before application, and at least
1,000 hours of oncology nursing practice
within 2.5 years of application. Nurses are not
required to have continuing education units to
take the exam. CNPP, Pages 2096–2098.

The American Society of Clinical Oncology and
the Oncology Nursing Society developed a set
of 36 safety standards for the prescription,
preparation, and administration of
antineoplastic agents. CNPP, Page 2116.

Antineoplastic agents are highly susceptible to
medication errors due to their complex
regimens, patient-specific dosing, narrow
therapeutic indices, and look-alike or sound-
alike names. CNPP, Page 2116.

Litigation has occurred when patients were
treated with agents with known
hypersensitivity potential but were not
premedicated or did not receive a test dose.
Legal actions also have been filed when
reactions occurred but were not promptly
recognized or properly treated. CNPP, Page
2117.

Best practice to reduce risk for litigation is
preparation for emergencies. Other strategies
are: standing orders to administer emergency
medications, patient education regarding
symptom reporting, staff education, and close
monitoring during infusion. CNPP, Pages 2116–
2117.

Although extravasation can occur with
peripherally administered vesicants as well as
with vesicants administered via indwelling
central venous access devices, such as
percutaneously placed central venous
catheters and implanted ports, use of central
devices reduces the risk of extravasation.
CNPP, Page 2117.

Institutional policies regarding vesicant
administration should be defined and aligned
with current literature and guidelines. To
avoid litigation due to negligence during
vesicant administration, the oncology must
follow institutional protocol, assure blood
return, take further action to verify placement
and patency with no blood return, and
administer appropriate antidote if
extravasation occurs. CNPP, Page 2117–2118.
Physicians may bill for 100% of the Medicare
fee schedule for the services provided by the
APN if the following requirements are met:
The collaborating physician must be present in
the same office suite. The APN must be seeing
the patient for a preexisting problem as
documented by the patient having been seen
by the physician at least once, and a plan of
care must be documented by the physician.
The patient must not have a new problem.
Services must be of the type commonly
provided in a physician’s office. The physician
need not countersign the patient’s chart, but
the office schedule must document the
physician’s presence in the office at the time of
the patient’s visit. CNPP, Pages 2099–2100.

The level of prescriptive authority varies from
independent prescriptive authority including
controlled substances to dependent
prescriptive authority excluding controlled
substances. The dependent authority requires
that the APN be under supervision of a
physician when performing this task. The task
may be prescribing controlled or noncontrolled
substances. Some states may require
documentation of a certain amount of
pharmacology coursework, but a doctorate is
not required. CNPP, Pages 2099–2100.

Misappropriation refers to an intentional or
reckless act of plagiarism or a violation of the
confidentiality associated with the review of
scientific manuscripts or grants. CNPP, Page
232.

Failure of the nurse and her employer to fulfill
their obligations and responsibilities could
result in increased pain and suffering, leading
to emotional and mental anguish. Ethically,
regardless of whether the patient is “addicted,”
the nurse has a responsibility to first do no
harm and call the doctor for more pain
medication. CNPP, Pages 234–235.

The Genetic Information Discrimination Act
prohibits health insurers from discriminating
against an individual based on their genetic
information to determine health insurance
eligibility or premiums. CNPP, Pages 143–144.

Nonmaleficence means to do no harm. The
other ethical principles guiding clinical
practice are autonomy, beneficence, and
justice. Autonomy is the process of helping
patients make the decisions that are right for
them. Beneficence is shown by helping the
patient balance the benefits against the risk of
harm. Justice is the distribution of resources
in a fair and reasonable way. CNPP, Pages
143–144.

While nonmaleficence (first do no harm) and
beneficence (opportunity for benefit) are
important ethical principles in genetic
counseling, providing informed consent and
maintaining confidentiality are the most
important principles to ensure. CNPP, Pages
141–143.

Improving safety when stocking, ordering, and
dispensing medications is one of The Joint
Commission’s National Patient Safety Goals.
Additional safety goals include improve patient
identification procedures, improve
communication, perform the correct surgical
procedure on the correct patient and correct
site, and reduce the risk of healthcare-acquired
infection. CNPP, Page 2115.
The Joint Commission has National Patient
Safety Goals and Recommendations delineated
for practice settings, for example, hospitals,
ambulatory care, and home care. CNPP, Page
2115.

Events categorized as sentinel events by the
Joint Commission include medication errors,
patient suicide in a healthcare facility, rape or
homicide, hemolytic transfusion reactions,
wrong-site or wrong-patient surgery,
unintended retention of foreign objects after
surgery, and over dosage of radiotherapy.
CNPP, Page 2115.

The Joint Commission’s National Safety Goals
and Recommendations published in 2016
include: Improving patient identification, staff
communication, and medication safety
processes; reducing healthcare associated
infections; medication reconciliation across
the continuum of care; encouraging patients’
active involvement in their own care as a
patient safety strategy; implement evidence-
based practice to prevent central line-
associated bloodstream infections; establish
clinical alarm safety procedures. CNPP, Page
2115.

To meet the Joint Commission goal of
improved medication safety processes
recommendations are: manage “look-alike,
sound-alike” medications, limit the number of
different drugs concentrations in stock, label
medications that are not labeled, and develop
procedures to prevent harm from
anticoagulation therapy. CNPP, Page 2115.

The Joint Commission mandates that all
patients are to be assessed for spiritual beliefs
and practices. CSM, Page 686.

Nurses repeatedly caring for dying patients
may experience compassion fatigue, previously
known as burnout which leads to
interpersonal difficulties. Examples of
symptoms that others might observe are
irritability and lack of flexibility. When
confronted, your colleague may express a
decreased sense of self-competence, feelings of
helplessness, and difficulty sleeping. CSM,
Pages 714–715.
The following are risk factors for compassion
fatigue: younger age, unresolved personal
trauma or loss, lack of professional or
institution supports, high level of empathy,
and frequent trauma or loss. CSM, Pages 714–
715.

Strategies to develop resilience include
spiritual practices such as meditation or
prayer, having a sense of humor, and
developing a person philosophy of nursing
care. CSM, Pages 713–714.
D. STANDARDS OF PROFESSIONAL
PERFORMANCE

The four widely accepted fundamental ethical
principles that guide medical decision-making
are autonomy, nonmaleficence, beneficence,
and justice. CNPP, Pages 141–144.
139. The correct answer is a.

Informed consent is a central focus of
autonomy, especially when it pertains to
genetic information. CNPP, Pages 141–143.

Beneficence is the healthcare provider’s
opportunity to provide an opportunity for
benefit. In this case, the patient would be
advised to have a more extensive procedure.

Justice is synonymous with equity or fairness
and is achieved through a balance of risks
versus benefits. CNPP, Pages 141–143.

Central to this code is the use of voluntary
consent to protect human subjects in
experimentation. Such consent assumes not
only the ability to consent and freedom from
coercion, but also that there is an
understanding of the risks and benefits and
that the subject is giving an informed consent.

The first step a nurse should take when
meeting a newly diagnosed patient from
another culture is to determine the preferred
language and learning process. Culturally
sensitive education practices include
identifying the preferred communication style,
such as the best way to address the patient,
and acceptable nonverbal communication.

Whenever possible, the optimal strategy is to
use professional interpreters. You should
avoid using family members for patient
teaching and consenting purposes. Family
members may not communicate the
information without bias from trying to
protect the patient, their own
misinterpretation of the information, or a lack
of comfort in discussing personal information
about the patient. CSM, Pages 626–627.

While all patient education starts with what
the patient already knows and includes the
treatment plan, expected outcomes, and side
effect management, the most important
information to include for patients undergoing
radiation therapy is sensory and procedural
information. CSM, Pages 626–627.

Although some pharmaceutical and behavioral
interventions have proven to be successful, the
most successful approaches result from
increasing excise taxes on tobacco products.
CSM, Pages 85–87.

Except for family NPs, a master’s degree is
now considered the minimum education
required for entry: family NP requires a
clinical doctorate in nursing. CNPP, Pages
2096–2098.

The three interacting domains of competencies
of OCNS practice are patient/client, nurses and
nursing practice, and organizations/systems.

The ONS recognizes nurses who have become
experts in coordinating and providing direct
and indirect care to people with cancer
through study and precepted clinical practice
in oncology at the graduate level as OCNSs.
The term “NP” describes the nurse whose
educational preparation includes completion
of an NP program at the master’s or doctorate
level. The role of the NP is to provide
comprehensive clinical care to individuals,
with an emphasis on health promotion,
disease prevention, diagnosis, and
management of acute and chronic diseases.
The ONS recognizes NPs who have expertise in
the specialty of oncology as oncology NPs.

Specialty certification among healthcare
providers has concentrated on linking provider
certification to patient outcomes. Other areas
of inquiry include identifying all
characteristics that differentiate certified and
noncertified providers and describing
variations in practice. Labor unions do not
have a role. CNPP, Pages 2096–2098.

As a consultant, the OAPN in secondary care is
involved in planning and implementing
initiatives aimed at patient and family
education and support. They also may act as
consultants to an institution in establishing
standards for oncology practice and developing
critical pathways. CNPP, Pages 2096–2098.

The Oncology Nursing Certification
Corporation administers a certification
program for cancer nurses. A certification
examination is offered twice yearly. Nurses
with a registered nurse license, 1-year
experience as a registered nurse within the last
3 years, and a minimum of 1,000 hours of
cancer nursing practice within the last 2.5
years are eligible to take this examination.

In a collaborative practice NPs function
independently in caring for a caseload of
patients, whether in the ambulatory or the
acute care setting. Care is provided based on
competence and the skills of the provider are
matched with the needs of the patient. CNPP,
Pages 2096–2098.

The ONS Putting Evidence into Practice
Weight of Evidence Rules use a 6-level grading
system that considers effectiveness and risk-
benefit ratio. CSM, Pages 3–5.

Surveys must be validated for reliability to
ensure that the participants understand the
questions in the way the researchers intended
the questions to be understood. Types of
reliability measures include alternate form,
internal consistency, interobserver,
intraobserver, and test–retest formats. CSM,
Pages 3–5.

Cronbach’s coefficient alpha is a statistic that
measures the strength of the internal
consistency or homogeneity of a set of survey
questions. It is an assessment that measures
the extent to which items included on a
questionnaire focus on a specific domain (e.g.,
patient satisfaction, well-being). CNPP, Pages
141–143.
Pilot studies are useful to assess the feasibility
of a research design and to pretest an
instrument. Pilot studies do not have the
power and effect size to prove the effectiveness
of an intervention. CNPP, Pages 141–143.

In the process of evidence-based practice, the
PICOT acronym is useful to clarify the specific
question/problem and stands for Patient or
population, Intervention or issue of interest,
Comparison intervention or group, Outcome
desired, Time frame. CSM, Page 4.

In the process of evidence-based practice, the
PICOT acronym is useful to clarify the specific
question/problem and stands for Patient or
population, Intervention or issue of interest,
Comparison intervention or group, Outcome
desired, Time frame. CSM, Page 4.

Although Level I evidence is considered the
strongest evidence supporting a practice, other
levels such as Levels II and III also support
practice change. CSM, Page 4.

Green, likely to be effective, indicates
interventions for which effectiveness has been
demonstrated from a single rigorously
conducted controlled trial, consistent
supportive evidence from well-designed
controlled trials using small samples, or
guidelines developed from evidence and
supported by expert opinion. CSM, Pages 3–5,
www.ons.org/practices-resources/pep.

Low-risk interventions that are consistent with
sound clinical practice, suggested by an expert
in a peer reviewed publication (an expert is an
individual who has published peer reviewed
material in the domain of interest), and for
which limited evidence exists are considered to
be expert opinion and may be used in clinical
practice. CSM, Pages 3–5,
www.ons.org/practices-resources/pep.

Using a team-based approach, the ONS PEP
teams search for relevant literature, create
comprehensive summaries of empirically
tested intervention research, and rank each
intervention according to its effectiveness.
CSM, Pages 3–6, www.ons.org/practices-
resources/pep.
Promoting a culture of safety involves a
philosophical shift from error measurement to
proactive assessment of potential harm. FMEA
analysis is a prospective risk analysis
technique that can be used to examine the
chemotherapy administration process. It is a
systematic, multidisciplinary, team-based
approach to error prevention, which is why the
other choices are not correct. CNPP, Page 2115.

FMEA is a prospective risk management
approach that allows cancer centers to
potentially prevent chemotherapy errors
rather than react to them, as is done in root-
cause analysis, which is a retrospective process
conducted after chemotherapy errors have
occurred. The fundamental purpose of FMEA
is to recommend and take actions to reduce
the likelihood of process errors (failures).
CNPP, Page 2115.

Errors in the route of administration for
vincristine prompted USP labeling
requirements and standards for vincristine
packaging, which include cautionary labeling
that states “FATAL IF GIVEN
INTRATHECALLY. FOR IV USE ONLY. DO
NOT REMOVE COVERING UNTIL MOMENT
OF INJECTION.” Cytarabine, methotrexate,
interferon, and thiotepa have all been given
safely intrathecally. CNPP, Pages 446–447,
492.

To decrease patient anxiety, it is important to
include the patient’s goals and concerns in the
treatment decision-making process. CSM, Page
620.

The professional nurse is often called upon to
assist grieving family members. The grieving
process is influenced by history of previous
loss and prior coping, the level of support, the
relationship to the deceased, and
characteristics of the deceased. CSM, Pages
676–678.

Attentive listening is a therapeutic approach
that helps reduce anxiety. CSM, Page 623.

Cognitive techniques include hypnosis,
biofeedback, music therapy, mindfulness-
based stress reduction, and cognitive
distraction or focusing. CSM, Pages 626–627.

Examples of behavioral techniques are passive
relaxation, progressive muscle relaxation, self-
monitoring, and systematic desensitization.

Seeking information is one important way that
patients cope with their cancer. Providing
patients and families with information about
the disease, its treatment, the diagnostic tests,
and the usual side effects help them to
participate, prepare, and feel less
overwhelmed. CSM, Page 662.

Cognitive rehabilitation uses holistic methods
to address social, emotional, and functional
issues related to cognitive impairment. CSM,
Page 649.

All healthcare providers can do a preliminary
cancer risk assessment. Patients and families
can then be referred to trained genetic
counselors for a full risk assessment and
testing. CNPP, Pages 147–148.
Palliative care should be provided by
professionals who have knowledge related to
palliative care, cultural issues, issues of death
and dying, and appropriate timing of referrals.
Providers working together can ensure
successful palliative care in hospital,
outpatient, and home settings. CNPP, Pages
2067–2068.

Patients with head and neck cancer are
evaluated for all treatment modalities. Prior to
beginning therapy, a dental assessment is done
to address dental caries and oral infections.
The nutritionist is consulted at diagnosis since
many patients are malnourished at the time of
diagnosis, and further compromise is expected
due to the side effects of treatment. CNPP,
Pages 1593–1595.

Potential hazards associated with the
administration of antineoplastic agents have
prompted the Occupational Safety and Health
Administration, Oncology Nursing Society,
American Society of Clinical Oncology, and
American Society of Hospital Pharmacists to
set guidelines for compounding, transporting,
administering, and disposing of toxic
chemotherapy agents. CNPP, Pages 420, 2116.

The American Cancer Society
(http://www.cancer.org), Lance Armstrong
Foundation (http://www.livestrong.org), and
Cancer Care (http://www.cancercare.org) are
all reputable organizations that provide useful
information for patients with cancer and their
families. CNPP, Pages 1431, 1972.

The Food and Drug Act of 1906 called for the
truthful labeling of ingredients used in drugs
but did not ban false therapeutic claims on
drug labels. The Cosmetic Act of 1938 require
that manufacturers of new drugs provide
evidence of their safety before being placed on
the market. Finally, in 1962, Congress added
that drugs must demonstrate efficacy in
addition to safety before they can be marketed,
and a process was created by which a
substance can become approved for
prescription use. CNPP, Page 730.

Many mechanisms exist to help ensure safe
delivery of patient care including federal laws,
professional licensing requirements, use of
medical equipment, institutional procedures,
personal practices, and use of personal
protective equipment. CNPP, Page 2114.

Oncology nurses work in high risk
environments due to many factors. Patients
are at risk for falls due to weakness, fatigue
and impaired mobility; cancer treatments
require individualized dosing rather than
standardized dosing; risk of infusion reactions
from chemotherapy or monoclonal antibodies;
and risk of extravasation due to vesicant
administration. CNPP, Page 2114.

Staff education to safely prepare, transport,
administrate, and use personal protective
equipment is shown to decrease exposure to
hazardous drugs. CNPP, Page 2114.

Medical surveillance of workers who handle
hazardous drugs recommended by the
National Institute for Safety and Health
includes a hazard identification program,
baseline information such as medical history,
physical examination, laboratory studies, and
biological monitoring. Annual monitoring is
recommended and a follow-up plan for
workers who have health changes or acute
exposure to hazardous drugs. CNPP, Page 2114.

Back and musculoskeletal injuries due to
patient handling as well as bending and lifting,
supplies and equipment; occupational
infection following accidental exposure to
patients’ blood or body fluids. CNPP, Page
2114.

The Institute of Medicine estimates at least
400,000 deaths per year are associated with
preventable harm. CNPP, Page 2114.

A sentinel event is defined as unexpected
occurrences that result in death or serious
physical or psychological risk or injury. CNPP,
Page 2115.

The definition of a sentinel event was
expanded in 2013 to include harmful events to
staff, visitors, or vendors that occur while they
are on the premises of a healthcare
organization. CNPP, Page 2115.
The American Society of Clinical Oncology and
the Oncology Nursing Society developed a set
of 36 safety standards for the prescription,
preparation, and administration of
antineoplastic agents. CNPP, Page 2116.

In recent years, the undertreatment of pain by
nurses has prompted litigation and state
licensing board actions. CNPP, Page 2122.

Best practice when using electronic
communication with patients includes
electronic communication for nonurgent
matters, a set turnaround time for responses,
and following HIPAA regulations. CNPP, Pages
2121–2122.

HIPAA provides comprehensive protection
against inappropriate or unintended disclosure
of personal health information. HIPAA was
enacted in 1996 and followed by the Privacy
Rule in 2001. The Privacy Rule does not
preempt state laws that provide more stringent
privacy protection. CNPP, Pages 2121–2122.
CHAPTER 3
Major Treatment Modalities

A. SURGERY
1. There are several types of biopsies that

can be used to obtain information for the
diagnosis of cancer. The best type of
biopsy to diagnose malignant melanoma
is:
1. Punch
2. Incisional
3. Excisional
4. Core-needle
2. Mrs. Jones is considering reconstruction

after surgery for breast cancer. You
explain to her that alloplastic
reconstruction uses:
1. Native tissue
2. A tissue expander with an implant
3. A combination of autologous flap with
implant
4. Transverse rectus abdominus muscle
3. Pancreatic insufficiency is a frequently

noted symptom in individuals with
pancreatic cancer, especially after partial
or complete pancreas resection. Nurses
should assess for which of the following
symptoms of pancreatic insufficiency?
1. Sudden weight gain, abdominal distension
2. Loss of appetite, pain after eating
3. Discomfort after eating, bowel evacuation
urgency, diarrhea
4. Alternating diarrhea and constipation along
with weight loss
4. The type of hysterectomy to treat cervical

cancer is based on which patient
characteristic?
1. Age
2. Patient preference
3. Comorbidities
4. Stage of disease
5. The only curative treatment for a woman

with pelvic recurrence of cervical cancer
is:
1. Radical hysterectomy
2. Pelvic exenteration
3. Radical hysterectomy followed by radiation
4. Radical trachelectomy
6. A woman with a history of modified

radical mastectomy with axillary
dissection and radiation therapy
completed chemotherapy 6 months ago
and calls concerned about slight swelling
and redness in her affected arm. On
questioning her, you learn that she has
recently been to Europe. What is the
appropriate nursing action and why?
1. She should keep the arm elevated. Slight
swelling is common following exposure to
compression changes in an airplane.
2. Instruct her to see her care provider as
soon as possible due to the redness and to
wear a compression garment and avoid
heavy lifting on future flights to minimize
the risk of lymphedema.
3. Keep the arm elevated. If it is not better in
a week, call back.
4. She needs a diuretic and an antibiotic, so
she should see her doctor.
7. Surgery may be used in the treatment of

patients with anal cancer at which stage?
1. Stages 0–II
2. Stages I and II
3. Stages 0–III
4. Stage 0 only
8. Surgery is the most important treatment
for nonmetastatic adrenal cortical
carcinoma (ACC). This is the first option
only for:
1. Stage I disease
2. Stage I and II disease
3. Stage I, II, and III disease
4. Stage I–IV disease
9. In women, radical cystectomy includes

removal of the:
1. Bladder, urethra, uterus, ovaries, fallopian
tubes, and the anterior wall of the vagina
2. Bladder, urethra, and anterior wall of the
vagina only
3. Bladder and urethra only
4. Bladder only
10. A new patient, Charles, undergoes

transurethral resection of the prostate
(TURP). He asks if this will cure the
disease. The best response is:
1. TURP is sometimes found to cure prostate
cancer, but the chances diminish with
increasing tumor involvement.
2. TURP is used to treat symptoms of bladder
outlet obstruction.
3. TURP is required to prove cancer is
present.
4. TURP is used to cure prostate cancer.
11. Treatment for Barrett’s esophagus with

high-grade dysplasia includes several
options. However, prevention of
progression from dysplasia to cancer can
only be accomplished by:
1. Endoscopic mucosal resection (EMR)
2. EMR with endoscopic ablative therapy
3. Esophagectomy
4. Endoscopic biopsy surveillance every 2–3
months
12. Although most cases of gallbladder

cancer are found incidentally either
during or after a cholecystectomy for
nonmalignant conditions, the best
surgical treatment is:
1. Laparoscopic surgery
2. Simple cholecystectomy
3. Palliative resection
4. Performed by an experienced surgeon
13. A sign of successful parathyroid enbloc

resection is:
1. Hyperphosphatemia
2. Hypophosphatemia
3. Hungry bone syndrome
4. Hypercalcemia
14. A contraindication for laser removal of

nonmelanoma skin cancer is which of
the following?
1. Scarring may occur.
2. Histopathologic analysis cannot occur.
3. Laser is only superficial and may not get all
the tumor.
4. Recurrence is common.
15. You have recently become part of a new

interdisciplinary oncology team. You are
aware that conditions lending
themselves to surgical treatment include:
1. Fast-growing tumors, and those diagnosed
at an early or localized stage
2. An ability to achieve resection of the entire
tumor mass as well as a margin of safety of
normal healthy tissue surrounding the
tumor
3. Embedded tumors
4. Encapsulated tumors that are deep in the
tissue
16. Tumor margins define the microscopic
three-dimensional edges of the tumor
adjacent to noncancerous tissue. When
deciding the extent of the surgical
excision of tumor, the most important
consideration is:
1. The size of the tumor
2. The location of the tumor
3. The type of cancer
4. The skill of the surgeon
17. Stereotactic biopsy is used to accomplish

1. Several biopsies are obtained from samples
of tissue from different locations.
2. Radiographic images are used to create
three-dimensional views of a tumor.
3. “Sound” waves are recorded in stereo to
outline a tumor.
4. Biopsies are used to diagnose metastatic
disease.
18. Robotic surgery allows better

visualization and more precise resection
of the tumor. A drawback of this type of
surgery for patients is:
1. Insurance often does not cover robotic
surgery.
2. Robotic surgery requires extensive training
for the surgical team.
3. Robotic surgery is generally available only
in academic and large institutions.
4. Recovery takes longer than conventional
surgery.
19. Which of the following lung tumor types

is thought to be nonresectable because it
is of neuroendocrine origin?
1. Small cell lung cancer
2. Large cell lung cancer
3. Squamous cell lung cancer
4. Adenocarcinoma of the lung
20. Sentinel lymph node biopsy (SLNB) is a

common diagnostic procedure in breast
cancer. Other cancer types where SLNB
may be considered are:
1. Thyroid, cervical, penile, head and neck
2. Thyroid, head and neck, melanoma
3. Cervical, vulvar, non-Hodgkin lymphoma
4. Hodgkin and non-Hodgkin lymphoma
21. Within a week of surgery for esophageal

cancer, contrast studies are likely to be
done to check for:
1. Local edema
2. Any signs of residual tumor
3. Anastomotic leaks
4. Swallowing ability
22. Fine needle aspiration is used to obtain

tissue from a palpable solid lesion
because:
1. There are few false negative results.
2. Tissue obtained is sent for histopathology.
3. The color of the aspirate can guide further
assessment.
4. Cellular material obtained is easily put on
slides for cytopathologic review.
23. Which of the following are possible

contraindications to hepatic resection
for liver cancer?
1. Jaundice, severe cirrhosis, and ascites
2. Elevated liver function tests
3. Chemotherapy failure
4. Previous hepatic resection
24. Your patient is newly diagnosed with

lung cancer and is scheduled to undergo
a pneumonectomy. You schedule a
preoperative teaching session to instruct
the patient and family on smoking
cessation. The rationale for this action is
based on which of the following?
1. Patients who quit smoking before surgery
have less immunosuppression and less
infection postoperatively.
2. Smoking cessation strategies are for the
family, because the patient should not be
around smoke postoperatively.
3. Risk of death is significantly higher in
patients who continue to smoke within 4
weeks of surgery.
4. There is no benefit at this point to
encourage smoking cessation.
25. The most popular autologous

reconstruction for women with breast
cancer is:
1. Inferior gluteal artery (I-GAP) flap
2. Superior inferior epigastric artery (SIEA)
flap
3. Deep inferior epigastric perforator (DIEP)
flap
4. Transverse rectus abdominus muscle
(TRAM) flap
26. Surgical intervention is sometimes
preferred over other treatments in the
palliative care setting. For patients with
soft tissue lesions that may be causing
pain, obstruction, or other symptoms,
surgery provides:
1. Moderate therapeutic results with few
complications
2. Immediate therapeutic results and a one-
time intervention
3. Less hospital days than other procedures
4. Less cost than radiation or chemotherapy
treatments
27. Which of the following conditions is

benign and iatrogenic in origin and is
usually secondary to radical cancer
surgery?
1. Pericardial effusion
2. Lymphedema
3. Pleural effusion
4. Anasarca
28. Surgery alone for local and loco-regional

control of esophageal cancer is the
primary treatment for people with
resectable disease whose comorbid
conditions do not prohibit surgical
treatment. However, these surgeries
should be performed in high-volume
centers, defined as those with how many
surgeries per year?
1. More than 20
2. More than 50
3. More than 100
4. More than 200
29. A woman who is about to have a

modified radical mastectomy for diffuse
multicentric breast cancer states,
“Having a lymph node dissection is all
right with me. I want all the cancer cells
taken out if they are there.” The most
appropriate nursing response is which
of the following?
1. The axillary dissection could cause
lymphedema depending on the number of
nodes removed.
2. The purpose of the lymph node dissection
is staging; it is not a therapeutic procedure.
3. Because her disease is all over the breast, it
is a good idea that she is having a more
extensive dissection under her arm.
4. If any nodes are left behind, radiation can
always be used.
30. The Joint Commission developed core
measures to ensure patient safety
through the Surgical Care Improvement
Project (SCIP). Which of the following is
a key intervention for preoperative care?
1. Shaving of the operative area with a razor
2. Glucose monitoring on day 1 after surgery
and daily until discharge
3. Maintaining the urinary catheter until the
patient is fully ambulatory
4. Broad spectrum prophylactic antibiotic
within 1 hour of surgical incision
B. BLOOD AND MARROW TRANSPLANT
1. The science of transplantation revolves

around hematopoiesis and immunology.
Hematopoiesis has three distinct phases,
which are:
1. Proliferation, maturation, and senescence
2. Proliferation, adhesion, and senescence
3. Proliferation, differentiation, and
maturation
4. Differentiation, multiplication, and
apoptosis
2. The three types of granulocytes are:

1. Neutrophils, segmented neutrophils, and
polymorphonuclear leukocytes
2. Neutrophils, basophils, and eosinophils
3. Segmented neutrophils, progenitors, and
white blood cells
4. Progenitors, antigen presenting cells, and
eosinophils
3. A patient is to receive a blood transfusion

of two units of packed red blood cells
that have been irradiated. Which of the
following explains the rationale for
irradiating the blood?
1. To kill any possible cancer cells in the
blood
2. To prevent the spread of the AIDS virus
3. To prevent graft-versus-host disease
4. To sterilize the blood
4. Mr. Jackson is admitted for marrow

infusion. He will receive an allogeneic
stem cell transplantation and is about to
undergo total body irradiation (TBI).
You tell him that TBI:
1. Offers optimal tumor cell kill, but without
penetrating the central nervous system
2. Is given before marrow infusion to prevent
graft rejection by the patient’s own
immune system
3. Is usually given in single doses to reduce
toxicities
4. Should not be given as a booster in any
form to patients with bulky disease because
of the risk of major organ toxicity
5. Bone marrow (BM) procurement is

usually done in the operating room, with
the person under general or epidural
anesthesia. To prepare your patient for
the procedure, you tell him to expect
1. He will have multiple puncture wounds on
both hips and the sternum.
2. The amount of BM collected is standard for
all patients.
3. He will be hospitalized for several days to
ensure that he is adequately hydrated.
4. He will need vitamin supplements for at
least a month after the procedure.
6. Following collection, the bone marrow

(BM) is processed to ensure which of the
following?
1. Platelets are removed to prevent clotting.
2. Leukocytes are removed to prevent red
blood cell lyses upon reinfusion.
3. Cellular debris such as bone chips and fat
cells are filtered out.
4. T-cells are added to decrease the risk of
graft-versus-host disease.
7. The advantage of using peripheral blood

stem cells for transplant is which of the
following?
1. Less risk of acute graft-versus-host disease
2. Less risk of relapse
3. Better response to colony stimulating
factors
4. More rapid hematopoietic recovery
8. Pneumocystis jiroveci is potentially fatal

and requires treatment with:
1. Foscarnet
2. Ganciclovir
3. Trimethoprim-sulfamethoxazole
4. An aminoglycoside
9. Umbilical cord blood (UCB) is

cryopreserved and stored for later use.
Advantages of using UCB include which
of the following?
1. Potential maternal T-cells
2. Easy and safe to collect
3. Dose of stem cells is comparable to dose
harvested from adult
4. Decreased risk of graft failure
10. A patient is first considered for bone

marrow transplant. However, the
physician selects blood cell transplant
(BCT) as the treatment of choice, using
pluripotent stem cells and progenitor
cells obtained from peripheral blood.
This procedure:
1. Delays recovery of neutrophils and
platelets when progenitor cells are used
2. Enables neutrophils and platelets to
recover rapidly
3. Involves collecting committed progenitors
that are not as far along the differentiation
pathway as the PPSCs harvested from the
bone marrow
4. Decreases the risk of graft-versus-host
disease
11. Mr. Jones has been waiting for results

from the National Bone Marrow
Transplant Registry to see if he has a
match for a transplant. Which of the
following would most likely be the type
of transplant he would have?
1. Syngeneic
2. Autologous
3. Matched unrelated
4. Umbilical cord blood (UCB)
12. Autologous stem cells are typically

collected how many days after
mobilization chemotherapy?
1. 1–3 days
2. 3–5 days
3. 5–7 days
4. 7–10 days
13. An important disadvantage of using

autologous stem cells is which of the
following?
1. An increased incidence and severity of side
effects
2. Later engraftment
3. Risk of residual disease cells in the
autologous cells
4. Higher cost compared to other types of
transplant
14. Miss Smith is diagnosed with multiple

myeloma and is going to receive tandem
transplants. You explain to her that
tandem transplants involve which of the
following?
1. Two sequential courses of high-dose
chemotherapy followed by autologous
peripheral stem cell rescue after each
course of therapy
2. Two sequential courses of high-dose
chemotherapy followed by umbilical cord
rescue
3. One course of high-dose chemotherapy
followed by two infusions of stem cells
administered 2 weeks apart
4. One course of high-dose chemotherapy
followed by two infusions of stem cells
administered 6 months apart
15. Patients who have disease in the bone

marrow or genetic and/or immunologic
disease would most likely receive which
type of transplant?
1. Syngeneic
2. Autologous
3. Allogeneic
4. Umbilical cord blood
16. The "gold standard" of human leukocyte

antigen (HLA) typing is a match of how
many HLA markers?
1. 6 out of 6
2. 6 out of 7
3. 8 out of 8
4. 10 out of 10
17. An advantage of allogeneic

transplantation is:
1. Less risk of graft-versus-host disease
2. Significant benefit of graft-versus-tumor
effect
3. Less post-transplant complications
4. Less time in the hospital when compared to
autologous transplant
18. Nonmyeloablative or "mini" transplants

use standard dosing of chemotherapy
followed by infusion of allogeneic stem
cells that coexist with the recipient’s
immune system. The state where both
the recipient stem cells and the donor
stems cells coexist is called:
1. Engraftment
2. Symbiosis
3. Chimerism
4. Graft-versus-tumor effect
19. The organization that has developed

evidence-based global standards for
quality patient care involving all aspects
of the process for transplant centers to
follow is:
1. American Cancer Society (ACS)
2. National Marrow Donor Program (NMDP)
3. American Society of Hematology (ASH)
4. Foundation for the Accreditation of
Cellular Therapy (FACT)
20. Sinusoidal obstruction syndrome of the
liver, formerly known as veno-occlusive
disease, begins with which of the
following?
1. Cytokine activation
2. Tumor necrosis factor leakage
3. Injury to the endothelial lining of the
venules and sinusoids
4. Prior history of hepatitis
21. A physical and psychosocial evaluation is

completed prior to transplant. Problems
that should be addressed prior to
transplant include which of the
following?
1. Alcohol, tobacco, or illicit drug use
2. Obesity or hypertension
3. Illicit drug use
4. Alcohol, tobacco, diabetes
22. Numerous acute hepatic complications

can arise following hematopoietic cell
transplantation (HCT). Which of the
following is diagnostic for sinusoidal
obstruction syndrome?
1. Fluid retention, hyponatremia
2. Hyperbilirubinemia, fluid retention
3. Hypernatremia, fluid retention
4. Right-upper quadrant pain, hypernatremia
23. The National Marrow Donor Program

(NMDP) was formed in response to a
federal mandate. To volunteer to be
typed and listed in the registry, a donor
must provide which of the following?
1. Proof of insurance coverage
2. A blood sample
3. A buccal swab sample
4. A bone marrow sample
24. Under which of the following

circumstances is administration of
platelet concentrate from a single donor
or human leukocyte antigen (HLA)–
matched donor preferable to that of a
random donor platelet concentrate?
1. When the patient is severely
immunosuppressed
2. When cost is a major factor
3. When a patient’s red blood cell antigens
(ABO) are not known
4. When time is a major factor
25. To prepare the patient who is going to

receive autologous stem cells, the nurse
tells the patient to expect a unique smell
coming from their breath that is likened
to garlic or creamed corn. This is due to:
1. Cryopreservation with dimethyl sulfoxide
(DMSO)
2. Rapid thawing of the cells
3. Filtering and processing of the cells after
collection
4. Late effects of chemotherapy
26. Ms. Daniels, who had an allogeneic stem

cell transplant, is about to receive a
blood product. You must ensure that the
blood has been treated to prevent graft-
versus-host disease. This means you will
check to be sure that the blood product
has been:
1. Exposed to alloimmunization and platelet
refractoriness
2. Infiltrated with saline solution
3. Treated via plasmapheresis
4. Irradiated
27. Hematopoietic recovery occurs the

earliest with which type of transplant?
1. Allogeneic
2. Peripheral stem cells
3. Umbilical cord blood (UCB)
4. Autologous
28. After transplantation, Ms. Daniels is

monitored for complications. Naturally,
you will monitor her for possible relapse
and any related complications. Besides
relapse, what reaction is the most
common life-threatening complication
experienced by stem cell transplantation
patients in response to preparative
regimen-related toxicity?
1. Renal complication
2. Sinusoidal obstruction syndrome
3. Congestive heart failure
4. Interstitial pneumonia
29. The use of peripheral blood stem cells

(PBSCs) is preferred over bone marrow
stem cells because:
1. It is less expensive to collect PBSCs.
2. Apheresis can be scheduled more quickly
than bone marrow harvest.
3. PBSCs confer less risk of graft-versus-host
disease.
4. Use of PBSCs allows faster hematopoietic
recovery.
Which of the following presents the best
60.
explanation for why blood-derived cells
rather than bone marrow-derived cells
are most often used for autologous
transplantation?
1. Bone marrow-derived cells are obtained by
bone marrow aspiration, and it is more
painful.
2. Bone marrow can be contaminated by
tumor cells.
3. The procedure of obtaining cells from the
bone marrow increases neutropenia.
4. A shortened nadir period is found with
blood cell transplant.
61. Mobilization of peripheral blood stem

cells (PBSCs) is accomplished by which
of the following?
1. Chemotherapy only
2. Chemotherapy and targeted therapy
3. Chemotherapy, hematopoietic growth
factors (HGFs), and chemokine antagonists
4. Investigational agents
62. Elise develops graft-versus-host disease

after undergoing allogeneic stem cell
transplant. Which of the following will
be the mainstay of Elise’s treatment
plan?
1. Systemic immunosuppressive therapy,
antithymocyte globulin
2. Topical steroids, nonsteroidal anti-
inflammatory drugs
3. Nonsteroidal anti-inflammatory drugs,
antithymocyte globulin
4. Immunoglobulin, topical steroids
63. Although chemotherapy is the most

common mobilization method in
autologous transplants, there are many
disadvantages to this method, including
1. Chemotherapy mobilization can be used
only in heavily treated patients.
2. There are many side effects, including
infection, nausea and vomiting, and
mucositis.
3. The time between administration of
chemotherapy and harvest of cells is more
than a month.
4. The patient is at increased risk of
hypersensitivity reactions.
64. Mrs. Adams has diseased marrow

because of leukemia. Her physician plans
a hematopoietic stem cell transplant and
chooses autologous rather than
allogeneic stem cell transplant. Mrs.
Adams tells you, “I’ve never heard of
using a person’s own bone marrow cells.
Why would anyone do that when I’m the
one with the disease?” You explain that
autologous stem cell transplant:
1. Eliminates the risk of graft-versus-host
disease (GVHD) and other toxicities, such
as myelosuppression
2. Is less toxic, although there is an increased
risk of sinusoidal occlusive syndrome
3. Reduces the risk of tumor contamination
seen in allogeneic stem cell transplants
4. Reduces the risk of the graft-versus-
leukemic effect (graft-versus-leukemic
effect can increase the risk of relapse)
65. Which of the following statements is true

about the use of hematopoietic growth
factors (HGFs) for mobilization of
peripheral blood stem cells (PBSCs)?
1. HGFs have been used for more than 30
years for the mobilization of PBSCs.
2. G-CSF and GM-CSF are preferred to use
with hematopoietic stem cell transplant
(HSCT).
3. Pegfilgrastin is the preferred HGF to use
with HSCT.
4. Mobilization of PBSCs requires
chemotherapy and HGFs.
66. Trimethoprim-sulfamethoxazole is
generally the treatment of choice for
Pneumocystis jiroveci. Which of the
following is the most serious side effect
of this drug?
1. Nausea and vomiting
2. Hemolytic anemia
3. Hepatotoxicity
4. Diarrhea
67. Plerixafor is a chemokine antagonist

used in combination with G-CSF to
mobilize peripheral blood stem cells. The
mechanism of action of plerixafor is
1. Binding of cytokines that block
hematopoiesis
2. Blocking adhesion of bone marrow (BM)
cells to the BM stromal cells
3. Increased production of stem cells for
release into peripheral circulation
4. Increased production of stem cells for
faster hematopoietic recovery
68. After a long period of time, Ms. Daniels,

who had an allogeneic stem cell
transplant, develops recurrent varicella
zoster virus. What is the most likely
treatment approach?
1. Cyclosporine
2. Methotrexate
3. Acyclovir
4. Cyclosporine and methotrexate in
combination
69. Autologous stem cells are cryopreserved

and stored in liquid nitrogen to preserve
function until the patient is ready for
reinfusion. The cells are brought to the
bedside in their frozen state. Which of
the following measures are required to
ensure the safety of both the patient and
the healthcare providers?
1. The room should be closed off to other
patients to avoid exposure to nitrogen gas.
2. The room should be well ventilated to
avoid asphyxiation.
3. No protective safety gear is needed.
4. Patients should wear a mask to avoid
inhalation of nitrogen gas.
70. Which of the following measures has

been found to be most consistently
effective in preventing infection in the
hematopoietic stem cell transplant
environment?
1. Meticulous hand washing, scrupulous
hygiene, and protective isolation
2. Antimicrobial prophylaxis
3. Bacterial prophylaxis
4. Fungal prophylaxis
71. There are two main methods of purging

stem cells to remove potential tumor
contamination. Which of the following
are positive selection methods?
1. Sorting of stem cells using columns
containing antibody-coated beads or
magnetic beads
2. Physical separation of malignant cells from
stem cells
3. Monoclonal antibodies to bind to the
malignant cells
4. Radionucleotides to attach to malignant
cells
Allogeneic transplantation is most
72.
frequently indicated for which of the
following diagnoses?
1. Breast cancer
2. Non-Hodgkin lymphoma (NHL)
3. Acute lymphocytic leukemia
73. One benefit of using total body

irradiation (TBI) to prepare the patient
for stem cell transplant is to:
1. Deliver radiation doses tailored to the
blood supply of various organs
2. Shield the heart and lungs from damage
3. Deliver the radiation in one dose
4. Reach sanctuary sites where tumor cells
may exist
74. Which of the following agents is used to

prevent graft-versus-host disease in
hematopoietic stem cell transplant?
1. Medroxyprogesterone acetate
2. Cyclosporine
3. Cyclophosphamide
4. Dexamethasone
75. A treatment option for patients who have
residual disease after hematopoietic
transplant is which of the following?
1. A second transplant
2. A mini transplant
3. Chemotherapy with or without radiation
4. Donor lymphocyte infusions
76. Hematopoietic growth factors (HGFs)

are administered to patients undergoing
blood cell transplant (BCT) just before
pheresis. The timing of administration of
the HGFs is intended to accomplish
which of the following outcomes?
1. Get the patient ready for BCT as soon as
possible.
2. Stimulate stem cell receptors to make them
more vulnerable to cell kill effects.
3. Mobilization, which makes more stem cells
available for collection from the
circulation.
4. HGFs are administered after pheresis to
encourage replacement of the harvested
cells.
77. The hematopoietic stem cell or

pluripotent stem cells possess a specific
marker used to identify stem cells for
collection from the transplant donor.
This marker is known as:
1. HLA
2. ABO
3. CD34
4. HCG
78. If Ms. Daniels were to acquire chronic

graft-versus-host disease (GVHD) as a
late complication of hematopoietic stem
cell transplantation, which factor is most
likely to be a causative risk factor?
1. Mismatched donor and recipient
2. Male-to-female transplant
3. Age under 18
4. Failure to receive methotrexate and
cyclosporine as chronic GVHD prophylaxis
in chronic myelogenous leukemia
79. A stem cell transplant patient has an oral

herpetic lesion and asks you how she
could have gotten it. Which of the
following statements is accurate
concerning oral herpes simplex virus
(HSV) infections?
1. Most oral infections are due to new viral
exposure rather than reactivation of latent
infections.
2. HSV infections in this population present
vesicles.
3. The incidence of HSV infection in this
population is about 50%.
4. This population is less at risk for
disseminated HSV infection than other
immunocompromised patients.
80. Neutrophils fight bacterial infections.

Which neutrophils mature into cells that
migrate from the bloodstream into
tissues for further differentiation?
1. Macrophages
2. Monocytes
3. Dendritic cells
4. Segmented neutrophils
C. RADIATION THERAPY
81. Which disease is often treated with

radiation alone?
1. Early-stage Hodgkin disease
2. Early-stage breast cancer
3. Sarcoma
4. Non-small cell lung cancer
82. According to target theory, an indirect

hit occurs when ionization takes place in
the medium surrounding the molecular
structures in the cell, causing:
1. Free radical formation
2. Breakage of the bond between
deoxyribonucleic acid (DNA) chains
3. Cross-linking of DNA chains
4. Change or loss of base (thymine, adenine,
guanine, or cytosine)
83. The dose rate of radiation refers to the

rate at which a dose is delivered by a
treatment machine or equipment. The
term used to describe the treatment
approach that takes the total dose of
radiation and divides it into equal
portions is:
1. Fractionation
2. Gray
3. Hyperfractionation
4. Radiation prescription
84. High-dose-rate-brachytherapy is used to

treat breast, gynecologic, and prostate
cancers due to which of the following
advantages over low-dose-rate-
brachytherapy?
1. Outpatient treatment and reduced staff
exposure to radiation
2. Less time for administration
3. Decreased mortality and local recurrence
4. Does not require computer optimization
85. Radionucleotides such as iodine-131,

yttrium-90, and strontium-89 work by
which mechanism?
1. Fusion of radioisotope and monoclonal
antibody
2. Direct injection into the tumor
3. Intra-arterial administration
4. Antibody cell killing
There are three phases of acute radiation
86. syndrome after a person has an acute
radiation exposure. The shortest phase
lasts 2 days and is characterized by fever
and tachycardia. This phase is the:
1. Prodromal phase
2. Latent phase
3. Manifestation phase
4. Hematopoietic suppression phase
87. The biological effects on tissue from

fractionated radiation therapy depend on
the four Rs of radiobiology, which are:
1. Redistribution, reevaluation,
reoxygenation, repair
2. Repair, resimulation, redistribution,
reoxygenation
3. Repair, redistribution, repopulation,
reoxygenation
4. Reoxygenation, redistribution,
radiosensitivity, repair
88. What percentage of patients will receive

radiation therapy during the course of
their cancer treatment?
1. < 25%
2. 50%
3. 60%
4. 75%
89. Breast-conserving radiotherapy after

conservative breast surgery is to prevent
local recurrence. The treatment
technique used is which of the following?
1. Partial breast radiotherapy
2. MammoSite radiation therapy
3. High-dose-rate brachytherapy
4. Proton therapy
90. An important advantage of megavoltage

equipment over conventional or
orthovoltage equipment used in
radiotherapy is that it:
1. Is more effective in treating surface lesions
2. Is more tissue and skin sparing
3. Delivers radioisotopes to the site of the
tumor
4. Limits release of dangerous heavy ions and
negative pi-mesons
91. Which of the following is a

radioprotectant?
1. Metronidazole
2. Amifostine
3. Leucovorin
4. Nimorazole
92. The possibility of contamination of

equipment, dressings, and linens is
greatest when radioactive isotopes are
delivered as:
1. Implants
2. Colloids or solutions
3. Molds
4. Ovoids separated by a spacer
93. Nurses caring for patients receiving

targeted therapy and concurrent
radiation therapy must distinguish side
effects of each modality, which may
require different interventions such as:
2. Skin reactions
3. Radiation recall
4. Lymphedema
94. Compounds that assist in maximizing the

tumor cell kill achieved with radiation
while minimizing injury to normal
tissues are called:
1. Radioantagonists
2. Radiosensitizers
3. Oxygen-enhancement ratios
4. Linear energy transfer through matter
95. Linear energy transfer (LET) describes

the rate at which energy is deposited as
radiation travels. High-LET has which of
the following advantages over low-LET
radiation?
1. Greater relative biologic effectiveness
(RBE)
2. Increased relative radio resistance of
hypoxic cells in tumors
3. Longer intertreatment recovery of tumor
cells when a fractionated dosage is given
4. Less damage to surrounding tissues
96. Nurses are often involved with managing

the side effects that result from
radiotherapy. To minimize the degree of
the symptoms experienced, the nurse
should schedule to see most patients:
1. Before treatment is started
2. On completion of the scheduled 5-week
course
3. At the end of the first week
4. 10–14 days after treatment has begun
97. Acute radiation exposure to doses
greater than 10 Gy leads to which two
syndromes that are irreversible and lead
to death?
1. Hematopoietic, cutaneous
2. Cerebrovascular, gastrointestinal
3. Cerebrovascular, cutaneous
4. Hematopoietic, gastrointestinal
98. Simulators are used in treatment

planning for radiotherapy to localize a
tumor and to:
1. Define the volume to be treated with
radiotherapy.
2. Remove a section of a tumor for a
laboratory evaluation.
3. Reduce the size of a tumor before surgical
resection.
4. Prepare a histopathologic profile of a
tumor.
99. Cell death after radiation has multiple

forms, but the two major forms are:
1. Senescence death and autophagic death
2. Apoptotic death and autophagic death
3. Mitotic death and apoptotic death
4. Mitotic death and necrotic death
100. Radiation effects take place primarily at
the level of:
1. Cells
2. Tissues
3. Organs
4. The whole body
101. Palliation using radiation therapy is used

1. Prevention of pathologic fractures
2. Prevention of superior vena cava syndrome
3. Prevention of fungating lesions
4. Prevention of spinal cord compression
102. One of the primary goals of dose

fractionation is to:
1. Redistribute cell age within the cell cycle,
making normal cells less radiosensitive.
2. Allow tumor cells to repopulate, making
them more vulnerable to the late
consequences that occur if new growth was
inhibited.
3. Deliver a dose sufficient to prevent tumor
cells from being repaired while allowing
normal cells to recover before the next dose
is given.
4. Provide time between treatments for
normal cells to reoxygenate, thus making
them less radiosensitive.
103. Which type of radiation is used to treat

deep-seated tumors such as those located
in the thoracic, abdominal, and pelvic
areas?
1. Ionizing radiation
2. Photon radiation
3. Particulate radiation
4. Electron radiation
104. The late effects of radiation that are

often seen 6 months or more after
radiotherapy are the result of:
1. Cell damage in which mitotic activity is
temporarily altered in some way
2. Acute damage that occurs to tissues and
organs outside the treatment field
3. The organism’s attempt to repair the
damage inflicted by ionizing radiation
4. Acute site-specific reactions to treatment
105. Which organs have high

radiosensitivity?
1. Muscle, brain, spinal cord
2. Bone marrow, ovaries, intestines
3. Stomach, growing cartilage or bone
4. Oral cavity, cervix, rectum
106. Hank received prostatic brachytherapy

with implantation of seeds of iodine-125.
Which of the following is included as
part of your patient education plan for
Hank and his family?
1. Implants are removed after they are no
longer radioactive.
2. The urine may be strained to retrieve any
dislodged seeds.
3. A condom should be worn during sexual
intercourse for the first 2 weeks following
implantation.
4. Hank must remain hospitalized until the
source that emits gamma radiation has
completely decayed so that he is not a
source of radiation to those around him.
107. An example of anticipatory palliation

with radiation therapy is which of the
following?
1. Treatment of the mediastinal mass causing
superior vena cava syndrome
2. Spinal radiation for the patient with lower
extremity paralysis
3. Whole brain radiation in a patient with
small cell lung cancer (SCLC)
4. Chest irradiation for the patient with a
fungating breast lesion
108. Your patient is scheduled to have

intensity-modulated radiation therapy
with low-energy nonthermal light-
emitting diode (LED) photomodulation
following lumpectomy for stage II breast
cancer. Which of the following teaching
points is most appropriate to describe
the purpose of LED photomodulation?
1. Photomodulation promotes skin repair and
collagen buildup.
2. Photomodulation promotes radiation effect
on the possible tumor cells.
3. Photomodulation enhances the skin-saving
effects of modern radiation therapy.
4. Photomodulation enhances oxygen
exposure to neighboring tissues.
109. Fatigue associated with radiation

therapy is most often associated with
which of the following:
1. An accumulation of cell-destruction end
products
2. Decreased energy requirements to repair
damaged epithelial tissue
3. Age, diagnosis, or stage of disease at
diagnosis
4. Pain, depression, and weight gain
110. The cellular response to radiation

therapy is understood through target
theory, which says damage caused by
energy deposited in the deoxyribonucleic
acid (DNA) or ribonucleic acid (RNA) is
referred to as a(n):
1. Indirect hit
2. Hydrogen bond breakage
3. Direct hit
4. Cross-linking of DNA chains
111. Which of the following side effects is

most likely to occur as a result of
radiation therapy to the pelvis?
1. Alterations in organ function (e.g.,
decreased vaginal lubrication) and vaginal
stenosis
2. Diminished hormonal activity (e.g.,
overstimulation of the hypothalamus or
pituitary)
3. General or psychologic side effects of
therapy that can alter sexual function (e.g.,
diarrhea, loss of sexual desire)
4. Secondary organ failure (e.g., ovarian
failure)
112. Rosa is about to receive radiation

therapy for the first time. She says, “I
have such sensitive skin. I’m worried
about the effect radiation could have on
my skin.” The best advice you can give
Rosa is:
1. Gently wash the skin with lukewarm water
and mild soap.
2. She can still use a safety razor in the
treatment field.
3. Wear sunblock products with at least SPF
15.
4. Use mild lotions on all treatment areas to
reduce dry skin.
113. Which of the following is true regarding

radiation-induced skin reactions?
1. Higher doses given over shorter periods of
time to larger volumes result in more
severe acute skin reactions.
2. Photons produce greater skin reactions
than electrons.
3. Placing tissue-equivalent material on the
skin creates a skin-sparing effect during
radiation therapy, minimizing dose at the
level of the skin.
4. When treatment is targeted at areas of skin
apposition, increased reaction secondary to
friction can be expected.
114. Because the effects of radiation are

known to be greatest during mitosis,
which cells are more likely to be sensitive
to radiation?
1. Differentiated
2. Undifferentiated
3. Senescent
4. Stem cells
115. Following radiation therapy to the chest,

your patient plans a trip to Bermuda.
You instruct her to use a sunscreen with
an SPF of 30 or more because radiation
has undoubtedly affected her skin via:
1. Skin-sparing effect during radiation
therapy
2. Slower rate of melanin production in new
epidermal cells in the radiation field
3. Faster rate of melanin production in new
epidermal cells in the radiation field
4. Destruction of lymphocytes in the
irradiated epidermis
116. Three months after sentinel lymph node

biopsy (SLNB), your patient complains
of tenderness and soreness at the site.
The most appropriate response to her
complaint would include which of the
following?
1. She should call her doctor to report these
symptoms because they are unusual.
2. She probably bumped herself and should
not be concerned.
3. These sensations are common for up to 6
months after SLNB, and she should not
worry.
4. Tenderness this long after the procedure
could mean hematoma formation, and hot
packs could help.
117. About 1 month after whole brain

radiation, your patient’s wife calls,
stating that her husband is more sleepy,
lethargic, and complaining of fatigue
and lack of appetite. The physician states
that the patient’s tumor has decreased in
size as expected. Therefore, your
response would include which of the
following nursing interventions?
1. Reassure the family that these symptoms
are expected and will gradually improve.
2. Reassure the family that the symptoms are
not related to radiation and are more likely
flu symptoms.
3. Explain that these symptoms could mean
the cancer has returned, and they should
make an appointment to see the doctor.
4. Explain that this side effect can last up to a
year.
118. Complications and side effects of

radiotherapy for esophageal cancer
1. Esophageal stricture
2. Interstitial lung disease
3. Mucositis
119. The standard for treatment of which

cancer changed when clinical trial
results revealed that patients who
received combined modality treatment
with platinum-based chemotherapy
concurrently with daily radiation had a
30%–50% increase in survival?
1. Breast cancer
2. Ovarian cancer
3. Lung cancer
4. Cervical cancer
120. A patient’s prostate cancer has recurred,

and he is receiving radiation to a portal
including the prostate, periprostatic
tissue, and pelvic lymph nodes. Possible
complications of radiation to this area
1. Constipation and bowel narrowing
2. Urinary incontinence and impotence
3. Spinal edema
4. Lymphedema
121. Your patient with prostate cancer is

scheduled to undergo brachytherapy.
Part of his preprocedural preparation
includes instructions on a low-residue
diet and antidiarrheal agents. The
primary purpose of these instructions is
1. Prevent gastrointestinal irritation to the
gastrointestinal mucosa
2. Prevent diarrhea from the radiation
3. Prevent bowel movements while implants
are in place
4. Prevent contamination of the operative
field
122. Common side effects due to radiation of

the large bowel are:
1. Enteritis and loose, watery stools
2. Abdominal cramping and gas
3. Alternating constipation and diarrhea
4. Small bowel obstruction
123. Larson is receiving radiation to his

posterior hypopharynx. Your teaching
would include which of the following
points regarding the effects of radiation
on taste?
1. Taste buds are extremely readiosensitive
and alterations of taste occur immediately
after the start of treatment.
2. The least affected taste qualities are salt
and bitter.
3. Sweet taste is generally most affected.
4. Taste returns within 2 weeks of completion
of therapy.
124. Delayed radiation injury to the heart can

manifest as which of the following?
1. Atrial fibrillation
2. Cardiomyopathy
3. Aortic valve disease
4. Cardiac tamponade
D. CHEMOTHERAPY
125. Your patient is receiving oxaliplatin. He

is instructed to avoid cold fluids during
therapy and for 5 days after therapy. He
also wears gloves and a scarf and covers
his mouth when breathing cold air such
as when opening a refrigerator. These
precautions are useful to avoid which of
the following complications of
oxaliplatin?
1. Pharyngolaryngeal dysesthesia
2. Acute neurotoxicity
3. Pancytopenia
126. When administering capecitabine

(Xeloda) to a patient who is also taking
warfarin, it is important to frequently
monitor the international normalized
ratio (INR) or prothrombin time (PT).
What is the nature of this drug
interaction?
1. Capecitabine interferes with the
metabolism of warfarin in the liver.
2. Capecitabine interferes with absorption of
warfarin.
3. Clinically significant decreases in PT and
INR occur.
4. Clinically significant increases in partial
prothrombin time occur.
127. An important teaching point for patients

with prostate cancer who are receiving
ketoconazole therapy is:
1. Ketoconazole should be taken on an empty
stomach with an acidic environment.
2. Ketoconazole should be taken before
meals.
3. Ketoconazole increases the production of
male hormones in the testes and the
adrenal glands.
4. Antacids and cimetidine interfere with
absorption of ketoconazole.
128. The metabolic activation and

inactivation or catabolism of drugs is
carried out primarily by the:
1. Liver
2. Spleen
3. Gastrointestinal system
4. Kidneys
129. Chemotherapy drug resistance occurs
primarily because the cancer cell can do
1. Decrease the number of target enzymes
2. Repair ribonucleic acid lesions
3. Modify target enzymes so as to interfere
with binding to antagonistic drugs
4. Decrease the number of target enzymes
130. Capecitabine is an oral agent used to

treat patients with metastatic colorectal
or breast cancer. Which of the following
statements best describes how this drug
becomes activated in the body?
1. This drug is activated via the cytochrome P-
450 system.
2. This drug undergoes enzymatic changes
before becoming fluorouracil (5-FU).
3. Once metabolized in the liver, the
metabolic by-products become cytotoxic.
4. Activation is dependent on the presence of
leucovorin to enhance tumoricidal effects.
131. Mrs. Collins has breast cancer and is

about to begin docetaxel. She has taken
her Decadron as premedication. As you
check her lab tests, you notice her liver
function test results are elevated. Which
of the following statements is important
regarding your course of action?
1. The docetaxel should be delayed until liver
function improves.
2. Docetaxel is eliminated by the kidney, so
liver function is not important.
3. The docetaxel dose may need to be reduced
because of elevated liver function results.
4. The steroid often causes an elevation of
liver functions and can be ignored.
132. The rationale for the use of preoperative

chemotherapy in patients with
osteogenic sarcoma is which of the
following?
1. It treats known metastases.
2. It decreases the size of the primary tumor,
possibly facilitating limb salvage surgery.
3. It enhances the effect of postoperative
radiation.
4. It evaluates the effectiveness of the
chemotherapy.
133. When telling Jeanne about

cyclophosphamide, methotrexate, and
fluorouracil (CMF), you are careful to
give her instructions regarding which of
the following potential side effects?
1. Severe thrombocytopenia and bleeding
2. Severe mucositis
3. Symptoms of bladder infection as early
signs of hemorrhagic cystitis
4. Transient peripheral neuropathies
134. Nursing care of patients receiving

capecitabine therapy includes teaching
patients to discontinue their drug at the
first sign of a Grade 2 toxicity. Which of
the following side effects of capecitabine
would warrant discontinuing the drug?
1. Four bowel movements over their normal
or one nocturnal stool in a 24-hour period
2. Neutropenia
3. Stomatitis with yeast infection
4. Tingling of the fingertips
135. Although fluorouracil (5-FU) is the

cytotoxic agent of choice for colorectal
cancer, it is most commonly
administered in combination with:
1. Floxuridine
2. Capecitabine
3. Leucovorin
4. Oxaliplatin
136. Mrs. Otis has been diagnosed with
multiple myeloma and will begin therapy
with melphalan and prednisone. You will
monitor Mrs. Otis closely for adverse
drug effects such as:
1. Decreased blood urea nitrogen and
creatinine
2. Hypercalcemia and bone pain
3. Bone marrow-suppressive effects
4. Stomatitis
137. One week into his first treatment with

capecitabine, your patient calls to report
some redness and slight peeling of the
palms of his hands and soles of his feet.
He also has some tolerable discomfort.
You instruct him to do which of the
following?
1. Continue therapy and report any worsening
in symptoms.
2. Continue therapy but reduce the dose by
one-half.
3. Discontinue therapy until symptoms go
away, and resume at full dose.
4. Discontinue therapy until symptoms go
away, and resume at 50% dose.
138. Chemotherapy agents damage the hair
most when it is in which phase of hair
growth?
1. Anagen
2. Catagen
3. Telogen
4. Transitional
139. Which of the following chemotherapy

agents is most likely to cause hair loss?
1. Epirubicin
2. Methotrexate
3. Vinorelbine
4. Etoposide
140. The primary rationale for the use of

corticosteroids in the management of
arthralgias and myalgias due to taxane
therapy is which of the following?
1. Corticosteroids decrease symptoms of
inflammation.
2. Steroids decrease the fever associated with
taxane therapy.
3. Steroids suppress muscle enzymes, which
cause myalgias.
4. Steroids increase proinflammatory genes.
Delayed nausea and vomiting occurs
141. more commonly with which of the
following agents?
1. Carboplatin
2. Mechlorethamine
3. Cisplatin
4. Vincristine

agents is commonly associated with
palmar-plantar erythrodysesthesia (hand
and foot) syndrome?
1. Topotecan
2. Sunitinib
3. Cisplatin
4. Low-dose cytarabine
143. The most common and lethal side effect

of chemotherapy is:
1. Respiratory distress
2. Electrolyte imbalance from nausea,
vomiting, and diarrhea
3. Myelosuppression
4. Increased liver function tests

chemotherapeutic agents causes
cumulative and often delayed
thrombocytopenia?
1. Ifosfamide
2. Mitoxantrone
3. Mitomycin
4. Vincristine
145. After the administration of doxorubicin,

you notice that swelling has occurred at
the injection site. The patient complains
of some burning. You determine that
there is a lack of blood return. These
clues alert you that the patient may be
experiencing:
1. Venous flare
2. Erythema
3. Extravasation
4. Venous streaking
146. The signs and symptoms of an

extravasation from chemotherapy can be
subtle. Which of the following might be
considered a definite sign of infiltration
of a vesicant agent?
1. A bleb formation at the injection site
2. Redness around the infusion site
3. Loss of a blood return
4. Slowing of infusion flow
147. Monique is experiencing

hyperpigmentation. You explain to her
that this may be a reaction to:
1. Asparaginase
2. Bleomycin
3. Paclitaxel
4. Cisplatin

drugs can cause acute cerebellar
dysfunction especially in elderly
patients?
1. Paclitaxel
2. Docetaxel
4. Vinorelbine
149. Metabolic encephalopathy manifested as

blurred vision, seizures, motor system
dysfunction, and irreversible coma has
been reported in up to 20% of patients
receiving which drug?
1. High-dose cisplatin
2. Etoposide continuous infusion
3. Ifosfamide
4. Cytarabine
150. Melanie is about to undergo treatment

with cyclophosphamide and
doxorubicin. She is at risk for developing
hemorrhagic cystitis. What preventive
measures can be taken?
1. Protection of the bladder focuses on
reduced hydration.
2. Intravenous acrolein may produce
sulfhydryl complexes and subsequent
detoxification.
3. She is instructed to drink 8–10 glasses of
fluid a day and void frequently.
4. She should receive amifostine therapy
daily.
151. The dose-limiting toxicity of fluorouracil

(5-FU) when given as a continuous
infusion is:
1. Myelosuppression
2. Mucositis
4. Cerebellar ataxia

agents is associated with a high
incidence of emesis?
1. Cytarabine
2. Vincristine
3. Doxorubicin
4. Topotecan
153. Mr. Johns is undergoing chemotherapy

for high-grade testicular cancer. He
complains of being jittery, and his lab
tests reveal low magnesium, albumin,
and calcium. He is most likely
experiencing which of the following
complications of chemotherapy?
1. Anorexia and weakness due to
chemotherapy
2. Low magnesium due to cisplatin therapy
3. Low calcium due to uremia syndrome
4. A paraneoplastic syndrome

agents is known to cause fluid retention
that may manifest as abdominal ascites,
as a pleural effusion, or as a
combination?
1. Mitoxantrone
2. Megestrol acetate
3. Docetaxel
4. Paclitaxel
155. Chemotherapy-related constipation is
associated with which of the following?
1. Colicky abdominal pain
2. Peripheral nerve dysfunction
3. Decreased colonic transit time
4. Reduced rectal emptying due to spinal cord
compression
156. Physiologically, the etiology of

chemotherapy-induced diarrhea involves
1. Lengthening of the intestinal villa
2. The destruction of intestinal lining
3. Microvilli flattening and reducing the
absorptive surface
4. Decreased gastrointestinal motility
157. Fluorouracil (5-FU) is commonly given

with leucovorin to treat gastrointestinal
malignancies. The best reason to
combine these two drugs is:
1. Combination effects of two
chemotherapeutic drugs
2. To potentiate the effect of 5-fluorouracil
3. To decrease diarrhea occurrence
4. To shorten the time of administration
Which of the following chemotherapy
158. agents is likely to cause diarrhea?
2. Vincristine
3. Bleomycin
4. Oral methotrexate
159. Which of the following metabolic

disorders is most common in patients
who receive cisplatin therapy?
1. Hypokalemia
2. Hypomagnesemia
3. Hypophosphatemia
4. Hypocalcemia

features of chemotherapy-induced
pulmonary toxicity?
1. There is an inflammatory-type reaction in
the endothelial cells of the lungs.
2. It is easily detected on x-ray.
3. It is common only in patients who smoke.
4. Pulmonary toxicity is reversible if detected
early.
161. The earliest symptom of chemotherapy-

induced pulmonary toxicity is:
1. Bilateral basilar rales
2. Hypoxia with hypocapnia
3. Productive cough
4. Hyperthermia

chemotherapeutic agents causes anemia
by inhibiting the maturation of the
erythroid lineage cells in the bone
marrow?
1. Cyclophosphamide
2. Nitrogen mustard
3. Cisplatin
4. Carboplatin
163. Several drugs cause cardiotoxicity,

especially the anthracyclines. Which of
the following statements about
cardiotoxicity is true?
1. Acute effects are immediate in onset and
resolve slowly often with serious
complications.
2. Chronic cardiotoxicity occurs years after
administration and effects are
nonreversible.
3. Acute effects are dose related and dose
reduction is not indicated.
4. Chronic effects are dose related and dose
reduction prevents further toxicity.

chemotherapeutic agents is most likely
to cause constipation?
1. Daunorubicin
2. Bleomycin
3. Vinblastine
4. Carmustine
E. BIOTHERAPY
165. Which of the following substances are

cytokines?
1. Alpha-interferon, Interleukin-2
2. Temsorilimus
3. Levamisole
4. PDL-1
166. Flulike syndrome, specifically fever, is

common when biological agents are
administered. This fever is believed to be
due to which of the following
physiological mechanisms?
1. Infection causes the fever, and
vasoconstriction causes the shivering.
2. Pyrogenic pathogens stimulate the release
of endogenous cytokines that act on the
thermal brain centers to create an increase
in the body’s temperature set point.
3. The hypothalamic temperature set point is
lowered as the level of endogenous
pyrogens increases.
4. Tachyphylaxis is common with biological
agents and is a normal physiological
response to the antigen-antibody response.
167. The mechanism of action of vaccines is

1. Stimulation of the complement system
2. Stimulation of the immune system
3. Modulation of antigens
4. Inhibition of the cytokine pathways

Bacillus Calmette-Guérin (BCG) is true?
1. BCG is approved for intravesical instillation
as treatment of invasive cancer of the
bladder.
2. BCG instillation sets off a cytokine cascade
that produces both inflammatory and
infectious processes.
3. BCG is indicated even when the patient has
an infection, recent surgery, or
hypersensitivity to BCG product.
4. Common side effects of BCG instillation
include bloody urination and fever.
169. Biologic response modifiers are:

1. Agents that restore, augment, or modulate
host antitumor immune mechanisms
2. Agents that bind with cell surface receptors
3. Cells or cellular products that have direct
antitumor effects
4. Biologic agents that have other biologic
antitumor effects
170. Certain malignancies are strongly

correlated with viruses. Which of the
following tumors can serve as specific
targets for immune destruction by viral
antigens.
1. Prostate and melanoma
2. B-cell non-Hodgkin lymphoma, and
chronic myelogenous leukemia
3. Pancreas and cervical
4. Cervical and hepatocellular
171. Among the therapeutic cellular activities

of interferons are which of the
following?
1. Antiviral activity: promoting a virally
infected cell attack by another virus
2. Immunomodulatory activity: interacting
with T lymphocytes that stimulate the
cellular immune response
3. Antiproliferative activity: directly
promoting deoxyribonucleic acid and
protein synthesis in tumor cells
4. Immunoregulatory activity: mediating the
proliferation and activation of
hematopoietic factors
172. Cytokines are glycoprotein products of

immune cells that share which of the
following properties?
1. They bind to surface receptors and regulate
cell growth.
2. They inhibit immune defense functions of
the body.
3. They produce antagonistic effects in the
cytokine network.
4. They direct lymphocyte migration.
173. Mr. Jones has nonmetastatic castration-

resistant prostate cancer and is about to
start treatment with sipuleucel-T, a
therapeutic autologous cellular vaccine.
You instruct him that he will receive the
vaccine as follows:
1. Three intramuscular injections at 0, 2, and
6 months
2. Two intramuscular injections at 0, 2, or 6
months
3. Two doses intravenously at 2-week
intervals
4. Three doses intravenously at 2-week
intervals
174. Mr. Ely has recently been told he will be

starting interleukin-2 therapy as part of
a research protocol. Which of the
following is a side effect of interleukin-2
therapy?
1. Moderate hair loss
2. Headache
3. Rapid weight gain
4. Skin sloughing
175. Shortly after beginning treatment with a

biologic response modifier, your patient
complains of intense chills and a
headache. She informs you that she has
been septic in the past and fears this may
be happening again. The best nursing
action in this situation would include
1. Stop the infusion and notify the doctor
because this could be a serious allergic
reaction.
2. Monitor her temperature and treat her
symptoms with opiates/acetaminophen or
benzodiazepines depending on the severity.
3. Consider administering the dose in the
evening, so the patient can sleep through
the worst of the symptoms.
4. Stop the infusion and notify the doctor to
see if blood cultures should be obtained.
F. IMMUNOTHERAPY
176. Immunotherapy is a cancer treatment

that harnesses a patient’s own immune
system. Which of the following are
among the major types of
immunotherapies?
1. Checkpoint inhibitors, immunoadjuvants
2. Monoclonal antibodies, tyrosine kinase
inhibitors
3. Tyrosine kinase inhibitors, anti-epidermal
growth factor receptor agents
4. Monoclonal antibodies, adoptive cellular
transfer therapy, and vaccines
177. Immunotherapy is used to treat the

following diseases:
1. Malignant melanoma, multiple myeloma,
lung, astrocytomas
2. Prostate, renal, multiple myeloma,
malignant melanoma
3. Gall bladder, liver, renal, multiple myeloma
4. Thyroid cancer, multiple myeloma,
malignant melanoma
178. The three immune checkpoints that are
targeted by checkpoint inhibitors are
1. EGFR, TKI, CTLA-4
2. PD-1, PD-L1, MEK
3. CTLA-4, PD-1, PD-L1
4. RAS, RAF, MEK
179. Mr. Jones is receiving tumor-infiltrating

lymphocytes (TILs) and IL-2 for
treatment of his malignant melanoma.
You explain that this is a form of:
1. Active immunotherapy
2. Adoptive immunotherapy
3. Tumor-specific T-cell therapy
4. Biotherapy
180. An example of adoptive immunotherapy

is the use of:
1. Cytokine genes
2. Deoxyribonucleic acid vaccines
3. Interleukins
4. Tumor-specific T-cells
181. Immunomodulatory agents have

changed the care of patients with
multiple myeloma in the last decade.
Which of the following are
immunomodulatory drugs used to treat
patients with multiple myeloma?
1. Bortezomib, carfilzomib
2. Lenalidomide, pomalidomide
3. Thalidomide, bortezomib
4. Lenalidomide, cyclophosphomide
182. Pomalidomide has a unique mechanism

of action that inhibits myeloma cell
growth. The mechanism of action is:
1. Alter adhesion in the bone marrow stroma
2. Cytotoxic to melanoma cells
3. Cytostatic to melanoma cells
4. Histone deacetylase inhibition
183. Patients with advanced renal cell

carcinoma (RCC) are often treated with
immunotherapy. Which drug used to
treat RCC is a PD-1 inhibitor?
1. Aldesleukin
2. Proleukin
3. Nivolumab
4. Interferon
184. Immunotherapy is either specific or

nonspecific and agents target the tumor
selectively. When low-dose interferon is
used in the treatment of malignant
melanoma, the mechanism of action is
thought to be:
1. Direct cytotoxicity to melanoma cells
2. Augmenting the host immune response
3. Anti-angiogenic action
4. Activation of lymphokine-activated killer
cells
185. Interleukin-2 (IL-2) is an

immunotherapy that has been used for
nearly two decades. It is used only in
select patients with malignant melanoma
due to which of the following reasons?
1. High cost
2. High toxicity
3. Requires inpatient administration
4. Risk of anaphylaxis
186. Although patients receiving checkpoint

inhibitors have some side effects similar
to those caused by chemotherapy, which
side effect is managed differently for
patients receiving a checkpoint
inhibitor?
1. Myelosuppression
2. Diarrhea
3. Stomatitis
4. Hair loss
187. Patients treated with CTLA-4 inhibitor

(ipilimumab) most commonly
experience which of the following?
1. Enterocolitis
2. Thyroid dysfunction
3. Hypothyroidism
4. Diabetes
G. TARGETED THERAPY
188. Proteins found or expressed on the cell

membrane that serve as a bridge between
an extracellular and intracellular
environment are called:
1. Growth factor receptors
2. Growth factor ligands
3. Oncoprotein
4. Oncogenes
189. Allen has non-small cell lung cancer and

has begun treatment with gefitinib
(Iressa), an epidermal growth factor
receptor–tyrosine kinase inhibitor.
Which of the following is considered to
be a common side effect of this
treatment?
1. Anaphylaxis
2. Hypotension
3. Skin rash
4. Pancytopenia
190. Monoclonal antibodies interfere with cell

membrane-bound targets by which of the
following mechanisms?
1. Activating ligand receptor and antibody-
dependent cellular cytotoxicity
2. Blocking complement-mediated
cytotoxicity activation and immune
modulation
3. Activating complement-mediated
cytotoxicity
4. Activating the body’s immune response
191. Which of the following side effects are

most often associated with cetuximab
therapy?
1. Hair loss, fatigue, constipation
2. Fatigue, hair loss, nausea, vomiting
3. Acne-like rash, swelling and redness of the
nails, malaise
4. Blood clots, disorientation, fever
192. Signal transduction is a communication

process used by regulatory molecules to
mediate essential cell processes such as
cell growth, differentiation, and survival.
Abnormalities in signal transduction
lead to:
1. Abnormal cell proliferation, altered
angiogenesis, and tissue invasion
2. Normal cell proliferation, sustained
angiogenesis, and aggressive tissue
invasion
3. Increased cell proliferation, sustained
angiogenesis, metastases, and apoptosis
inhibition
4. Increased cell proliferation, sustained
angiogenesis, tissue invasion, metastases,
and apoptosis inhibition
193. Ligand or growth factor activation of the

receptors on the cell membrane causes
receptor dimerization, which means that
the receptors are:
1. Blocked
2. Activated
3. Activated in matching pairs
4. Activated in mismatched pairs
194. The primary mechanism of action of an

epidermal growth factor receptor
monoclonal antibody (e.g., cetuximab) is
1. It disrupts mitosis by spindle binding.
2. By attaching to the receptor, it blocks the
signaling agents.
3. By attaching to the signaling agent, it
prevents attachment to the receptor.
4. It disrupts the cell dividing process.
195. Cell signaling is affected by both

extracellular and intracellular events.
Intracellular events that turn on the
signals include the binding of
intracellular proteins, receptor
mutation, loss of regulatory
mechanisms, and:
1. Ligand binding
2. Receptor activation
3. Heterodimerization
4. Cross talk
196. While teaching your patient about

cetuximab, the most important point you
would be certain to include is:
1. Infusion reactions such as tightening in the
throat, hoarseness, and rash can occur with
the first infusion or with subsequent
infusions.
2. If a mild infusion reaction occurs, the
cetuximab would be discontinued
permanently.
3. If a reaction does not occur with the first
infusion of cetuximab, it will not occur
with subsequent infusions.
4. Infusion reactions are preventable with
medications.
197. The mechanism of action of tyrosine

kinase inhibitors, such as gefitinib, is the
activation of the intracellular tyrosine
kinase pathway through:
1. Phosphorylation
2. Heterodimerization
3. Adenosine triphosphate (ATP) binding
4. Cell cycle activation
198. The primary action of bevacizumab

(Avastin) is to accomplish which of the
following?
1. Decrease nitric oxide production, thus
regulating vascular tone
2. Enhance blood vessel formation
3. Block blood flow at the tumor site, thereby
increasing efficacy of chemotherapy
4. Inhibit vasodilation
199. Patients who receive bevacizumab may

complain of headache and experience
severe (Grade 3) hypertension. The
occurrence of these two relatively serious
side effects is due to which of the
following?
1. Bevacizumab was infused too rapidly.
2. Bevacizumab decreases vascular
endothelial growth factor (VEGF), which
decreases nitric oxide production.
3. Bevacizumab reduces nitric oxide
production, which results in vasodilation.
4. Bevacizumab increases VEGF, which
increases nitric oxide production.
200. The level of epidermal growth factor

receptor (EGFR) overexpression may
predict the response to EGFR inhibitors
in non-small cell lung cancer patients.
The likelihood of greater response to
EGFR tyrosine kinase inhibitors has been
found in which group of patients?
1. Females with squamous cell histology,
Asian ethnicity, and no history of smoking
2. Males with adenocarcinoma and history of
smoking
3. Females, those with adenocarcinoma
histology, patients of Japanese ethnicity,
and patients with no previous history of
smoking
4. Males with adenocarcinoma histology,
patients of Japanese ethnicity, and patients
with no previous history of smoking
201. Your patient has been on bevacizumab

(Avastin) for 3 months and complains
that testing his urine for protein results
in delay of his treatment, and he believes
it can be stopped after all this time. To
increase his compliance with therapy
and to help him understand his
treatment, you would most likely
respond with which of the following?
1. These are doctor’s orders and must be
followed.
2. Vascular endothelial growth factor (VEGF)
impairs glomerular endothelial cells.
3. The bevacizumab can impair the ability of
the kidneys to filter proteins.
4. Agree to test his urine for proteins with
every other treatment.
202. K-RAS gene mutations are good

predictors of resistance to which two
anti–epidermal growth factor receptor
(EGFR) monoclonal antibodies used in
the treatment of metastatic colorectal
cancer?
1. Cetuximab and panitumumab
2. Bevacizumab and cetuximab
3. Ofatumumab and panitumumab
4. Pertuzumab and dabrafenib
203. Recombinant humanized monoclonal

antibodies directed against vascular
endothelial growth factor (VEGF) are
effective in impeding tumor growth
based on which of the following basic
facts regarding how tumors grow?
1. Tumors grow exponentially rather than at
the same rate over time.
2. Tumors cannot grow beyond 1–2 mm
without establishing a new blood vessel
system.
3. Tumors require certain proteins to supply
the tumor with nutrients.
4. Tumors invade regional blood vessels to
gain blood and nutrients for tumor growth.
204. The first anti-mTOR (mechanistic target

of rapamycin) pathway inhibitor to be
approved by the Food and Drug
Administration was Temsirolimus, for
the treatment of:
1. Lung cancer
2. Breast cancer
3. Pancreas cancer
4. Renal cell cancer
205. Rituximab is a monoclonal antibody

used to treat patients with non-Hodgkin
lymphoma. During the initial infusion, a
patient begins to shake and complains of
feeling very cold. The first nursing
intervention is:
1. Stop the infusion, and administer
diphenhydramine and acetaminophen as
well as bronchodilators and epinephrine, as
needed.
2. Stop the infusion and restart at 50% of
dose after symptoms have resolved,
because the reactions are related to the
infusion rate.
3. Monitor the patient for cardiac arrhythmias
because arrhythmias and angina have been
reported with rituximab infusion.
4. Stop the infusion, start oxygen therapy, and
notify the physician.
206. Mrs. Andrews has just begun her first

dose of cetuximab. One-third of the way
through the infusion, she complains of
feeling cold. She is experiencing a
shaking chill and has a temperature of
101.4°F. Your interventions include
1. Stop the infusion and notify the physician
that the patient is having a reaction to the
cetuximab therapy.
2. Monitor vital signs, and administer
epinephrine as directed.
3. Inform the patient that people who react to
the cetuximab the first time are more likely
to react more intensely with each
subsequent treatment.
4. Resume the infusion at the same rate when
vital signs are stable.
207. The mitogen-activated protein kinase

pathway has several targets, including
Ras, Raf, and MEK. RAS gene mutations
are found in 90% of which cancer?
1. Pancreas
2. Colon
3. Non–small cell lung
4. Prostate
208. The mutated BRAF gene stays on once

activated by growth signals causing
continued growth of malignant cells. The
BRAF gene is the most commonly
mutated gene in melanoma. What other
two cancers have been found to have
high percentages of BRAF mutations?
1. Colorectal and chronic myelogenous
leukemia
2. Colorectal and hairy cell leukemia
3. Breast and colorectal
4. Breast and lung
209. Imatinib, dasatinib, and nilotinib are all

tyrosine kinase inhibitors that inhibit a
specific gene translocation known as:
1. KRAS
2. BCR-ABL
3. PDGFRβ
4. VEGF
210. Shortly after beginning therapy with an

epidermal growth factor receptor
inhibitor, your patient experiences a
macular papular rash over 25% of his
body. The best intervention at this stage
is:
1. This is a mild rash, and only water-based
skin products should be used to minimize
dryness.
2. This is a moderate rash that requires
antibiotics for treatment.
3. This is a mild rash, and the patient may use
cortisone cream.
4. This is a moderate rash that requires
clindamycin gel for treatment.
211. Trastuzumab, bevacizumab, and

pertuzumab are all examples of what
type of monoclonal antibody?
1. Humanized
2. Chimeric
3. Fully human
4. Mouse
212. Overexpression of epidermal growth

factor receptors has been found to
correlate with a poor prognosis in which
of the following?
1. Breast cancer, bladder cancer, glioblastoma
2. Breast, ovary, endometrial
3. Bladder, kidney, glioblastoma
4. Glioblastoma, astrocytoma, breast cancer
213. Black box warnings are issued by the

Food and Drug Administration when a
drug is determined to carry a significant
risk of serious or life-threatening adverse
events. Black box warnings have been
issued for cetuximab for which of the
following adverse events?
1. Bone marrow ablation with severe
bleeding, anemia, and infection
2. Hepatic occlusive disease
3. Reversible posterior leukoencephalopathy
syndrome (RPLS)
4. Idiopathic pulmonary fibrosis
214. Epidermal growth factor receptors

(EGFRs) have recently been found to be
an important prognostic indicator in
breast cancer. Which of the following
statements regarding the relationship
between epidermal growth factor
receptors and breast cancer is true?
1. The presence of the epidermal growth
factor receptor means that a woman is
most likely to be estrogen receptor (ER)
and progesterone receptor positive.
factor receptor means the patient has a
good prognosis.
3. Inhibiting growth factor receptors is
therapeutic in women with breast cancer.
factor has no implications for selection of
chemotherapy protocols.
215. Lapatinib is approved in combination

with capecitabine for women with HER2-
positive advanced or metastatic breast
cancer who have received prior therapy.
Due to the risk of cardiac changes, such
as decreased left ventricular ejection
fraction or prolonged QT intervals,
baseline assessment includes:
1. Ventilation/perfusion scan
2. Multigated acquisition scan
3. Electrocardiogram
4. Echocardiogram
216. Vascular endothelial growth factor

(VEGF) stimulates endothelial cell
growth. Which of the following is the
primary trigger for activation of VEGF?
1. Apoptosis
2. Anemia
3. Thrombocytopenia
4. Tumor hypoxia
217. Epidermal growth factor receptor

inhibitor agents have distinctly different
side effects from traditional
chemotherapy drugs. The most common
toxicities associated with targeted agents
are:
1. Dermatologic reactions and diarrhea
2. Endocrine and cardiac changes
3. Cardiac changes and dermatologic
reactions
4. Hypersensitivity reactions

tumor angiogenesis?
1. A process whereby tumor cells can divide
despite low hemoglobin
2. A response to tumor hypoxia
3. A process whereby tumors create their own
vascular network
4. A process whereby tumors are deprived of a
vascular network
H. VASCULAR ACCESS DEVICES
219. Following administration of

cyclophosphamide and fluids via an
implanted port, your patient complains
of chills, which she states she has had in
the past after her chemotherapy. You
take her temperature and note a slight
elevation. The best subsequent nursing
action would be:
1. Let her go home and instruct her to call
with any temperature elevation.
2. Notify the doctor and prepare to draw blood
cultures.
3. Keep her for 2 more hours, and then
recheck her temperature.
4. Vigorously flush the catheter to avoid
thrombus formation.
220. Which of the following skin disinfection

solutions has been found to provide the
best protection against central venous
catheter colonization in hospitalized
patients?
1. 2% aqueous chlorhexidine
2. 70% isopropyl alcohol
3. 10% povidone-iodine
4. Sterile water
221. Which of the following is a major

advantage of the peripherally inserted
central catheter (PICC)?
1. It does not require frequent flushing
because of the one-way valve.
2. Dressing changes are simpler and more
cost-effective.
3. It can be inserted at home by a certified
nurse.
4. It has a separate designated port for blood
withdrawal.
222. Your patient has had an implanted port

for 4 months. He is currently due for
routine cisplatin and fluorouracil.
Following access with a Huber point
needle, the port flushes easily with no
evidence of swelling or pain. However,
there is no blood return. The best
subsequent action would be:
1. Avoid using the port if there is no blood
return.
2. Infuse fluids for 1 hour then check again
for blood return.
3. Send patient for a dye study to assess for
sheath formation.
4. Follow institutional protocol for tissue
plasminogen activator.
223. An Ommaya reservoir is generally placed

underneath the skin of the scalp
overlying the cranium with the catheter
extending to the ventricle of the brain.
The purpose of this catheter placement is
1. Measurement of intracerebral pressure
2. Treat brain metastases
3. Injection of systemic chemotherapeutic
agents
4. Injection of chemotherapeutic agents
through the intrathecal route

describes the best reason to use
peripherally inserted central catheters
(PICCs)?
1. PICCs are excellent for long-term
intermittent infusional therapy.
2. PICCs can be inserted at the bedside by
certified nurses.
3. PICCs do not require sterile external site
care and routine flushing.
4. PICC lines are used for short-term
intermittent infusional therapy.
225. Which of the following is the best

statement regarding use of the epidural
implanted port?
1. Epidural ports are used to administer
intrathecal or epidural medications,
including chemotherapy and analgesics.
2. To prevent infection, only medication with
preservative is instilled or infused into the
port.
3. The port is flushed with preservative-free
heparin after each use.
4. A standard 24-gauge needle and meticulous
sterile technique are used to access
epidural ports.
226. Mr. Archer has had an implanted port for

4 weeks and recently complained of pain
in his right neck and shoulder, just above
the catheter insertion site. On
examination, you notice slight swelling
over the neck, face, shoulder, and arm.
He also complains that his arm is cold at
times and there is some tingling in his
arm and shoulder. What is the most
appropriate action to take?
1. These symptoms are normal following port
placement and should resolve in 2–3
weeks. Have him return to the clinic in a
week if he is not better.
2. Flush the line with heparin to make sure it
is not clotted.
3. Continue the treatment and observe for
increased swelling.
4. Notify the physician to examine the patient
and expect an order for a venogramter.
227. Ms. Charles needs a peripheral

intravenous injection of doxorubicin, a
known vesicant. When giving a vesicant
through a peripheral vein, the most
important step is:
1. To maintain a blood return throughout the
injection
2. To use a smaller-gauge, steel needle
3. To use a vein below the vein used for
venipuncture
4. To administer the vesicant as quickly as
possible to decrease the risk of
extravasation
228. Which of the following factors should

influence the choice of catheter used in
the mobilization process for a patient
preparing for a blood cell transplant
(BCT)?
1. The patient undergoing BCT requires a
catheter that is stiffer than the traditional
central venous catheter used for
autologous bone marrow transplant
(ABMT).
2. The stiff catheters used in ABMT are not
necessary in BCT pheresis because there is
a less rapid withdrawal of blood in BCT.
3. Low volume and pressure are needed
during pheresis.
4. The patient undergoing BCT needs a
catheter like the ones used for ABMT.
229. Alfred is a patient with colon cancer who

is scheduled to have a vascular access
port placed before beginning continuous
infusion of fluorouracil. He has recently
experienced diarrhea and fever of
unknown origin. His hemogram reveals
a hemoglobin of 11.0 g/100 mL, a white
blood cell count of 2000/mm3 with an
absolute neutrophil count of 750/mm3,
and platelets of 92,000/mm3. His
surgeon has delayed his port placement
for another week. The likely cause of this
delay is which of the following?
1. Diarrhea is a common cause of fever of
unknown origin.
2. Platelets less than 100,000/mm3 are
associated with bleeding during surgery.
3. Neutropenia is the primary risk factor for
infection with vascular access catheters.
4. Anemia is associated with postoperative
complications.
Answer Rationales
Please note: All Page numbers referenced in the
Learning, © 2018).
A. SURGERY
1. The answer is c.
Research has demonstrated that excisional
biopsy for diagnosis of malignant melanoma
provides the most accurate Breslow thickness
as compared to other types of biopsies. CNPP,
Page 251.
2. The answer is b.
There are three types of reconstructive breast
surgery. Alloplastic reconstruction uses a
tissue expander with an implant
reconstruction. CNPP, Pages 260–261.
3. The answer is c.
The symptoms of pancreatic insufficiency are
discomfort after eating, bowel evacuation
urgency, diarrhea, excessive malodorous gas,
weight loss, steatorrhea as evidenced by
floating bowel movements, and abdominal
cramping. CNPP, Pages 1842–1843.
4. The answer is d.
The stage of the cervical cancer determines the
extent of the surgical procedure needed. CNPP,
Pages 1411–1412.
5. The answer is b.
Pelvic exenteration, a radical surgical
procedure that removes all the same organs
and tissues as in a radical hysterectomy with a
pelvic lymph node dissection as well as the
bladder, vagina, rectum, and part of the colon,
is the only curative treatment for a woman
with pelvic recurrence of cervical cancer.
6. The answer is b.
Women at risk of lymphedema should always
wear a compression garment for air travel and
avoid heavy lifting with the affected arm.
CNPP, Page 368.
7. The answer is c.
Patients with anal cancer may have a surgical
resection only for small, in situ lesions,
sphincter preservation along with
chemotherapy and radiation for stage I and II
lesions, resection for residual, or recurrent
disease. CNPP, Pages 1475–1476.
8. The answer is c.
Surgery is the most important treatment for
nonmetastatic adrenal cortical carcinoma
(ACC) and complete resection is recommended
for stages I–III disease. Surgery may be the
first option for stage IV disease only when
resection of the complete tumor and
metastasis is feasible. CNPP, Page 1505.
9. The answer is a.
In women, a radical cystectomy includes the
removal of the bladder, urethra, uterus,
ovaries, fallopian tubes, and anterior wall of
the vagina. In men, the term is synonymous
with prostatectomy and includes excision of
the bladder with pericystic sac, the attached
perineum, the prostate, and the seminal
vesicles. CNPP, Page 1235.

Prostate cancer is not cured by TURP. Rather,
TURP is used to treat symptoms of bladder
outlet obstruction, and in some patients
provides pathologic evidence that a cancer,
previously unsuspected, is present. CNPP,
Page 1868.

Esophagectomy, EMR with or without
endoscopic ablative therapy, and endoscopic
biopsy surveillance every 2–3 months are all
treatments for Barrett’s esophagus.
Esophagostomy is the only treatment that can
definitively prevent the progression from
dysplasia to cancer through resection of the
mucosa at risk. CNPP, Page 1544.

Although the method (laparoscopic or open)
and type of surgical procedure (simple or
radical cholecystectomy, palliative resection)
may be important, the most important factor is
the experience of the surgeon who must be
trained to perform radical cholecystectomy.

Hungry bone syndrome signifies successful
parathyroid tumor remove. Hungry bone
syndrome occurs after parathyroid resection as
calcium and phosphorus are deposited into the
skeleton, causing symptomatic hypocalcemia.

Treatments for nonmelanoma skin cancer
include surgical excision, curettage and
electrodesiccation (C&E), Mohs micrographic
surgery, and cryosurgery. Laser removal,
cryosurgery, and C&E do not produce a
specimen for histopathological diagnosis and
evaluation for free margins so should only be
used when diagnosis is confirmed. CNPP,
Pages 1926–1927.

A surgical procedure intended to be curative
must involve resection of the entire tumor
mass as well as a margin of safety of normal
healthy tissue surrounding the tumor. Other
situations lending themselves to surgical
treatment include such factors as slow-
growing tumors that consist of cells with
prolonged cell cycles. Superficial and
encapsulated tumors are more easily resected
than those that are embedded in inaccessible
or delicate tissues. CNPP, Pages 255–256.

Although the size and location of the tumor
are considerations in surgical excision of
cancer, the type of cancer is the most
important consideration. For example,
malignant melanoma requires wide excision
with wide margins, margin status in breast
cancer surgery is variable depending upon the
planned follow up treatment with radiation
and/or chemotherapy. CNPP, Pages 256–257.

Stereotactic biopsy uses radiographic images
to create three-dimensional views of a
suspected neoplasm. A biopsy that involves
obtaining several samples of tissue from
different locations within a tumor is called a
regional biopsy. Regional biopsies are used to
diagnose metastatic disease in a defined, but
not localized, region of the body. CNPP, Pages
190–191.

Robotic machinery is very expensive and
requires a significant learning curve for
surgeons. There is a lack of access to this
surgery in rural and smaller hospitals;
therefore, patients must be willing to travel to
large centers for treatment. CNPP, Pages 257–
258.

Small cell lung cancer invades the submucosa
and is thought to arise from neuroendocrine
cells that secrete peptide hormones. Squamous
cell carcinoma, adenocarcinoma, and large cell
carcinoma are all examples of non-small cell
lung cancer. CNPP, Page 1689.

SLNB is a common and well-accepted
diagnostic procedure in breast cancer. Other
cancer types where SLNB may be considered
are thyroid, cervical, penile, and head and
neck. CNPP, Page 257.

Because the esophagus is thin walled and
draws upward with each swallow, an
anastomosis involving the esophagus has
more of a tendency to leak than any other area
of the gastrointestinal tract. For this reason,
contrast studies are performed 4–6 days after
surgery to check for patency of the
anastomosis. Small leaks usually close
spontaneously; larger leaks often require
surgical approximation. CNPP, Pages 1546–
1547.

Cellular material obtained is easily put on
slides for cytopathologic review. However,
false-negative results are common and require
further biopsy. Fine needle aspirate specimens
are not suitable for histologic review. CNPP,
Pages 249–250.

Possible contraindications to major hepatic
resection for liver cancer include the
following: (1) severe cirrhosis; (2) distant
metastases in the lung, bone, or lymph nodes;
(3) jaundice, which is often indicative of
obstruction of the common bile duct; (4)
ascites, which is usually indicative of liver
failure and an inability to tolerate a surgical
procedure; (5) poor visualization on
angiographic studies, which may jeopardize
the certainty with which the surgeon resects
the tumor; (6) certain biochemical changes
that indicate poor liver function and lower the
probability of survival; and (7) involvement of
the inferior vena cava or portal vein, which
would make surgical intervention hazardous.

Risk of death is significantly higher in patients
who are still smoking within 1 month of
pneumonectomy. There is higher morbidity
and mortality for smokers who continue to
smoke before surgery. Patients who stop
smoking within 10 weeks of surgery have the
same risk as those who had never smoked.
CNPP, Page 1685.

The TRAM flap is the most commonly used
autologous reconstruction technique used for
women with breast cancer. SIEA, DIEP, and I-
GAP are emerging approaches. CNPP, Page
261.

Palliative surgery provides patients with
symptom relief and low treatment toxicity.
Benefits include immediate therapeutic
results, short stay hospitalizations, relatively
low cost, and a one-time intervention. CNPP,
Page 262.

Lymphedema is a benign iatrogenic problem
caused by radical cancer surgery. Arm
lymphedema often developed after the most
common treatment for all types of breast
cancer in the past: radical mastectomy with
axillary node dissection followed by radiation.
It now occurs much less frequently.
Lymphedema of the leg may develop after
groin dissection that is performed for the
treatment of metastatic disease from primary
tumors. Mechanical interruption (surgical
technique) and radiation often produce
lymphatic obstruction, the most common
cause of lymphedema. CNPP, Pages 368, 1816.
High volume centers are defined as those
having more than 20 esophagectomies per
year. CNPP, Pages 1545–1546.

A lymph node dissection stages disease. It is
not a therapeutic procedure. CNPP, Pages
1306–1307.

SCIP standards that are routinely monitored
by the Joint Commission are: (1) broad
spectrum antibiotics prophylactic antibiotics
administered within 1 hour of surgical incision
and discontinuation within 24 hours following
surgery; (2) glucose monitoring with 6:00 a.m.
sample on day 1 after surgery and
discontinuation within 24 hours of surgery if
normal; (3) elimination of preoperative skin
shaving with a razor; and (4) removal of
urinary catheter on postoperative day 1 or 2.
CNPP, Page 252.
B. BLOOD AND MARROW TRANSPLANT

The three distinct phases of hematopoiesis are
proliferation, differentiation, and maturation.
Proliferation refers to growing blood cells,
whereas differentiation refers to developing
these into different but specific cell lines, and
maturation refers to attain full functional
capacity. CNPP, Page 557.

Granulocytes, which are distinguished based
on their appearance under microscopic
investigation using Wright’s stain, include
neutrophils, basophils, and eosinophils. CNPP,
Page 559.

A serious transfusion complication in patients
who are significantly immunosuppressed is
the risk of developing graft-versus-host
disease. It is generally recommended that all
blood products given to the severely
immunocompromised host be exposed to
pretransfusion irradiation. Blood is irradiated
to inhibit proliferation of lymphocytes without
impairment of platelets, red cells, or
granulocytes. CNPP, Pages 594–595.

TBI is given before marrow infusion to prevent
graft rejection by the patient’s immune
system. It offers optimal tumor cell kill
because it penetrates the central nervous
system and other privileged sites. It is usually
given in fractionated doses to reduce toxicities,
and it can be given as a booster to patients
with bulky disease. CNPP, Pages 281, 575.

The BM procurement procedure involves
multiple needle aspirations from the bilateral
posterior ileac crests. The sternum and/or
anterior portions of the iliac crests can also be
used if an inadequate number of cells are
obtained from the preferred site. The amount
of BM collected is based on the recipient’s
body weight. Patients are generally discharged
the same or next day. CNPP, Page 560.

Following collection, the BM is mixed with an
anticoagulant and filtered to remove bone
chips, fat cells, blood clots, and other cellular
debris. If the donor and recipient are not ABO
compatible, then RBCs can be removed from
the sample to avoid RBC lysis upon reinfusion.
CNPP, Page 560.

Advantages of using PBSCs for transplant are
more rapid hematopoietic recovery, lower risk
of contamination by tumor cells, ability to be
performed as an outpatient basis without
general anesthesia, and similar outcomes to
use of bone marrow cells in terms of acute
graft-versus-host disease, relapse, nonrelapse
mortality, and overall survival. CNPP, Page
561.

P. jiroveci is a protozoan that causes infection
in children with primary immunodeficiency
disorders, persons with AIDS, and those with
cancer who are undergoing
immunosuppressive therapy. Untreated, P.
jiroveci is fatal, and even with therapy,
mortality is high. The treatment of choice is
trimethoprim-sulfamethoxazole. CNPP, Page
593.

Advantages of using UCB include that it is easy
and safe to collect; use of an abundant stem
cell source that is usually discarded; may be
stored for unrelated matches; low incidence of
graft-versus-host disease; and low risk of viral
contamination. Disadvantages include
potential maternal T-cell contamination, and
limited number of stem cells harvested with
risk of graft failure. CNPP, Pages 561–562.

One advantage to using peripheral pluripotent
stem cells (PPSCs) and progenitor cells
obtained from peripheral blood is the more
rapid recovery of neutrophils and platelets
when progenitor cells are used. This is because
the committed progenitors collected for BCT
are farther along the differentiation pathway
than are the PPSCs harvested from the bone
marrow. Another advantage is that no
anesthesia is required for BCT, so there is less
risk of complications and fewer medical
contraindications than with bone marrow
harvest. CNPP, Page 501.

Mr. Jones would be awaiting the results for a
matched, unrelated donor transplant. An
autologous transplant would use his own cells;
syngeneic stem cells would be from an
identical twin; UCB would be obtained from an
UCB registry bank. CNPP, Pages 561–562.

Autologous stem cells are typically collected7–
10 days after mobilization chemotherapy during
the recovery period of the patient’s systemic
blood counts. CNPP, Page 564.

The risk of residual disease cells in the
autologous cells is an important disadvantage
of using autologous stem cells. Advantages
include decreased incidence and severity of
side effects, earlier engraftment, and lower
cost compared to other types of transplant.
CNPP, Page 564.

Tandem transplants involve the
administration of two sequential courses of
high-dose chemotherapy followed by
autologous peripheral stem cell rescue after
each course of therapy. CNPP, Page 564.

Allogeneic transplant is the treatment of
choice for individuals with cancer who have
diseased bone marrow or genetic and/or
immunologic diseases. CNPP, Page 564.
A perfect match of HLA markers between the
donor and the recipient is called an 8 out of 8
match and represents today’s gold standard.
CNPP, Page 567.

An advantage of allogeneic transplantation is
the significant benefit of graft-versus-tumor
effect. Disadvantages include increased risk of
graft-versus-host disease, more post-
transplant complications, and longer and more
difficult hospitalizations when compared to
autologous transplant. CNPP, Page 564.

Chimerism is the state where both the
recipient stem cells and the donor stems cells
coexist. Chimerism ultimately induces
favorable graft-versus-tumor effects. CNPP,
Pages 565, 578.

FACT is the organization that has developed
evidence-based global standards for quality
patient care involving all aspects of the process
for transplant centers to follow. CNPP, Pages
565–566.

Sinusoidal obstruction syndrome of the liver,
formerly known as veno-occlusive disease,
begins with injury to the endothelial lining of
the venules and sinusoids that leads to
cytokine and tumor necrosis factor activation.
This results in coagulation and thrombosis,
impairing blood flow, and produces the
syndrome known as VOD/SOS. CNPP, Page
594.

Problems that should be addressed prior to
transplant include alcohol, tobacco, or illicit
drug use. CNPP, Page 566.

The diagnosis of sinusoidal obstruction
syndrome disease is based on clinical findings
in the first 21 days after HCT. Diagnostic
criteria include two or more of the following
symptoms: hyperbilirubinemia, hepatomegaly,
right-upper quadrant pain, and fluid retention.
CNPP, Page 594.

To volunteer to be typed and listed in the
NMDP registry, a donor must provide a buccal
swab sample. All medical costs for the
donation procedure are covered by Be the
Match registry or the patient’s medical
insurance. CNPP, Pages 567–568.

A random donor platelet concentrate may
expose the recipient to multiple tissue
antigens, leading to platelet refractoriness. A
single donor platelet concentrate is taken from
one donor or one HLA-matched donor;
patients are therefore not exposed to multiple
antigens. This may be important with patients
who are severely immunosuppressed, such as
those who have undergone stem cell
transplantation. CNPP, Page 874.

The autologous stem cells are cryopreserved
with DMSO prior to being frozen and stored.
Upon thawing, the DMSO emits a
characteristic odor likened to creamed corn or
garlic. CNPP, Pages 569, 572–573.

Blood products must be irradiated to destroy T
lymphocytes, which can cause graft-versus-
host disease in the marrow recipient. Patients
whose platelets become refractory to random
platelet transfusions can receive human
leukocyte antigen–matched platelets from
family or community donors, and platelets
that have undergone plasmapheresis from
marrow donors yield optimal increments.
Alloimmunization and platelet refractoriness
contribute to a 1% case fatality rate from
hemorrhage complications. CNPP, Pages 594–
595.

Engraftment after transplant with peripheral
blood stem cells occurs approximately 1 week
earlier than bone marrow stem cells.
Following autologous transplant, counts
recover in approximately 8–10 days; after
allogeneic transplant, recovery is at
approximately 19–21 days. Recovery after UCB
transplant takes place at 28 days for
neutrophils and 60 days for platelets. CNPP,
Page 569.

Sinusoidal obstruction syndrome is almost
exclusive to hematopoietic stem cell
transplantation and is the most common
nonrelapse life-threatening complication of
preparative regimen–related toxicity for
hematopoietic stem cell transplantation.
CNPP, Page 594.
The use of PBSCs is preferred over bone
marrow stem cells because these cells are
slightly more mature and reduce the time an
individual is pancytopenic (prone to infection
and/or bleeding). CNPP, Page 569.

One of the main reasons for using blood rather
than bone marrow-derived cells for autologous
transplantation is to avoid tumor
contamination from bone marrow. Gene-
marking experiments have clearly indicated
that relapses can originate from tumor cells
contaminating the cryopreserved cells. It is
true that there is a shortened nadir with blood-
derived cells, but it is not the best answer.

Mobilization of PBSCs is accomplished by
chemotherapy, HGFs, chemokine antagonists,
and investigational agents. CNPP, Pages 569–
570.

The mainstay of treatment for graft-versus-
host disease (GVHD) is systemic
immunosuppressive therapy and
antithymocyte globulin as a single agent or in
combination with steroids. Topical steroids are
used but they may or may not be beneficial.
CNPP, Page 598.

Although chemotherapy alone can be used to
mobilize stem cells, the approach has several
disadvantages such as side effects including
infection, nausea and vomiting, and mucositis.
Mobilization failure can occur in patients who
were heavily treated and hematopoietic
recovery can take 10–16 days. CNPP, Pages
569–570.

The advantages of autologous transplant over
allogeneic transplant are the absence of GVHD
and fewer toxicities. Autologous transplant is
less toxic because there is no sinusoidal
occlusive disease or GVHD. However, there is
a risk of tumor contamination in the
autologous marrow, and there is no benefit of
the graft-versus-leukemic effect, which can
reduce the risk of relapse. CNPP, Pages 562–
564.

Pegfilgrastin is the preferred HGF to use with
HSCT because there is reduced dose frequency
(one subcutaneous injection versus daily) with
comparable efficacy, extended circulating life,
and increased drug stability. CNPP, Page 570.

The most serious side effect of trimethoprim is
hepatotoxicity. Other less severe and
reversible side effects are rash, nausea,
vomiting, and myelosuppression. CNPP, Page
593.

Plerixafor, a chemokine antagonist, is a
reversible inhibitor of SDF-Iα/CXCR4 binding,
blocking the adhesion of stem cells to the BM
stromal cells. This action directly frees cells
from inside the BM to migrate and be released
into the circulation. CNPP, Page 570.

Aggressive antiviral therapy with intravenous
acyclovir is the standard therapy. CNPP, Page
593.

Liquid nitrogen transitions from liquid to gas
quickly when the sealed container is opened.
Adding a lot of nitrogen to the air reduces the
relative amount of oxygen in the atmosphere,
potentially causing an asphyxiation risk.
Therefore, the area where the stem cells are
thawed and administered must be well
ventilated. In addition, healthcare providers
must wear proper safety gear to prevent
contact with the liquid nitrogen or inhalation
of extremely cold vapor when handling frozen
stem cell product. CNPP, Pages 574, 578–579.

Hand washing, scrupulous hygiene, and
protective isolation may be the most cost-
effective and meaningful conventions for
infection control. Anecdotal reports and
clinical observations suggest that use of masks
and garment covers is declining. Cost–benefit
analysis does not ensure that such methods
eliminate or reduce infection. CNPP, Page 592.

Positive cell selection involves removing the
stem cells from the product using sorting
devices, such as columns containing antibody-
coated beads or magnetic beads, and target
antigens (such as CD34 antigens). Negative
cell selection involves removing tumor cells
from the product by physical separation,
chemotherapy, monoclonal antibodies, toxins,
magnetic beads, or radionucleotides. CNPP,
Page 574.

Allogeneic transplants are indicated for acute
myelogenous leukemia, chronic myelogenous
leukemia, and acute lymphocytic leukemia.
Autologous transplants are indicated for breast
cancer predominantly and are used for NHL
and multiple myeloma. CNPP, Page 563.

TBI reaches sanctuary sites where tumor cells
may exist (e.g., central nervous system, testes,
and ovaries), delivers homogeneous dosages to
the entire body regardless of blood supply, and
can be individualized by using shields to
reduce cardiopulmonary effects or to boost
targeting of specific anatomic sites. CNPP,
Pages 575–576.

Immunosuppressive medications are aimed at
removing or inactivating T lymphocytes that
attack target organs. Cyclosporine and
methotrexate inhibit T lymphocytes that are
believed to be responsible for acute graft-
versus-host disease and are the first-line
Donor lymphocyte infusions are used to treat
residual malignant disease. Donor
lymphocytes are collected from the donor
using apheresis and then later reinfused into
the recipient after processing. CNPP, Page 581.

Growth factors, made through recombinant
DNA processes, stimulate pluripotent stem
cells to differentiate and mature. These
products are administered in transplantation
and cause the body to overproduce pluripotent
stem cells beyond the body’s required needs
and induce cell differentiation and maturation.
The administration of HGFs takes place right
before pheresis so that more cells are available
for collection from the circulation. This
process is referred to as mobilization. CNPP,
Page 698.

CD34 is the name of the human gene that
encodes the protein used to identify stem cells
for collection from the autologous (self) or
allogeneic (related or unrelated) donors.
CNPP, Page 558.
78. The answer is a

Risk factors for late chronic GVHD include,
among others, mismatched donor and
recipient, female-to-male transplants, positive
herpes simplex and cytomegalovirus, patient
age over 18 years, prior grade 2–3 acute
GVHD, and chronic myelogenous leukemia
recipients who received methotrexate and
cyclosporine as chronic GVHD prophylaxis.

The incidence of oral HSV virus infection in
cancer patients receiving chemotherapy is
approximately 50%. In the hematopoietic stem
cell transplantation population, the incidence
approaches 80%. Most infections are due to
reactivation of latent infections and the stem
cell transplant population is more at risk for
disseminated HSV infection than other
immunocompromised patients. CNPP, Page
515.

Monocytes are circulating neutrophils that
migrate from the bloodstream into tissues
where they further differentiate into
macrophages or dendritic cells. CNPP, Page
559.
C. RADIATION

Early-stage Hodgkin disease and some skin
cancers are often treated with radiation alone.
CNPP, Page 269.

An indirect hit occurs when ionization takes
place in the medium surrounding the
molecular structures in the cell causing free
radical formation. The free radical knocks the
electrons out of orbit, triggering a variety of
chemical reactions, all destructive to the
tumor. CNPP, Pages 272–273.

The term used to describe the treatment
approach that takes the total dose of radiation
and divides it into equal portions is
fractionation. Hyperfractionation uses smaller
doses per fraction and delivers a dose twice a
day. CNPP, Pages 274–275.

The biggest advantage of high-dose-rate-
brachytherapy is its delivery as an outpatient
treatment and reduced staff exposure to
radiation. HDR brachytherapy has been shown
to be just as efficacious as LDR therapy,
without any increase in mortality, local
recurrence, or late effects. CNPP, Page 276.

Radionucleotides such as iodine-131, yttrium-
90, and strontium-89 are formed by the fusion
of a radioisotope and monoclonal antibody and
work by antibody cell killing related to the
biologic properties of the given antibody.

The prodromal phase is the shortest phase of
acute radiation syndrome, lasting 2 days and
characterized by fever and tachycardia. CNPP,
Page 281.

The four Rs of radiobiology and their influence
on dose fractionation is as follows: Repair of
damaged cells; Redistribution of cell age so
tumor cells will become more radiosensitive;
Repopulation, which takes place during cell
division; and Reoxygenation, which allows the
tumor cells that are in a hypoxic or anoxic
state to become oxygenated and radiosensitive.
CNPP, Page 275.

Approximately 50% of cancer patients will
receive radiation at some point in their disease
trajectory either to cure, control, or palliate the
disease. CNPP, Page 269.

The MammoSite system delivers high-dose
radiation directly to the site of tumor excision
and targets the area where the cancer would
most likely recur. Whole breast radiotherapy is
still used in breast-conserving radiotherapy;
however, treatment is changing for patients
with early-stage breast cancer to include the
concept that partial breast irradiation yields
similar control. CNPP, Pages 320–322.

Megavoltage equipment operates at 2–
40 million electron volts, compared to
orthovoltage equipment’s 40,000–400,000
electron volts. It has the advantages of deeper
beam penetration, more homogeneous
absorption of radiation (minimizing bone
absorption), and greater skin sparing.
Megavoltage equipment includes cobalt and
cesium units, the linear accelerator, the
betatron, and such experimental units as those
producing neutron beams, heavy ions, and
negative pi-mesons. CNPP, Page 309.

Amifostine is a radioprotectant used in
patients receiving radiation for head and neck
cancer. Metronidazole and nimorazole are
radiosensitizers. CNPP, Pages 277–278.

In addition to radioactive implantation, some
radioactive isotopes are administered orally or
intravenously or by instillation. Liquid sources
administered as colloids or solutions are
adsorbed or metabolized and present a
possibility of contamination of equipment,
dressings, and linens, depending on the mode
of administration and metabolism. CNPP,
Pages 1493–1495.

Nurses caring for patients receiving a targeted
therapy such as cetuximab in combination
with radiation therapy must distinguish side
effects of each modality that may require
different interventions such as skin reactions.
Acneiform rash and pruritis caused by the
targeted therapy is managed differently than a
radiation skin reaction. CNPP, Page 278.

Efforts to improve the therapeutic ratio have
resulted in the development of certain
compounds that act to increase the
radiosensitivity of tumor cells or to protect
normal cells from radiation effect.
Radiosensitizers are compounds that
apparently promote fixation of the free
radicals produced by radiation damage at the
molecular level. CNPP, Page 277.

High-LET has greater RBE than low-LET
radiation. Other advantages include decreased
relative radio resistance of hypoxic cells in
tumors and less intertreatment recovery of
tumor cells when a fractionated dose is given.
CNPP, Page 272.

Best practice is to begin teaching prior to the
start of therapy. Assessment and continued
management of symptoms coincides with the
expected timing of symptom development.
During a course of radiotherapy, certain
treatment-related side effects can be expected
to develop, most of which are site specific as
well as dependent on volume, dose
fractionation, total dose, and individual
differences. Many symptoms do not develop
until approximately 10–14 days into treatment,
and some do not subside until 2 or more
weeks after treatments have ended. CNPP,
Page 341.

Acute radiation exposure to doses greater than
10 Gy leads to four syndromes, two of which
are irreversible: cerebrovascular and
gastrointestinal. Hematopoietic failure can be
treated with transplantation. CNPP, Pages
281–282.

Simulator machinery may involve the use of
diagnostic x-rays, fluoroscopic examination,
transverse axial tomography, computed
tomography, and ultrasound, with the goal of
localizing a tumor and defining the volume to
be treated with radiotherapy. Other aspects of
treatment planning include the tattooing of
the treatment area, installing various
restraining and positioning devices to
immobilize the person, shaping the field, and
determining what structures are to be blocked
and protected from radiation. CNPP, Pages287–
290.

Cell death after radiation has multiple forms,
but the two major forms are mitotic death and
apoptotic death. Other forms are necrotic
death, senescence death, and autophagic
death. CNPP, Page 274.

The biologic effects of radiation on humans
are the result of a sequence of events that
follows the absorption of energy from ionizing
radiation and the body’s attempt to
compensate for this assault. Radiation effect
takes place at the cellular level, with
consequences in tissues, organs, and the entire
body. CNPP, Pages 270–271.

Palliation using radiation therapy is used for
prevention of pathologic fractures and return
of mobility. Radiation is used to reduce the
symptoms of superior vena cava syndrome,
fungating lesions, and spinal cord
compression. CNPP, Page 269.

All of the other choices are opposites of the
actual goals of fractionation. Fractionation
redistributes cell age within the cell cycle,
making tumor cells more radiosensitive. It
allows normal cells to repopulate, sparing
them from some of the late consequences that
occur if new growth is inhibited. It also
provides time between treatments for tumor
cells to reoxygenate, thus making them more
radiosensitive. CNPP, Pages 274–275.

Photon radiation is used to treat deep-seated
tumors such as those located in the thoracic,
abdominal, and pelvic areas. Ionizing radiation
has the shortest wave length and the greatest
energy. Particulate radiation has large alpha
particles that penetrate only a short distance
into tissues. Electrons are used to treat surface
lesions. CNPP, Pages 270–271.

Effects of radiation may be acute and
immediate (seen within the first 6 months) or
may be late (seen after 6 months). Acute
effects are due to cell damage in which mitotic
activity is altered. If early effects are not
reversible, late or permanent tissue changes
occur. These late effects are due to the
organism’s attempt to heal or repair the
damage inflicted by ionizing radiation. CNPP,
Page 339.

Bone marrow, ovaries, blood, testes, intestines,
and lymphoid organs have high
radiosensitivity, followed by skin, cornea, oral
cavity, esophagus, rectum, bladder, vagina,
cervix, and ureters. Stomach, growing
cartilage, and growing bone have fairly low
radiosensitivity and muscle, brain, and spinal
cord have low radiosensitivity. CNPP, Page
275.

After insertion of the source, the urine is
strained to retrieve any dislodged seeds.
Hospitalization lasts until decay of the source
is reduced to 30 millicuries or less. A condom
should be worn during intercourse for 2
months after implantation, but the patient
poses no danger as a radioactive source. CNPP,
Page 1861.

Whole brain radiation given to a patient with
SCLC to minimize the risk of developing brain
metastasis. Another example of anticipatory
palliation is treatment of vertebral lesion when
symptoms of impending spinal cord
compression (pain, urinary retention) are
present. CNPP, Page 269.

Exposing women to LED photomodulation can
significantly reduce painful treatment-
interrupting skin reactions. The process
consists of LEDs in a specific array that emits
a nonthermal low-energy light at a pulsating
frequency. It promotes skin repair. Fibroblasts
repair themselves to build up the collagen.

Fatigue associated with radiation therapy may
be caused by an accumulation of cell
destruction end products, anemia, or increased
energy requirements to repair damaged
epithelial tissue. Fatigue has been reported to
affect 65%–85% of individuals receiving
radiation therapy and has been related to
length of treatment, pain, depression, and
weight loss. Fatigue has not been found to
consistently be influenced by age, stage of
disease, time since surgery, weight, or length
of time since diagnosis. CNPP, Pages 345–346.
According to target theory, a direct hit occurs
when molecules within the tumor are
damaged by energy that is directly deposited in
the DNA or RNA. CNPP, Page 273.

Radiation therapy can cause sexual and
reproductive dysfunction through alterations
in organ function (e.g., decreased vaginal
lubrication, enhanced hormonal activity,
overstimulation of the hypothalamus or
pituitary, primary organ failure, ovarian
failure, and testicular aplasia), and through the
temporary and permanent effects of therapy
associated with reproduction (e.g., diarrhea
and fatigue). In addition, radiation therapy can
cause decreases in sexual enjoyment, ability to
reach orgasm, libido, and frequency of
intercourse and sexual dreams, as well as
vaginal stenosis in women. CNPP, Pages 369–
370.

Gentle skin washing with lukewarm water and
mild soap should be initiated when treatment
begins. Rosa should avoid shaving in the
treatment field, avoid lotions in the treatment
field, and protect her skin when outside using
sunblock products with at least SPF 30. CNPP,
Pages 340–345.

Factors that determine the degree, onset, and
duration of radiation-induced skin reactions
include the following, among others: higher
doses given over shorter periods of time to
larger volumes result in more severe acute
skin reactions; electrons produce greater skin
reactions than do photons; and placing tissue-
equivalent material on the skin reduces the
skin-sparing effect of radiation therapy,
allowing for maximum dose at the level of the
skin. Finally, when treatment is targeted at
areas of skin apposition, increased reaction
secondary to warmth and moisture can be
expected. CNPP, Pages 341–345.

Because the effects of radiation are known to
be greatest during mitosis, undifferentiated
cells are more likely to be sensitive to
radiation. The main role of undifferentiated
cells is to divide and provide new cells to
maintain its own population. CNPP, Page 273.

Following radiation therapy, the skin’s ability
to protect itself from ultraviolet rays is
decreased as a result of destruction of
melanocytes in the irradiated epidermis and
the slower rate of melanin production in new
epidermal cells in the radiation field. CNPP,
Pages 340–345.

Tenderness and soreness remain highly
prevalent after SLNB at 3 to 6 months after the
procedure. Tenderness, soreness, tightness,
and numbness are among the most severe and
distressing symptoms associated with both
SLNB and axillary lymph node dissection.

Somnolence syndrome is a cluster of
symptoms consisting of excessive sleepiness
and drowsiness, lethargy, and fatigue with
anorexia. The cause is related to transient
demyelination secondary to radiation.
Symptoms occur 4–12 weeks after radiation
and can last for 2–8 weeks. Patients need
reassurance as the syndrome generally runs its
course. CNPP, Page 350.

Esophageal fistula, stricture, hemorrhage,
radiation pneumonitis, and pericarditis are all
possible complications of radiotherapy for
esophageal cancer. Side effects to be expected
are swallowing difficulties, including burning,
pain, dryness, and skin reactions. CNPP, Pages
355, 357.

The standard for treatment changed when
clinical trial results revealed that of women
with cervical cancer who received platinum-
based chemotherapy concurrently with daily
radiation had a 30%–50% increase in survival.
CNPP, Page 278.

Radiation therapy side effects include
impotence, urinary incontinence, bone marrow
depression, lower extremity edema, cystitis,
urethral strictures, diarrhea, proctitis, and
rectal bleeding. Diarrhea can be problematic,
because a part of the colon and rectum lie
within the irradiated pelvic field. CNPP, Page
1861.

Constipation is sometimes induced
intentionally among patients undergoing
brachytherapy for gynecologic or prostate
cancers. In these situations, a low residue diet
and antidiarrheal agents are prescribed to
prevent bowel movements while implants are
in place. CNPP, Pages 1861–1862.

Common side effects due to radiation of the
large bowel are enteritis, diarrhea, nausea and
vomiting, and flank pain. CNPP, Page 1447.

Alterations in taste are reported during the
second week of treatment. Doses in the 50- to
65-Gy range cause maximum taste loss. The
most severely affected taste qualities are salt
and bitter while sweet taste is generally least
affected. CNPP, Page 352.

Although cardiac complications are much less
frequent using current radiotherapy
techniques, long-term effects include
cardiomyopathy, pericarditis, and congestive
heart disease. CNPP, Page 367.
D. CHEMOTHERAPY

Teach patients that paresthesias may occur in
hands, feet, and hypopharynx. Patients should
avoid exposure to cold for 1 to 5 days after the
drug is given. A scarf wrapped around the neck
and mouth prevents inspiration of cold air that
could cause pharyngolaryngeal dysesthesia,
which is an acute neurotoxicity. CNPP, Page
399.

For patients receiving capecitabine and
warfarin concomitantly, frequent monitoring
of INR or PT is recommended. Clinically
significant increases in PT and INR have been
observed within days to months after starting
capecitabine and infrequently within 1 month
of stopping capecitabine. The interaction of
capecitabine and warfarin is probably due to
an inhibition of cytochrome P-450 by
capecitabine and/or its metabolites, whereby
warfarin is not metabolized properly. CNPP,
Page 462.

Ketoconazole is a drug used to treat fungal
infections but is also used as a second or third
choice hormonal agent to treat prostate cancer.
It blocks the production of male hormones in
the testes and the adrenal glands, slowing the
growth of some prostate cancers. Food,
antacids, cimetidine, and rifampin impair
absorption, whereas the acidic nature of cola
and orange juice has been shown to enhance
absorption. CNPP, Pages 737, 1629.

The metabolic activation and inactivation or
catabolism of drugs is carried out primarily by
the liver. CNPP, Page 391.

Cancer cells can overcome the effects of
cytotoxic drugs either by increasing the
number of target enzymes or by modifying the
enzyme so as to interfere with binding to
antagonistic drugs. The ability of cells to repair
DNA lesions is an important resistance
mechanism seen with alkylating agents and
cisplatin. CNPP, Pages 385–386.

Capecitabine is a prodrug, a chemical
precursor of 5-FU. It undergoes three
enzymatic changes in the body before
becoming 5-FU within the body tissues. CNPP,
Pages 1448–1449.

Docetaxel is metabolized by the liver, and
elevated liver functions can interfere with
metabolism, causing enhanced toxicity of
docetaxel. The dose needs to be reduced.

Chemotherapy currently is given
preoperatively. The rationale for preoperative
chemotherapy is to decrease the size of the
primary tumor (thereby increasing the
likelihood of limb salvage surgery) and to treat
micrometastasis. The route of the
chemotherapy is either intravenous or intra-
arterial. CNPP, Page 1265.

Side effects associated with CMF include
myelosuppression, hair loss, and hemorrhagic
cystitis. CNPP, Pages 396, 398.

Capecitabine is stopped at the first sign of any
of the following grade 2 toxicities: (a) four
bowel movements over normal; (b) nocturnal
stool; (c) stomatitis with pain or discomfort;
(d) vomiting more than once in a 24-hour
period; (e) hand–foot syndrome with pain or
discomfort or affecting activities of daily
living; (f) nausea, loss of appetite, or decrease
in food intake over a 24-hour period; or (g)
unexplained bleeding (especially for those on
warfarin). CNPP, Page 462.

Although 5-fluorouracil is the cytotoxic agent
of choice for colorectal cancer, it is most
commonly administered in combination with
leucovorin. Floxuridine is used in intraportal
chemotherapy through the portal vein or
hepatic artery into the liver in individuals with
metastasis to the liver. CNPP, Page 389.

Patients are monitored closely for signs of
renal impairment (increased blood urea
nitrogen and creatinine, proteinuria), and the
dose of melphalan may need to be reduced
based on the severity of renal toxicity. It is also
important to closely monitor serial blood
counts because the bone marrow-suppressive
effects of melphalan may be cumulative in
older patients. Hypercalcemia and bone pain
are symptoms of the disorder itself rather than
adverse effects. CNPP, Page 1776.

On the first occurrence of grade 2 toxicity
(hand–foot syndrome with pain or discomfort
or affecting activities of daily living) hold
therapy until toxicity reaches a grade 0–1, and
then restart at 100% dose. On the second
occurrence, hold therapy until toxicity reaches
grade 0–1, and then restart at 75% dose. Third
occurrence, hold therapy until toxicity reaches
grade 0–1, and then restart at 50% dose.
Fourth occurrence, discontinue therapy. CNPP,
Page 532.

Chemotherapy agents affect actively growing
(anagen) hairs. Because anagen hair is the
most rapidly proliferating cell population in
the human body, alopecia is a common
toxicity. CNPP, Page 533.

Chemotherapy agents associated with
moderate to severe hair loss include
cyclophosphamide, doxorubicin, datinomycin,
daunorubicin, etoposide, idarubicin,
ifosfamide, irinotecan mechlorethamine,
paclitaxel, topotecan, and vincristine.
Chemotherapy agents associated with only
mild hair loss include vinorelbine, bleomycin,
carmustine, epirubicin, 5-FU, methotrexate,
mitoxantrone, and capecitabine. CNPP, Pages
533–544.

Arthralgias and myalgias with the taxanes is
thought to be due to an inflammatory process.
Corticosteroids are effective because of their
ability to reduce the symptoms of
inflammation and inhibit a variety of
proinflammatory genes. Although arthralgias
and myalgias are not associated with muscle
inflammation per se, corticosteroids are
effective in relieving the aches and pains
associated with these symptoms. CNPP, Page
539.

Despite effective antiemetic regimens, 93% of
patients receiving a high dose of cisplatin
experience delayed nausea and vomiting up to6–
7 days. CNPP, Pages 514–524.

Sunitinib causes a bullous manifestation of
hand-foot syndrome. The hand–foot syndrome
is characterized by an often-painful rash and
swelling of the palms of the hands and soles of
the feet with difficulty walking. CNPP, Pages
532, 632.

Myelosuppression is the most common and
lethal side effect of chemotherapy. Because
hematopoietic cells divide rapidly, they are
vulnerable to chemotherapy, potentially
resulting in dangerously low levels of red
blood cells, white blood cells, and platelets.
When this occurs, patients are at risk for
bleeding, infection, and circulatory
compromise. CNPP, Page 509.

Mitomycin causes cumulative and often
delayed thrombocytopenia. CNPP, Page 510.

Symptoms that could indicate extravasation
include swelling; stinging, burning, or pain at
the injection site (not always present); redness
(not often seen initially); and lack of blood
return. Lack of blood return alone is not
always indicative of an extravasation. An
extravasation can occur even if a blood return
is present. This patient is presenting the
classic signs of extravasation, and the
possibility of a flare reaction is inappropriate.
CNPP, Page 438.

The most obvious sign of drug infiltration is a
bleb formation at the injection site or swelling
that occurs in more deeply accessed veins. The
absence of a blood return does not confirm an
extravasation. The needle bevel or cannula tip
may be positioned against the vein wall,
preventing appropriate and obvious blood
return. CNPP, Page 438.

Hyperpigmentation occurs with bleomycin.
Other drugs inducing this reaction include
cyclophosphamide, busulfan, carmustine,
nitrogen mustard, 5-FU, and etoposide. The
other drugs listed as choices in this question
have in common hypersensitivity reactions.

5-FU may cause acute cerebellar dysfunction,
especially in elderly patients, and is
characterized by gait ataxia, dysarthria,
nystagmus, diplopia, limb incoordination, and
the inability to make fine, coordinated
movements. CNPP, Page 539.

Neurotoxicity characterized by metabolic
encephalopathy manifested as blurred vision,
seizures, motor system dysfunction, urinary
incontinence, cranial nerve dysfunction, or
irreversible coma has been reported in 10%–
20% of patients treated with ifosfamide. CNPP,
Pages 537–539.

To help prevent hemorrhagic cystitis during
therapy with cyclophosphamide, patients are
encouraged to drink 8–10 glasses of fluid a day
and to void frequently. CNPP, Pages 543–545.

The dose-limiting side effect for 5-FU when
given as an intravenous bolus is
myelosuppression, but when the drug is given
by continuous intravenous infusion, the dose-
limiting side effect is mucositis. CNPP, Page
1447.

Cytarabine has a very high (> 90%)
emetogenic potential. CNPP, Pages 518–519.
Cisplatin frequently causes hypomagnesemia,
which manifests as shaking. Daily magnesium
supplementation is indicated during cisplatin
therapy, and electrolyte levels should be
monitored frequently. CNPP, Pages 470–471.

A side effect of docetaxel is fluid retention. The
incidence is related to the cumulative dose,
which can be disabling and worsens with
higher doses. Fluid retention is exhibited
peripherally as abdominal ascites, as a pleural
effusion, or as a combination. CNPP, Page 476.

Chemotherapy agents cause constipation
because of autonomic nerve dysfunction
manifested as colicky abdominal pain. Rectal
emptying is diminished because nonfunctional
afferent and efferent pathways from the sacral
cord are interrupted. CNPP, Page 515.

When these cells are destroyed, atrophy of the
intestinal mucosa and shortening of the
intestinal villa with flattening and reduction of
the absorptive surface results in a “slick gut.”
Thus, the intestinal contents move rapidly
through the gut, reducing absorption of
nutrients. CNPP, Pages 514–515.

The leucovorin potentiates the antitumor
effect of the 5-fluorouracil, but it also
increases the diarrhea. CNPP, Page 389.

Fluorouracil is the chemotherapy drug that
most commonly causes diarrhea. CNPP, Pages
513–514.

Platinum-based chemotherapy can cause a
specific nutritional deficiency, resulting in
hypomagnesemia. The deficiency is highly
specific to this drug. CNPP, Pages 470–471.

Pulmonary toxicity usually is irreversible and
progressive because of chemotherapy
administration. The initial site of damage
seems to be the endothelial cells, with an
inflammatory-type reaction resulting in drug-
induced pneumonitis. CNPP, Page 541.

Pulmonary toxicity usually presents clinically
as dyspnea, unproductive cough, bilateral
basilar rales, and tachypnea. CNPP, Page 541.

Cyclophosphamide and nitrogen mustard are
alkylators and quite toxic but generally do not
cause significant anemia. Carboplatin is
platelet sparing. CNPP, Page 509.

Acute effects are immediate in onset, resolve
quickly without serious complications, and
dose reduction is not indicated. Chronic
cardiotoxicity occurs weeks or months after
administration. Because effects are
nonreversible, the cumulative dose is
monitored and discontinued prior to onset of
toxicity. CNPP, Page 535.

Vincristine, vinblastine, and vinorelbine are
the most common chemotherapy agents to
cause neuropathies that can result in
constipation. CNPP, Page 537.
E. BIOTHERAPY

Cytokines (which include lymphokines) are
substances released from activated immune
system cells that affect the behavior of other
cells. Included among the cytokines are the
interferons and interleukins, tumor necrosis
factor, and colony-stimulating factors. CNPP,
Pages 31–32.

Body temperature is controlled by preoptic
anterior hypothalamic brain centers in a
feedback mechanism. Pyrogenic pathogens,
toxins, or drugs stimulate the release of
endogenous pyrogenic cytokines, which act on
thermal brain centers via prostaglandin release
and create an upward reset of the body’s
temperature set point. Feedback mechanisms
now read the body temperature as cold and
initiate heat-producing actions such as
involuntary muscular contractions or rigors.
CNPP, Page 628.

Vaccination entails the administration of an
immune-stimulating agent, thereby causing an
immune reaction against the foreign
substances contained in the vaccine. CNPP,
Page 638.

BCG is approved for intravesical instillation as
treatment of cancer in situ of the bladder. BCG
instillation sets off a cytokine cascade that
produces a T-cell mediated immune response
and a mucosal infection that may last several
months. BCG is contraindicated when the
patient has an infection (including active
tuberculosis), recent surgery (biopsy,
transurethral resection) or hypersensitivity to
a BCG product. Common side effects of BCG
instillation include painful urination and fever.

Biologic response modifiers can be classified
as agents that restore, augment, or modulate
host antitumor immune mechanisms; cells or
cellular products that have direct antitumor
effects; and biologic agents that have other
biologic antitumor effects. Agents that bind
with cell surface receptors are targeted
therapies. CNPP, Pages 629–633.
Cervical and hepatocellular cancer are two
types of cancer that are strongly correlated
with viruses. The antigens for targets for
destruction by viral antigens are HPV
(cervical) and Hepatitis B and C
(hepatocellular cancer). CNPP, Pages 638–639.

The interferons (IFNs) are a family of
naturally occurring complex proteins that
belong to the cytokine family. Each of the
three major types in humans—alpha-IFN,
beta-IFN, and gamma-IFN—originates from a
different cell and has distinct biologic and
chemical properties. Immunomodulatory
activity consists of interaction of interferon
with T lymphocytes that stimulate a cellular
immune response. CNPP, Pages 623–627.

The cytokine network is an overlapping,
interactive communication pattern within the
immune system. Cytokines share many
properties, such as mediating and regulating
the immune defense functions of the body.
They can influence the stimulation of other
cytokines to produce synergistic effects, as in a
cytokine network, or to antagonize the actions
of other cytokines. They do not direct
lymphocyte migration. CNPP, Page 32.

Sipuleucel-T is administered in three
intravenous doses given at 2-week intervals.

Although some thinning can occur, true
alopecia is rare. Rapid weight gain occurs
because of capillary leak syndrome. Severe
itching and pruritus can be intense because of
severe skin dryness. The most severe side
effects of nausea, vomiting, and diarrhea occur
with interleukin-2 therapy, particularly high-
dose regimens. CNPP, Pages 615–620.

Intense chills and headache generally occur
before fever spike and are predictable within
the first 2–4 hours of administering biologics.
Ways to minimize the severity of the
symptoms is to administer the drug by
subcutaneous injection or in the evening so
the patient can sleep through the symptoms.
Patients should be prepped prophylactically
with acetaminophen with or without
benzodiazepine to avoid symptoms from
becoming so intense they have a negative
impact on the patient’s quality of life. They
should also be informed that these symptoms,
including myalgias, arthralgias, and fatigue,
are common with flu-like syndrome. This
syndrome has been identified as one of the
most common dose-limiting toxicities
associated with therapy with biologics due to
its interference with normal activities. CNPP,
Page 617.
F. IMMUNOTHERAPY

The types of immunotherapies are monoclonal
antibodies, adoptive cellular transfer therapy,
cytokines, and vaccines. CNPP. Pages 32,33,
614–623, 638, 644.

Prostate, renal, multiple myeloma, and
malignant melanoma are all cancers that have
immunotherapies approved by the Food and
Drug Administration. CNPP, Pages 688, 1777,
1866, 1888, 1931–1932.

The immune checkpoints that are targeted by
checkpoint inhibitors are CTLA-4, PD-1, and
PD-L1. CNPP, Pages 631, 665.

Host immunological response can be used to
alter the natural course of some cancers,
especially malignant melanoma. Infusion of
TILs is an active form of immunotherapy. TILs
can mediate tumor regression in patients with
melanoma. CNPP, Pages 688–689.
Tumor-specific T-cells are a form of adoptive
immunotherapy and cytokine genes and DNA
vaccines are examples of active
immunotherapy. CNPP, Pages 688–689.

Lenalidomide, pomalidomide, and thalidomide
are immunomodulatory drugs used to treat
patients with multiple myeloma. CNPP, Page
1777.

The unique mechanism of action of
pomalidomide is to affect adhesion and the
bone marrow stroma such that myeloma cells
cannot grow. CNPP, Page 1777.

Nivolumab is a PD-1 checkpoint inhibitor that
selectively blocks interaction between PD-1
and PDL-1 & PDL-2. CNPP, Pages 1886, 1888.

Interferon (IFN) in standard and high doses
has both direct cytotoxicity and indirect
stimulation of the host immune response. In
low doses, IFN has antiangiogenic properties.
Due to high toxicity, high-dose IL-2 is given
only to patients with few comorbidities. CNPP,
Pages 1931–1932.

Immune-related gastrointestinal adverse effect
results in diarrhea and colitis. Patients with
grade 2 diarrhea are treated with dose delays
and corticosteroids; grades 3 and 4 are treated
with higher doses of steroids and may even
require hospitalizations. CNPP, Pages 635–
636.

Approximately 35% of patients treated with
CTLA-4 inhibitor (ipilimumab) experience
enterocolitis. CNPP, Pages 635–636.
G. TARGETED THERAPY

Growth factor receptors are proteins found or
expressed on the cell membrane that serve as a
bridge between extracellular and intracellular
environments. CNPP, Page 654.

The major side effects of gefitinib (Iressa) are
skin rash and diarrhea. It rarely causes any
allergic-type reaction, hypotension, or effect
on the bone marrow. CNPP, Pages 667–669.

Monoclonal antibodies interfere with cell
membrane-bound targets by blocking ligand
receptor activation, antibody-dependent
cellular cytotoxicity, complement-mediated
cytotoxicity, and immune modulation. CNPP,
Page 654.

The most common side effects reported by 774
patients are asthenia/malaise, abdominal pain,
fever, headache, nausea, vomiting, diarrhea,
acneform rash, and others. Nail disorders are
rare, but choice c is the best answer. Rarely is
alopecia or disorientation seen with
cetuximab. CNPP, Page 662.

Abnormalities in signal transduction lead to
increased cell proliferation, sustained
angiogenesis, tissue invasion, metastases, and
apoptosis inhibition. CNPP, Page 654.

Cell signaling begins with the activation of the
receptor on the cell membrane by the ligand or
growth factor. The ligand binds to the receptor
causing dimerization (activation). The signal
crosses the cell membrane into the
intracellular domain where tyrosine kinase
(TK) activation occurs. This triggers a
downstream cascade of signaling pathways
that influence cell regulation. CNPP, Page 654.

Cetuximab (Erbitux) is a monoclonal antibody
that attaches to epidermal growth factor
receptor on both normal and tumor cells.
When cetuximab attaches to the epidermal
growth factor receptor, it blocks the signaling
agents from attaching and starting the cell
dividing process. CNPP, Page 661.
Cell signaling is affected by both extracellular
and intracellular events. Extracellular events
are ligand binding and receptor
overexpression. Intracellular events that turn
on the signals include the binding of
intracellular proteins, receptor mutation,
crosstalk (heterologous signaling), and loss of
regulatory mechanisms. CNPP, Page 654.

Severe infusion reactions are rare with
cetuximab, but they do occur. Approximately
90% of severe infusion reactions were
associated with the first infusion despite the
use of prophylactic antihistamines. These
reactions were characterized by the rapid onset
of airway obstruction (bronchospasm, stridor,
and hoarseness), urticaria, and/or
hypotension. Caution must be exercised with
every cetuximab infusion because some
patients experienced their first severe infusion
reaction during later infusions. Severe
infusion reactions require the immediate
interruption of therapy and permanent
discontinuation from further therapy. CNPP,
Page 666.

The activation of the intracellular tyrosine
kinase region begins with binding of the ATP
molecule, which then causes phosphorus to be
released. Phosphorylation triggers the
intercellular pathways. CNPP, Page 656.

Bevacizumab is an antiangiogenic agent that
inhibits blood vessel formation, which starves
the tumor. In addition, bevacizumab may have
an effect of remodeling existing tumor
vasculature to improve drug penetration,
thereby enhancing antitumor efficacy of
chemotherapeutic agents. CNPP, Pages 660–
661.

Nitric oxide is a messenger molecule (a
molecule that carries signals between cells)
that can regulate various physiologic
functions, including blood pressure. Some
studies suggest that VEGF increases nitric
oxide production, resulting in vasodilation.
Reducing nitric oxide production results in
vasoconstriction; it has been hypothesized that
this process could play a role in hypertension.

The likelihood of greater response to EGFR
tyrosine kinase inhibitors has been found in
females, those with adenocarcinoma histology,
patients of Japanese ethnicity, and patients
with no previous history of smoking. CNPP,
Page 568.

Proteinuria can occur with cancer and some
cancer therapies. In a clinical setting,
impairment of the glomeruli that make up the
kidney may be a pathologic cause of persistent
proteinuria. Inhibition of VEGF, a key
endothelial growth factor, has been shown to
impair glomerular endothelial cells that
normally filter water and small solutes and the
risk remains as long as the patient is on
treatment. CNPP, Pages 660–661.

K-RAS gene mutations are good predictors of
resistance to cetuximab and panitumumab,
two anti-EGFR monoclonal antibodies used in
the treatment of metastatic colorectal cancer.
Approximately 40% of patients with colorectal
cancer have a K-RAS mutation. CNPP, Page
568.

Because malignant tumors cannot grow
beyond 1–2 mm without establishing a new
blood vessel system, agents are being studied
that have the capacity to neutralize growth
factors, such as VEGF. CNPP, Page 660.

Temsirolimus was approved as first in class in
May 2007, for the treatment of advanced renal
cell carcinoma. CNPP, Pages 659, 664.

Hypersensitivity reactions are common and
are related to the infusion rate. Hypotension,
bronchospasm, and angioedema may occur.
The first action is to stop the infusion and
restart at 50% of the dose after the symptoms
have resolved. Stop the infusion if serious
cardiac arrhythmias develop. Angina may
occur post-infusion, especially in individuals
with a prior history. CNPP, Pages 670, 913.

Patients who react to the cetuximab usually
react the first time with the loading dose but
then not again during subsequent dosing. The
patients generally do very well once they have
the diphenhydramine and can continue their
treatment. CNPP, Pages 670, 913.
RAS gene mutations are associated with
approximately 1 in 3 human cancers, including
90% of all pancreatic cancers, 50% of all colon
cancers, and 30% of all non-small cell lung
cancers. CNPP, Page 659.

BRAF is the most commonly mutated
oncogene in melanoma (in 50%–60% of
cases). BRAF mutations are also found in
colorectal cancer (57%) and hairy cell
leukemia (100%).

Imatinib, dasatinib, and nilotinib are all
inhibitors of BCR-ABL. BCR-ABL is a protein
tyrosine kinase formed when a specific gene
translocation known as the Philadelphia
chromosome occurs. The BCR-ABL oncogene
is formed when the BCR gene on chromosome
22 becomes fused with the ABL gene located
on chromosome 9. CNPP, Pages 660, 664.

This is not considered an allergic reaction
because it is the result of direct interference
with the functions of epidermal growth factor
receptor signaling in the skin and is treated
locally with steroid cream. Antibiotics are used
for pustular lesions. The drug would only be
stopped if the rash covered greater than 60%
of the body with symptomatic erythroderma or
if vesicular eruption or desquamation occurs.

Trastuzumab, bevacizumab, and pertuzumab
are all examples of humanized monoclonal
antibodies. CNPP, Pages 657, 661–662.

High levels of EGFRs on cells from cancers of
the breast and bladder indicate a worse
prognosis. High levels of EGFRs are noted on
many epithelial carcinomas, and mutant
EGFRs have been found on high-grade
glioblastomas. CNPP, Page 658.

Black box warnings have been issued for
cetuximab for risk of RPLS with hypertension
and fluid retention, thromboembolic events
such as cerebral vascular accidents, myocardial
infarction, transient ischemia attack and
angina, risk of fistula formation including
tracheoesophageal, bronchopleural, biliary,
vaginal, and bladder fistulas. CNPP, Page 662.
There is an inverse correlation between EGFRs
and ER status, with ER-negative tumors
tending to have a higher level of epidermal
growth factor receptor than ER-positive
tumors. Therapy that interferes with EGFRs
provides therapeutic benefit in women who
overexpress EGFR. CNPP, Page 1306.

A MUGA (multigated acquisition scan) is
indicated for baseline assessment of patients
to receive lapatinib. The therapy is
discontinued if the left ventricular ejection
fraction drops below normal. CNPP, Page 663.

The angiogenic switch refers to the ability of
tumor cells to release angiogenic factors and
convert the tumor cell to an angiogenesis
inducer. This switch correlates with an
increased production of VEGF, which is known
to induce angiogenesis. A primary trigger of
the angiogenic switch is tumor hypoxia, which
turns on the VEGF tyrosine kinase signaling
pathway. CNPP, Page 662.

The most common toxicity associated with
targeted agents are dermatologic reactions and
diarrhea. CNPP, Pages 665–668.

Tumor angiogenesis is a complex multistep
process that enables tumors to develop a new
blood supply from a preexisting vascular
network. CNPP, Page 662.
H. VASCULAR ACCESS DEVICES

Since she has had chills in the past after
chemotherapy, she can go home, but needs to
report any temperature elevation. Systemic
infections can be thrombus related or caused
by intraluminal catheter colonization with a
wide variety of infective organisms. Signs and
symptoms include fever and chills, especially
following vigorous flushing of the catheter.
Blood cultures are obtained peripherally.
CNPP, Page 458.

During a landmark prospective-randomized
study in a surgical intensive care unit,
researchers evaluated 10% povidone-iodine,
70% isopropyl alcohol, and 2% aqueous
chlorhexidine skin disinfection before central
venous catheter insertion and for site
maintenance every other day. The
chlorhexidine treatment group had a
significantly decreased incidence of local
catheter-related infection and infusion-related
bacteremia. CNPP, Page 454.
The PICC requires daily flushing and central
line dressing changes as frequently as every 3–
7 days. Although some PICCs have more than
one lumen, any lumen can be used for blood
withdrawal. The major advantage is that the
catheter can be placed by specially trained
nurses in the home, so the patient can avoid
going to the hospital or doctor’s office. CNPP,
Page 548.

Catheter position can inhibit blood return and
flushing with extra fluid may change the
position to allow blood return. In addition,
leakage or extravasation of fluid will be
detected. In the case of implanted ports, the
cause of drug extravasation is usually a
misplaced or displaced needle. Another
mechanism for drug extravasation from ports
involves retrograde subcutaneous leakage
from percutaneously inserted catheters
obstructed by a fibrin sheath. CNPP, Page 452.

The Ommaya reservoir is surgically implanted
through the cranium. It is placed underneath
the skin with the catheter extending from the
reservoir to the ventricle. It provides
permanent intraventricular access for patients
in whom repeated translumbar puncture is
impractical. Cerebrospinal fluid is gently
aspirated and sent for cytology or laboratory
studies. The chemotherapy drug is
administered slowly. CNPP, Pages 416, 447.

PICCs are ideal for short-term access (1 week
to several months). CNPP, Page 448.

Epidural ports are used to administer
intrathecal or epidural medications. Epidural
ports are flushed with 1–2 ml of sterile
preservative-free saline after use. Never flush
epidural lines with heparin. CNPP, Pages 446–
447.

Signs and symptoms of a venous thrombosis
are related to impaired blood flow and include
edema of the neck, face, shoulder, or arm;
prominent superficial veins; neck pain;
tingling of the neck, shoulder, or arm; and skin
color or temperature changes. A venogram
with contrast media is used to assess for a
venous thrombosis. CNPP, Page 456.

When giving a vesicant, it is always better to
have a blood return throughout the injection,
so a smaller gauge needle is not preferable in
that situation. For patients with small veins,
choose an angiocatheter that is thin walled
with an over-the-needle cannula. Avoid
starting the IV below a venipuncture site.

A patient undergoing BCT requires a catheter
that is stiffer than the traditional central
venous catheter used for ABMT because of the
need for high volume and pressure during
pheresis. CNPP, Pages 452–453.

The incidence of catheter-related bacteremia is
influenced by specific therapy, degree of
catheter use, patient population, catheter
insertion technique, and care and maintenance
procedures. However, neutropenia remains the
primary risk factor for patients with an
infection who have a vascular access catheter.
CHAPTER 4
Symptom Management and

Palliative Care
A. ETIOLOGY AND PATTERNS OF SYMPTOMS
1. Mr. Huang has metastatic prostate

cancer, diabetes, and uncontrolled
hypertension. He has mild congestive
heart failure and is currently receiving
two units of packed red blood cells for a
hemoglobin of 8 g/dL. Your colleague
asks why he is not given erythropoietin
alfa rather than risk complications of a
fluid overload. Your most appropriate
response would be which of the
following?
1. Erythropoietin alfa injections take 2–6
weeks to be effective.
2. Erythropoietin alfa is contraindicated in
patients with uncontrolled hypertension.
3. Erythropoietin alfa can potentially increase
his severity of congestive heart failure and
stroke.
4. Erythropoietin alfa is only given to anemic
patients being treated with
myelosuppressive chemotherapy with
noncurative intent and who are mildly
symptomatic.
Disseminated intravascular coagulation
2. (DIC) is an oncologic emergency
characterized by exaggerated
overstimulation of normal coagulation,
in which thrombosis and then bleeding
occurs. What is the most common cause
of DIC in patients with cancer?
1. Liver disease
2. Prosthetic devices
3. Thrombocytopenia
4. Infection and sepsis
3. Alex has undergone allogeneic stem cell

transplantation, and it is now day + 30.
He is experiencing itching and burning
of the skin. Which of the following
statements is true concerning his
symptoms?
1. These symptoms suggest an appropriate
immune response.
2. These symptoms are indicative of acute
graft-versus-host disease (GVHD).
3. These symptoms are indicative of chronic
GVHD.
4. These symptoms are to be expected and are
likely due to the multiple medications he is
taking.
4. Factors that increase the risk for the
development of graft-versus-host disease
(GVHD) include:
1. Related donor, matched human leukocyte
antigen (HLA), younger donor/recipient
age, negative donor/recipient viral
seropositivity
2. Unrelated donor, matched HLA, older
donor/recipient age, positive
donor/recipient viral seropositivity
3. Related donor, mismatched HLA, younger
4. Unrelated donor, mismatched HLA, older
5. Ocular graft-versus-host disease (GVHD)

is often characterized by:
1. Frequent eye infections
2. Overproduction of tears
3. Visual acuity changes due to retinal
damage
4. Eye dryness with an associated gritty/sandy
feeling in the eye
6. The most common risk factors for veno-

occlusive disease (VOD) of the liver in
hematopoietic stem cell transplantation
(HSCT) include which of the following?
1. Mismatched sibling transplant
2. Cytomegalovirus and fungal infections
3. Treatment with multiple blood
transfusions
4. Chemotherapy and radiation therapy
before transplant
7. Common symptoms experienced by

patients with obstructive jaundice
include:
1. Diarrhea
2. Constipation
3. Hypocalcemia
4. Hyperglycemia
8. Mary is receiving paclitaxel on a weekly

basis. She commonly experiences nausea
and is prescribed the antiemetic
granisetron to take if she needs it. She
complains that she is having trouble
sleeping and often feels agitated at night.
Which of the following is a logical
explanation for her symptoms?
1. She is probably feeling agitated due to the
granisetron.
2. Insomnia and restlessness are common in
anyone undergoing treatment for cancer.
3. Adverse neurologic effects, including sleep
disruption, are common in patients taking
paclitaxel.
4. Her difficulty in sleeping is likely due to
the Decadron she takes to prevent
hypersensitivity reactions to the paclitaxel.
9. Your patient has lymphoma and has

been tracking his fever for the past week
and complains of a fever that has been
low grade with only a slight spike
without returning to normal. He is
frequently tachycardic and tachypneic
with some periods of extreme fatigue.
His last chemotherapy was 2 weeks ago.
Given these symptoms his fever pattern is
probably indicative of which type of
infection?
1. Viral infection
2. Bacterial infection
3. Gram-negative infection
4. Disseminated fungal infection
10. Mr. Joseph received high-dose

methotrexate for sarcoma of his pelvis 6
days ago and is currently at home
complaining of a low-grade fever, slight
mucositis, and diarrhea (5 to 6 times per
day) for the past 2 days. His medications
include prophylactic antibiotics and
morphine sulfate for pain. Nursing
management includes which of the
following?
1. Stop the antibiotics because they are
probably causing the diarrhea.
2. Push fluids and oral hygiene as slight
mucositis and diarrhea are expected.
3. Give loperamide 2 mg orally with each
loose stool, not to exceed 16 mg per day.
4. Get a stool specimen to test for
Clostridium difficile, which is common in
patients receiving prophylactic antibiotics.
He is probably neutropenic.
11. Nursing management of a febrile

nonhemolytic transfusion reaction
presenting as fever, chills, headache,
hypotension, tachypnea, and dyspnea
includes which of the following?
1. Slow the transfusion and evaluate the
response to the decreased rate.
2. Place the patient in the Trendelenburg
position, and administer a fluid bolus.
3. Stop the transfusion, and maintain a patent
intravenous line with normal saline.
4. Maintain the infusion rate and continue to
monitor the patient’s response to the
transfusion.
12. The primary cause of acute hemolytic

transfusion reactions results from:
1. The presence of leukocyte antibodies in
donor plasma
2. Destruction of incompatible donor red cells
by recipient antibodies
3. Release of antibody-mediated endogenous
pyrogens and/or release of cytokines
4. Viable lymphocytes contained in transfused
blood engraft in the recipient and mount an
immunologic response against the
immunocompromised host
13. Your patient has notified you that she

has pain across her scalp 2.5 weeks after
her first dose of chemotherapy. Which of
the following would be included in her
patient teaching?
1. Advise her not to wash her hair as this may
promote alopecia.
2. Refer her to her doctor/advanced practice
provider for narcotic pain management.
3. Refer her to her doctor/advanced practice
provider because this could indicate skin
metastases.
4. Explain that gentle massage and the use of
pain medication such as a nonsteroidal
anti-inflammatory agent may alleviate the
pain.
14. A 70-year-old patient is receiving

cyclophosphamide, doxorubicin, and
vincristine for lung cancer. He also is
receiving opioid analgesics for pain. He
normally has a bowel movement every
day. He reports that he has not had a
bowel movement in 3 days but does not
feel the urge and has not been eating
normally. Appropriate nursing
assessment and management include
1. He should take a laxative and call if there
are no results in 24 hours.
2. Elderly patients often have a decrease in
colonic transit time, and with time he will
have results.
3. He should take a laxative, such as milk of
magnesia, and call if he has no bowel
movement in 48 hours.
4. He has not had a normal routine so it is a
good idea to increase fiber and fluids and
call if there is no bowel movement in 24
hours.
15. John just completed brachytherapy for

early stage prostate cancer and he is
complaining of constipation for 4 days.
You explain to him that the most
significant risk factors for the
development of constipation related to
his therapy is which of the following?
1. The treatment-related bedrest
2. Opioid therapy for his prostate cancer
3. The high residue diet and hydration that he
has been instructed to be on due to the
implants
4. The low residue diet and antidiarrheal
agents he has been instructed to be on due
to the implants
16. The etiology of anemia of malignancy is

complicated, but the two most common
causes include:
1. Protein-calorie malnutrition and bleeding
2. Increased red blood cell destruction due to
chronic hemorrhage and hemolysis
3. Tumor secretion of cytokines that affect
red blood cell metabolism and anemia of
chronic disease
4. Decreased red blood cell production
secondary to primary disease and
myelosuppressive therapy
17. Your patient with leukemia who has

recently undergone a stem cell
transplant is severely
immunosuppressed and is experiencing a
coagulopathy. She is also experiencing
hemoptysis, dyspnea, and fatigue. She is
most likely suffering from which of the
following?
1. Lung cancer
2. Pneumonia
3. Cardiac tamponade
4. Alveolar hemorrhage
18. A 75-year-old patient with lung cancer

complains of extreme fatigue. He is not
very active, and due to a hemoglobin of
g/dL, the decision is made to bring
him into the outpatient infusion
center to be transfused with two
units of packedred blood cells. The
primary problem associated with a
low hemoglobin count
and the reason to transfuse this patient is
1. Risk for stroke
2. Risk for angina
3. Risk for hemorrhage
4. Risk for hypovolemia
19. Emesis is a complex physiologic response

to the toxic effects of chemotherapy.
Which of the following is considered to
be a part of the chemotherapy-induced
nausea–vomiting response mechanism?
1. Physical injury to cancer cells
2. Stimulation of peripheral nerves
3. Vagal stimulation of the medulla oblongata
4. Stimulation of the acupressure points in
the head and neck

agents is most likely to potentiate the
problem of esophagitis in patients also
receiving radiation therapy to the
esophagus?
1. Paclitaxel
2. Procarbazine
3. Dactinomycin
21. An elderly woman presents with a
thyroid mass and symptoms of dyspnea
and dysphagia. Assessment indicates
carcinoma of the thyroid with metastases
to the lung. Her symptoms of dyspnea
and dysphagia are most likely to be the
result of which of the following?
1. Infection caused by irritation of the oral
mucosa
2. Compressive effects of the tumor on the
larynx and esophagus
3. A high concentration of iodine in the
follicular cells of the thyroid
4. Involvement of the parathyroid gland and
associated hypercalcemia
22. Following a course of high-dose

chemotherapy, your patient complains of
mouth soreness. Upon physical
inspection you notice the lining of her
mouth to be ulcerated with red patches.
Your care recommendations are based
on which of the following facts regarding
oral care?
1. She should rinse with a chlorhexidine
solution.
2. She should rinse with a normal saline or
bicarbonate solution 4 times daily.
3. She should rinse with granulocyte-
macrophage colony-stimulating factor
mouthwash.
4. She should decrease the frequency of her
oral care because the lining of her oral
cavity is becoming irritated.
23. Mucositis is observed more often when:

1. High-dose methotrexate is given alone.
2. Fluorouracil (5-FU) is given as a bolus.
3. Bleomycin is used to abruptly replace 5-FU.
4. 5-FU is given as a continuous infusion.
24. Which of the following poses the

greatest risk of mucositis to a patient
receiving radiation to the base of the
tongue?
1. Tobacco usage
2. Poor oral hygiene
3. Metal tooth fillings
4. Alcohol consumption
25. Which of the following would be

considered an example of direct
stomatotoxicity?
1. Pancytopenia and gingivitis occur.
2. Cellular breakdown is due to high alcohol
content in mouthwashes.
3. Bleeding from the gums following flossing
in the patient with low platelets
4. The cytotoxic action of drugs on the cells of
the oral basal epithelium causes a decrease
in the rate of cell renewal.
26. After radiation treatment, Michelle

complains of a dry mouth and within 3
weeks develops thick, ropy saliva. What
is the side effect Michelle is
experiencing?
1. Trismus
2. Mucositis
3. Xerostomia
4. Desquamation
27. Four weeks after radiation therapy ends,

Mr. Allen complains that the xerostomia
is not improving. The physician
prescribes 5 mg of oral pilocarpine three
times a day. Your teaching includes
which of the following points?
1. Photosensitivity worsens over time.
2. The pilocarpine is a saliva substitute.
3. The pilocarpine is used to suppress the
exocrine gland production.
4. Side effects include diaphoresis,
lacrimation, and increased gastric
secretion.
28. Besides a dry mouth, the primary

problem with xerostomia is:
1. Increased risk of dental caries
2. Lack of pH balance in the mouth
3. Increased tracheal and esophageal
irritation
4. Heightened taste sensation for sweet and
sour foods
29. Which of the following risk factors are

closely associated with the development
of radiation-induced nausea and
vomiting?
1. Female gender, older age (> 65), high
alcohol intake, history of motion sickness
2. Female gender, younger age (< 55), low
alcohol intake, history of radiation-induced
nausea and vomiting
3. Female gender, younger age (< 55), high
alcohol intake, history of radiation-induced
nausea and vomiting
4. Male gender, younger age (< 55), high
alcohol intake, history of post-anesthesia
nausea and vomiting
30. The most common cause of anticipatory
nausea and vomiting is:
1. Combination chemotherapy
2. Patients who have a significant history of
motion sickness
3. Emetic control related to chemotherapy
has been inadequate
4. Serotonin release from enterochromaffin
cells when the patient thinks about
chemotherapy
31. Your 25-year-old patient was just

diagnosed with acute myelogenous
leukemia and will be starting on
induction-remission therapy of “7 + 3”
(cytarabine and daunorubicin).
Important teaching includes which of
the following about these agents?
1. These drugs may cause significant
constipation and she will need to eat a high
fiber diet.
2. These drugs may cause reproductive
dysfunction including decreased libido and
ovarian dysfunction.
3. These drugs have a high risk of the
development of pulmonary dysfunction
and pleural and pericardial effusions.
4. Due to a high risk of allergic reactions to
these agents, she will be pretreated with a
dose of diphenhydramine prior to the
administration of both agents.
32. Predisposing factors in the development

of cancer-related sleep disturbance
include:
1. Female gender, advanced age, anxiety-
prone personality
2. Type of cancer, stage of cancer, treatment-
related side effects
3. Poor sleep hygiene practices, irregular
sleep schedule, sedentary lifestyle
4. Naps, fear of sleeplessness, excessive
worries about daytime consequences of
sleep loss
33. Which of the following solid tumors has

the highest incidence of brain
metastasis, thereby increasing the
patients’ risk of developing increased
intracranial pressure?
1. Lung cancer, breast cancer, and melanoma
2. Lung cancer, breast cancer, and
osteosarcoma
3. Lung cancer, head and neck cancer, and
renal cancer
4. Head and neck cancer, breast cancer, and
renal cancer
34. Your patient with pancreatic cancer is

noted to have anorexia, progressive
involuntary weight loss, and ongoing
loss of skeletal muscle mass. This
syndrome is called:
1. Ageusia
2. Dysgeusia
3. Early satiety
4. Cancer cachexia
35. The consequence of infection with gram-

negative organisms that can quickly lead
to death is:
1. Dehydration
2. Anaphylaxis
3. Endotoxic shock
4. Gastrointestinal bleeding
36. What is the single most important risk

factor in the development of sepsis in the
patient with cancer?
1. Skin breakdown
2. Granulocytopenia
3. Hematologic malignancy
4. Low albumin at the onset of symptoms of
sepsis
37. Which of the following is considered to

be the cardinal symptom of infection?
1. Fever
2. Inflammation
3. Pus formation
4. Elevated white blood cell count
38. The primary cause of infection in cancer

patients continues to be:
1. Fungal infections
2. Mycobacterial infections
3. Gram-positive organisms
4. Gram-negative organisms
39. The body’s first line of defense against

bacteria, which is commonly altered by
cancer therapies, is/are:
1. The skin
2. Macrophages
3. Granulocytes
4. The acid pH of fluid
40. The specific white blood cell that

constitutes 35%–76% of circulating white
blood cells and responds quickly to
bacterial invasion is the:
1. Monocyte
2. Macrophage
3. Lymphocyte
4. Polymorphonuclear neutrophil (PMN)
41. What is the name given to the microbes

that normally live in the body and lead to
a large percentage of infections in
immunocompromised patients?
1. Exogenous organisms
2. Endogenous organisms
3. Intracellular organisms
4. Extracellular organisms
42. Poorly treated or unrelieved pain is a

common problem for the individual with
cancer. A common reason for this is
1. Reluctance of the patient to report pain
2. Access to health care and appropriate
treatment
3. Difficulty controlling cancer pain and
expensive medications
4. Failure of the healthcare profession to
routinely assess pain and pain relief
43. Joan has been treated with vincristine
therapy and now complains of a burning-
like pain with a sensation of pins and
needles in her toes and feet. This type of
pain is:
1. Cognitive pain
2. Neuropathic pain
3. Nociceptive: somatic pain
4. Nociceptive: visceral pain
44. Management of neuropathic pain often

includes what type of drug or drug
classification?
1. Opioids
2. Acetaminophen
3. Antispasmodics
4. Tricyclic antidepressants
45. The primary criteria for assessment of

situational depression include which of
the following characteristics?
1. Depressed mood once in awhile
2. Characteristics that were preexistent
3. Fatigue or loss of energy for 1 or 2 days
4. Characteristics that are a change from
previous functioning
A patient’s physical performance
46. classification is established before
treatment and is intended to accomplish
1. Influence the type of treatment planned.
2. Decide when to definitively stop treatment.
3. Establish the individual’s quality of life
using numeric values.
4. Provide information about whether the
patient should seek hospice care.
47. A proxy rater in quality-of-life studies

should be used when:
1. The patient is not considered to be a
reliable rater.
2. The patient is not likely to give an honest
response.
3. The patient does not want to complete a
quality-of-life study.
4. The patient has cognitive impairment that
makes them unable to complete the rating.
48. The Functional Assessment of Cancer

Therapy (FACT/FACIT) instrument is
used to measure which of the following
dimensions of quality of life?
1. Sexual well-being
2. Marital well-being
3. Physical well-being
4. Cognitive well-being
49. Risk factors for the development of post-

traumatic stress disorder in cancer
include:
1. Female gender, older age, prior negative
life stressors
2. Male gender, younger age, prior negative
life stressors
3. Female gender, younger age, prior negative
life stressors
4. Female gender, older age, increased
distress prior to the diagnosis of cancer
50. Jeff describes his pain as a 7 on the

verbal numeric rating scale. He has no
evidence of tachycardia, hypertension,
diaphoresis, or pallor. From these
observations, you conclude which of the
following regarding Jeff’s pain?
1. His pain medication is inadequate.
2. He is likely experiencing chronic pain.
3. He is likely experiencing acute or
intermittent pain.
4. Because he does not appear to be in pain,
no pain medication is required.
B. ANATOMICAL AND SURGICAL
ALTERATIONS
51. Patient teaching for an individual who

will undergo an allograft for a bone
tumor includes which of the following?
1. Once healed, the patient will be able to
participate in any sport.
2. Once healed, the patient will not be allowed
to participate in any sports.
3. Once healed, the patient will not be able to
participate in any high-impact sport.
4. Once healed, the physical therapist and
surgeon will evaluate what sport(s) in
which the patient can participate.
52. A graft or flap is most often used in the

surgical treatment of a head and neck
cancer when:
1. The lesion is small, superficial, or
recurrent.
2. Risks of bleeding are high, and vasculature
must be maintained.
3. The lesion is large or located in an area
with insufficient tissue for closure.
4. The extent of the tumor must be accurately
assessed, and margins are relatively
unclear.
53. Mr. Jessup, who has a tracheostomy, is

having a carotid hemorrhage. Besides
controlling the bleeding, what should
you do first to prevent aspiration of the
blood?
1. Inflate the tracheostomy cuff.
2. Suction his throat and oral cavity.
3. Deflate the cuff and remove the
tracheostomy tube to clear the airway.
4. Transport him immediately to the
operating room for ligation of the carotid
artery.
54. The risk of carotid artery rupture after

radical neck dissection is associated with
which the following?
1. The site has fully healed.
2. A small trickle of blood from the area
3. Coverage of the artery with a skin flap
4. The area has been previously radiated.
55. Which of the following procedures will

the surgeon usually perform when a
lesion involves the middle and left
transverse colon?
1. A two-stage procedure involving a
temporary colostomy or ileostomy
2. A one-stage procedure involving resection
of the lesion and a primary anastomosis
3. A right hemicolectomy that includes the
related lymphatic and circulatory channels
4. A three-stage procedure involving a
diverting colostomy, a resection of the
tumor, and take-down of the colostomy
56. Signs and symptoms of an anastomotic

leak related to colorectal surgery
include:
1. Ileus, postoperative fever, abdominal pain
2. Diarrhea, postoperative fever, fecal
incontinence
3. Constipation, postoperative fever,
abdominal distention and pain
4. High pitched to absent bowel sound,
postoperative fever, abdominal pain
57. For upper and midrectal

adenocarcinomas, the treatment
approach of choice is:
1. Prophylactic oophorectomy
2. Abdominoperineal resection with a
temporary colostomy
3. Low anterior resection, preserving external
anal sphincter control
4. Laser therapy to the tumor bed through a
colonoscope or flexible sigmoidoscope
58. If the urine passing from a stoma is

cloudy, it may be that:
1. The patient is dehydrated.
2. Antispasmodics are indicated.
3. The stoma was formed from intestinal
tissue.
4. A leak in the stoma pouch has occurred,
allowing air and bacteria to enter a sterile
area.
59. Which of the following postoperative

assessments of stoma viability is a matter
of concern that should be brought to the
surgeon’s attention?
1. A dusky or gray stoma
2. Protrusion of the stoma
3. Persistent peristalsis in the bowel
4. Bleeding of the stoma when rubbed
60. Postoperative care and teaching of the

patient undergoing abdominoperineal
resection (APR) for rectal cancer is most
likely to be influenced by which of the
following?
1. The extent of hepatic invasion
2. The type of colostomy to be performed
3. The patient’s age, sex, and physical
condition
4. The type of closure of the perineal wound
to be used
61. In the early postoperative period

following pneumonectomy, your patient
experiences a cardiac arrhythmia. He has
a history of a myocardial infarction and
is currently on cardiac medications.
Nursing actions would include which of
the following?
1. Ensure he has received his cardiac
medication on schedule.
2. Administer oxygen and encourage the
patient to cough and deep breathe.
3. Arrhythmias are common in the
postoperative period and should be
monitored.
4. Notify the physician immediately because
he may be experiencing atrial fibrillation or
another myocardial infarction.
62. Your patient is immediate post-op
following a right hepatectomy. He is
most at risk for which of the following
non-liver-related complications?
1. Hemorrhage
2. Subphrenic abscess
3. Deep vein thrombosis
4. Pneumonia and pleural effusion
63. A common complication following a

supraglottic laryngectomy is which of the
following?
1. Fatigue
2. Infection
3. Bleeding
4. Aspiration
64. Which of the following agents pose a

high risk for the development of
alopecia?
1. Imatinib
2. Ifosfamide
3. Fludaribine
4. Vincristine
65. Mary is starting doxorubicin therapy for

treatment of her breast cancer. Patient
teaching regarding hair loss includes:
1. Hair loss is generally temporary and
usually starts 2 to 3 weeks following a dose
of chemotherapy.
2. Hair loss is generally permanent and
usually starts 2 to 3 weeks following a dose
of chemotherapy.
3. Hair loss is generally permanent and
usually starts immediately following a dose
of chemotherapy.
4. Hair loss is generally temporary and
complete hair growth occurs in 4 to 6
weeks after the completion of
chemotherapy.
66. Which of the following agents poses a

high risk of extravasation if the
medication leaks outside of the vein into
the surrounding tissue?
1. Busulfan
2. Rituximab
3. Vincristine
4. Gemcitabine
67. Jeff complains of pain and burning at the

site of a vincristine injection. What are
the steps to managing this potential
extravasation?
1. Stop the infusion, attempt to aspirate any
remaining drug, inject the site with sodium
thiosulfate, apply local cooling
remaining drug, inject the site with
hyaluronidase, apply local cooling
hyaluronidase, apply local warming
dextrazoxane, apply local cooling
68. Shawn is receiving an infusion of a

known vesicant through his implanted
port and complains of pain and slight
swelling at the site of the port. What are
important steps to minimize potential
tissue damage?
1. Stop the infusion, leave the needle in the
port, administer appropriate antidote,
continue with infusion
2. Stop the infusion, attempt to aspirate
residual drug, remove the needle from the
port, administer appropriate antidote
3. Stop the infusion, attempt to aspirate
residual drug, remove the needle from the
port, express any remaining drug from the
site
4. Stop the infusion of the drug, ensure that
the needle is in the right place, and
continue with the infusion as there is no
risk of an extravasation with an implanted
port.
69. Susan underwent a partial mastectomy

with lymph node dissection 5 months
ago. She is planning a vacation to Hawaii
and remembers to bring her sunscreen
with her based on her postoperative
teaching from her nurse. What is the
rationale to ensure that she wears
sunscreen while outside?
1. Susan will enjoy her vacation more if she
does not get a sunburn.
2. All patients should wear sunscreen as
prevention against skin cancer.
3. Sunscreen will help to prevent
lymphedema in the affected arm and hand.
4. Patients who are at risk for lymphedema
must understand the need for meticulous
skin care, including minimizing the risks of
cracks in the skin related to a sunburn.
70. While on vacation, Susan experiences a
bee sting to her affected arm and she
notices some swelling and her affected
arm feels stiff. Based on her
postoperative teaching, Susan takes what
steps?
1. She looks for someone in Hawaii that can
administer low-level laser therapy to treat
her lymphedema.
2. She makes an appointment with her
primary care physician to evaluate her arm
when she returns from her vacation.
3. She seeks medical care, as she is aware that
the swelling and stiffness may contribute
to the development of lymphedema.
4. She continues to enjoy her vacation as she
assumes that a bee sting has nothing to do
with the development of lymphedema.
71. Measures to prevent lymphedema in a

woman who is planning to undergo
radiation therapy to the breast, chest
wall, and axilla include:
1. Lose weight to minimize the risk of
lymphedema.
2. Do not travel long distances, especially on
an airplane.
3. Avoid wearing tight clothing, jewelry, and
elastic bands.
4. Chronic antibiotic use to minimize the risk
of a skin infection
72. Trichomegaly is associated with which of

the following agents?
1. Cetuximab, erlotinib, gefitinib
2. Procarbazine, vincristine, vinblastine
3. Prednisone, dexamethasone, tamoxifen
4. Doxorubicin, 5-fluorouracil, capecitabine
73. When a patient experiences trichomegaly

related to their cancer therapy they
should be evaluated by a(n):
1. Surgeon
2. Cardiologist
3. Dermatologist
4. Ophthalmologist
74. Which of the following agents is most

commonly associated with ototoxicity?
1. Cisplatin
2. Oxaliplatin
3. Vinblastine
4. Carboplatin
75. Men receiving radiation therapy to the
pelvis may experience erectile
dysfunction due to what
pathophysiologic change?
1. Psychological fear about dying from cancer
2. Fibrosis of blood vessels and nerves needed
for erection
3. Engorgement of the blood vessels causing
edema and pain
4. Changes in the hormonal milieu due to the
radiation therapy
76. Infertility is common with what group of

chemotherapy agents?
1. Nitrosoureas
2. Antimetabolites
3. Alkylating agents
4. Monoclonal antibodies
C. PHARMACOLOGIC INTERVENTIONS
77. Contraindications to oral antimicrobial

therapy in the ambulatory setting for the
treatment of fever in neutropenic
patients include which of the following?
1. Sarcoma
2. Breast cancer
3. Renal cell cancer
4. Hematopoietic stem cell transplantation
78. After a long period of time, Ms. Daniels,

who had an allogeneic stem cell
transplant, develops recurrent varicella
zoster virus. What is the most likely
treatment approach?
1. Acyclovir
2. Cyclosporine
3. Methotrexate
4. Cyclosporine and methotrexate in
combination
79. Patients with human immunodeficiency

virus (HIV) and neutropenia who have
received treatment with corticosteroids
immunosuppression should be
monitored for which of the following?
1. Tuberculosis
2. Second malignancies
3. Pneumocystis jiroveci pneumonia
4. Elevated CD4 lymphocyte count
80. The drug of choice to prevent

Pneumocystis jiroveci pneumonia is:
1. Fluconazole
2. Levofloxacin
3. Valacyclovir
4. Trimethoprim/sulfamethoxazole
81. Which of the following agents is used to

prevent graft-versus-host disease
(GVHD) in hematopoietic stem cell
transplant patients?
1. Cyclosporine
2. Dexamethasone
3. Cyclophosphamide
4. Medroxyprogesterone acetate
82. Trimethoprim-sulfamethoxazole is
generally the treatment of choice for
Pneumocystis jiroveci pneumonia.
Which of the following is a serious side
effect of this drug?
1. Diarrhea
2. Bleeding
3. Mucositis
4. Macular itchy rash
83. A patient diagnosed with candida

esophagitis is about to receive her first
dose of amphotericin B. Which of the
following is a common side effect of this
drug for which the patient should receive
premedication?
1. Vertigo
2. Diarrhea
3. Fever and chills
84. Nathan develops rigors 30 minutes after

amphotericin-B is being infused. The
actions of the nurse to minimize this
reaction include:
1. Provide comfort to the patient with
blankets and treat with intravenous (IV)
morphine.
blankets and treat with IV potassium.
blankets and treat with per oral (PO)
acetaminophen.
blankets and treat with IV
diphenhydramine.
85. The primary rationale for the use of

corticosteroids in the management of
arthralgias and myalgias due to taxane
1. Steroids increase proinflammatory genes.
2. Corticosteroids decrease symptoms of
inflammation.
3. Steroids decrease the fever associated with
taxane therapy.
4. Steroids suppress muscle enzymes, which
cause myalgias.
86. What drugs may be given to prevent flu-

like symptoms related to interleukin-2
(IL-2) therapy?
1. Acetaminophen only
2. Acetaminophen and a histamine-2 blocker
3. Acetaminophen and a nonsteroidal anti-
inflammatory drug (NSAID)
4. Acetaminophen, a histamine-2 blocker, and
an NSAID
87. Nonsteroidal anti-inflammatory drugs

(NSAIDs) and acetaminophen are
effective in pain management because
they facilitate which of the following
pharmacologic actions?
1. They are antipyretic.
2. They inhibit platelet aggregation.
3. They inhibit prostaglandin synthesis.
4. They facilitate the conversion of
arachidonic acid to prostaglandins.
88. Corticosteroids and nonsteroidal anti-

inflammatory drugs (NSAIDs) are
commonly used in the treatment of
patients with mildly increased
intracranial pressure. Which of the
following are considered anticipated side
effects of this therapy?
1. Hypotension and hypoglycemia
2. Hypertension and hyperglycemia
3. Hypertension and gastric ulceration
4. Hypotension and psychiatric reactions
89. Elise develops graft-versus-host disease

(GVHD) 85 days after undergoing an
allogeneic stem cell transplant. Which of
the following is considered to be the gold
standard treatment for confirmed acute
GVHD?
1. Glucocorticoids
2. Fluoride therapy
3. Systemic immunosuppressive therapy
90. What therapy is considered to be the

cornerstone of treatment of
antihypercalcemic therapy?
1. Loop diuretics
2. Corticosteroids
3. Bisphosphonates
4. Vigorous rehydration
91. Zoledronic acid is the most potent

bisphosphonate in use in the United
States for the treatment of hypercalcemia
of malignancy. It is recommended that
zoledronic acid be infused over not less
than 15 minutes and that the dose not
exceed 4 mg every 3–4 weeks. The
rationale behind this recommendation is
1. Doses higher than 4 mg given in less than
15 minutes increase liver toxicity.
15 minutes increase renal toxicity.
15 minutes increase nausea and diarrhea.
15 minutes increase bone marrow
suppression.
92. Joseph is about to start on a course of

pamidronate for treatment of
hypercalcemia related to his lung cancer.
His physician has recommended that he
have a comprehensive dental
examination prior to starting this
therapy. What potential adverse event
related to pamidronate is the rationale
for the dental exam?
1. Mucositis
2. Xerostomia
3. Dental caries
4. Osteonecrosis of the jaw
93. Which of the following drugs is most

commonly associated with platelet
dysfunction?
1. Heparin
2. Aspirin
3. Estrogen
4. Cimetidine

effect that nonsteroidal anti-
inflammatory drugs (NSAIDs) have on
platelets?
1. NSAIDs inhibit platelet function.
2. NSAIDs inhibit platelet aggregation.
3. NSAIDs enhance the platelet secretory
process.
4. NSAIDs increase epinephrine-induced
aggregation.

(NSAIDs) are known to cause
gastrointestinal (GI) side effects. The
etiology of these GI effects is best
explained by which of the following?
1. The increased release of prostaglandin
increases GI side effects.
2. The loss of the cytoprotective effect of
prostaglandin causes increased GI side
effects.
3. The drugs directly irritate the GI mucosa,
which is why they should be taken with an
antacid.
4. NSAIDs cause GI side effects only in the
presence of preexisting mucosal irritation,
as would occur with chemotherapy.
96. Aprepitant is indicated for the

prevention of delayed nausea and
vomiting with highly emetic
chemotherapy. Which of the following
statements is true with regard to its
mechanism of action?
1. Aprepitant is a 5-hydroxytryptamine type 3
(5-HT3) receptor antagonist.
2. Aprepitant effectively blocks substance P, a
neurokinin-1 (NK1) receptor.
3. To be effective, aprepitant must be given
daily for 5 days with a serotonin antagonist.
4. Aprepitant acts to suppress all major
neuroreceptors in the nausea and vomiting
process.
97. Ms. Jones returns for her third round of

high-dose chemotherapy and states that
she continues to have unrelenting
nausea for a week. Which of the
following factor(s) will most influence
your approach to managing this
problem?
1. Ondansetron before chemotherapy will
help manage delayed nausea.
2. Neurokinin-1 (NK1) receptor antagonist on
days 1, 2, and 3 will help to manage delayed
nausea.
3. Lorazepam is useful on days 1–4 to
increase the effectiveness of other agents,
and the sedation helps to decrease nausea.
4. NK1 receptor antagonist, plus a 5-
hydroxytryptamine type 3 (5-HT3) receptor
antagonist and dexamethasone, will help
manage delayed nausea.
98. The primary mechanism of action of

granisetron and ondansetron as
antiemetics is which of the following?
1. Sedation
2. Dopamine antagonist
3. Serotonin antagonist
4. Suppression of autonomic pathways
99. The primary mechanism of action of

dexamethasone as an antiemetic is:
1. Anti-inflammatory
2. Dopamine antagonist
3. Histamine receptor antagonist
4. Inhibits prostaglandin synthesis
100. Delayed nausea and vomiting occurs
more commonly with which of the
following agents?
1. Cisplatin
2. Vincristine
3. Carboplatin
4. Mechlorethamine
101. Dexamethasone is usually administered

along with granisetron or ondansetron.
The purpose of the dexamethasone is to
do which of the following?
1. To produce euphoria
2. To treat delayed nausea
3. To prevent side effects of granisetron or
ondansetron
4. To potentiate the antiemetic effect of the
granisetron or ondansetron
102. A common side effect of dopamine

antagonists includes which of the
following?
1. Insomnia
2. Amnesia
3. Constipation
4. Extrapyramidal reactions
Quinn develops a spasm of the lower jaw
103. after receiving droperidol to prevent
nausea and vomiting. What drug can be
given to treat this symptom?
1. Lorazepam
2. Dronabinol
3. Dexamethasone
4. Diphenhydramine
104. When highly emetogenic chemotherapy

is to be administered, the patient
generally receives a combination of
antiemetics rather than a single drug.
The rationale for the use of multiple
antiemetics is which of the following?
1. The vomiting center is directly activated by
multiple pathways.
2. Drugs such as prochlorperizine and
granisetron are synergistic in their action.
3. A combination of different antiemetic
agents permits the use of lower doses of
each agent and is therefore more
economical.
4. A combination of different agents allows
the care provider to change regimens to
different categories.
105. The discovery of serotonin has greatly
increased the efficacy of antiemetic
protocols. Which of the following best
describes the role of serotonin in nausea
and vomiting?
1. Serotonin acts on dopamine receptors in
the brain.
2. Serotonin activates 5-hydroxytryptamine
type 3 (5-HT3) receptors on visceral and
vagal afferent pathways.
3. When serotonin levels are reduced by
serotonin antagonists, the patient is more
at risk for delayed nausea and vomiting.
4. Serotonin levels are increased when toxic
substances such as chemotherapy drugs
stimulate the parafollicular cells of the
gastrointestinal tract.
106. Substance P/neurokinin-1 (NK1) receptor

antagonists are a newer class of drugs.
Which of the following is an example of
these agents and their appropriate
indication for use?
1. Atovaquone is used to treat taste
alterations.
2. Gabapentin is used to treat respiratory
congestion in patients with end-stage
disease.
3. Aprepitant is used to prevent or reduce
acute and delayed nausea and emesis with
chemotherapy.
4. Dapsone is used to prevent or treat
retrovirus, common in immunosuppressed
patients.
107. Mr. Zahir is receiving cisplatin therapy

for testicular cancer and requires a 5-
hydroxytryptamine type 3 (5-HT3)
receptor antagonist and a corticosteroid
daily during his treatment. The rationale
for this combination is based on which of
the following?
1. The corticosteroid is used to boost the
immune system.
2. The 5-HT3 receptor antagonist alone is not
compatible with cisplatin.
3. The corticosteroid enhances the antiemetic
effect of the serotonin antagonist.
4. The corticosteroid and 5-HT3 antagonist
provide a significant analgesic effect.
108. Cannabinoids such as dronabinol are

generally used as second-line
antiemetics. Which of the following is a
common side effect of cannabinoids?
1. Anxiety
2. Amnesia
3. Disorientation
4. Extrapyramidal symptoms
109. What is the metabolite of meperidine

that with repeated doses is responsible
for central nervous system (CNS)
excitation and seizures?
1. Cyclooxygenase
2. Normeperidine
3. Morphine-3-glucuronide
4. Morphine-6-glucuronide
110. Patients with metastatic disease to the

bone who have little benefit from
nonsteroidal anti-inflammatory drugs
(NSAIDs) and steroids are most likely to
benefit from which of the following
systemic therapies?
1. Calcitonin
2. Mithramycin
3. Zoledronic acid
4. Saline hydration
111. The most likely drug to be used to treat

neuropathic pain is:
1. Baclofen
2. Morphine
3. Gabapentin
4. Pamidronate

regarding the transdermal fentanyl
system is accurate?
1. Fentanyl is equal to morphine in potency.
2. Transdermal fentanyl is appropriate for the
treatment of postoperative pain.
3. It is poorly absorbed through the skin,
buccal mucosa, and blood-brain barrier.
4. Approximately 92% of the drug is absorbed
into the systemic circulation by 72 hours.
113. What drug may be given to counteract

the sedation effects of opioids?
1. Lorazepam
2. Droperidol
3. Hydroxyzine
4. Methylphenidate
114. Antidepressants such as amitriptyline

may be used to treat pain that is caused
by:
1. Surgery
2. Brain metastases
3. Narcotic withdrawal
4. Tumor infiltration of nerves
115. Steroids are effective in the management

of pain related to:
1. Bowel obstruction
2. Trigeminal neuralgia
4. Tumor pressing on a vital organ
116. Scheduling of oral analgesics generally

should be:
1. As needed
2. Every 2 hours
3. At fixed intervals
4. Related to a patient’s activity level
117. The clinical efficacy of antidepressants in

persons with cancer is thought to be
caused by which of the following?
1. Antidepressants suppress serotonin and
norepinephrine.
2. Antidepressants act to dull awareness of
one’s situation.
3. Antidepressants act as stimulants and
promote wakefulness.
4. Antidepressants exert effects on the 5-
hydroxytryptamine (5-HT)
neurotransmission system.
118. Following chemotherapy treatment for

her Hodgkin disease, Allison developed
shingles that was successfully treated,
but she was instructed to take an
antidepressant for approximately 2
weeks. Which of the following explains
the purpose of the antidepressant?
1. Treatment for her depression
2. Treatment for her insomnia and fatigue
3. Treatment for itching caused by shingles
4. Treatment to inhibit uptake of the
neurotransmitters into nerve terminals
119. Lorazepam is commonly used in

combination antiemetic therapy. Side
effects of this drug include which of the
following?
1. Diarrhea
2. Amnesia
3. Xerostomia
4. Constipation
120. Hematopoietic growth factors (HGFs) act

on stem cells to specifically mediate
which of the following steps in
hematopoiesis?
1. Stem cell production
2. Cellular differentiation
3. Programmed cell death
4. Programmed neutrophil death
121. Granulocyte and granulocyte-

macrophage colony-stimulating factors:
1. Decrease anorexia
2. Increase mucositis
3. Increase febrile episodes
4. Decrease myelosuppression
122. Hematopoietic growth factors (HGFs)

are given to help prevent infection in
potentially neutropenic patients. These
injections achieve which of the
following?
1. Enhance neutrophil regeneration
2. Enhance phagocytosis, antibody-dependent
cytotoxicity, and chemotaxis
3. Decrease the time from the administration
of the drug to the onset of the nadir
4. Decrease the activity of mature cell
lineages, thereby preserving them for the
period of neutropenia and infection
123. The most common side effect of myeloid
growth factors is:
1. Rashes
2. Fatigue
3. Bone pain
4. Wheezing
124. Prophylactic use of granulocyte colony-

stimulating factor (G-CSF) to prevent
febrile neutropenia is recommended
when:
1. Febrile neutropenia risk is < 10%.
2. Febrile neutropenia risk is > 10%.
3. Febrile neutropenia risk is > 20%.
4. Febrile neutropenia risk is 10%–20%.

be the most potent stimulus for
erythropoietin production?
1. Hypoxia
2. Active bleeding
3. Hemoglobin less than 9 g/dL
4. Hematocrit less than 30 g/dL
126. Epoetin alfa is restricted in patients with

which of the following medical
conditions?
1. Glaucoma
2. Chronic diarrhea
3. Renal insufficiency
4. Uncontrolled hypertension
127. Hematopoietic growth factors (HSFs) are

used as supportive therapy for which of
the following conditions?
1. A patient with severe cachexia
2. A patient with iron-deficiency anemia
3. A patient undergoing modified radical
mastectomy
4. A patient receiving myelosuppressive
therapy or a hematopoietic stem cell
transplantation (HSCT)
128. High-dose interleukin-2 (IL-2) is

approved by the Food and Drug
Administration (FDA) for treatment of:
1. Metastatic breast cancer
2. Metastatic prostate cancer
3. Metastatic renal cell cancer and metastatic
melanoma
4. Metastatic renal cell cancer and metastatic
breast cancer
129. Side effects of high-dose interleukin-2

(IL-2) therapy, such as generalized
edema, hypotension, and pulmonary
congestion are related to:
1. Anemia
2. Capillary leak syndrome
3. Penetration of the drug into the blood-
brain barrier
4. Direct effect on the hypothalamic
regulatory center
130. The most appropriate actions related to

grade 3 or 4 immune-related adverse
events (irAEs) associated with
ipilimumab include:
1. Treatment with corticosteroids
2. Permanent cessation of ipilimumab and
treatment with corticosteroids
3. Reinitiating ipilimumab following the
resolution of symptoms to grade 0 or 1
4. Treatment with corticosteroids and
reinitiating ipilimumab following the
resolution of symptoms to grade 0 or 1
131. When talking with the parent of an

adolescent about Gardasil and Cervarix
vaccines, it is important to stress that:
1. The vaccines are most effective up to the
age of 26.
2. The vaccines are equally effective whether
the adolescent is sexually active or not.
3. The vaccines are effective against human
papillomavirus (HPV) infection, but are not
effective against cervical or penis cancer.
4. The vaccines are most effective when given
prior to onset of sexual activity, as they do
not stimulate regression of established
infection.
132. Which of the following monoclonal

antibodies pose the greatest risk for
infusion reactions?
1. Cetuximab
2. Bevacizumab
3. Panitumumab
4. Blinatumomab
133. Jon will be starting on sunitinib for the

treatment of his advanced renal cell
cancer. What test will he need at baseline
and regular intervals related to the side
effect profile of sunitinib?
1. Pulmonary function test at baseline, 7 days
after initiation of the drug, and at regular
intervals
2. Echocardiogram at baseline, 7 days after
initiation of the drug, and at regular
intervals
3. Electrocardiogram (ECG) at baseline, 7
days after initiation of the drug, and at
regular intervals
4. Drug allergy testing at baseline, 7 days after
initiation of the drug, and at regular
intervals
134. A patient who is on imatinib shares with

you that he is taking St. John’s wort for
depression. An appropriate response
would include:
1. Keep taking the St. John’s wort, as this is
important for your depression.
2. St. John’s wort is just an herbal remedy, so
it has no effect on other medications.
3. The use of St. John’s wort should be
avoided as it can increase the elimination
of the gefitinib and can decrease the drug
effect.
4. The use of St. John’s wort should be
avoided as it can decrease the elimination
of the gefitinib and can increase the drug
effect.
135. Tricia is started on venlafaxine 37.5

mg/day for the treatment of hot flashes
related to her tamoxifen therapy. Your
teaching with this patient includes:
1. She should not abruptly stop this
medication.
2. The drug can cause headaches, diarrhea,
and seizure.
3. She should stop taking the drug if it does
not help her hot flashes.
4. She should not eat grapefruit or drink
grapefruit juice while on this drug.
136. Your patient recently began oral

morphine therapy. He complains of
nausea and vomiting. You explain to him
that the best option to initially manage
these symptoms includes which of the
following?
1. Switch to tramadol.
2. Switch to fentanyl or oxymorphone.
3. Treat the nausea with an appropriate
antiemetic.
4. Change the dosing regimen or route of the
same drug.

regarding the use of tricyclic
antidepressants (TCAs) in pain
management is true?
1. TCAs (low dose) are effective for the
treatment of neuropathic pain.
2. TCAs have not been found to be effective in
treating neuropathic pain.
3. The dose of TCAs must be increased from
the doses used to treat depression to be
effective in pain management.
4. Concomitant use of opioid analgesics is not
problematic because sedation and
orthostatic hypotension are uncommon
with low-dose TCAs.
138. Which of the following is effective

treatment for pruritus related to
systemic opioids?
1. Naloxone
2. Antihistamines
3. Topical anesthetics
4. Decreasing the dose of the opioid
139. Mrs. James has recently started

morphine sulfate to control her pain.
She is concerned about the side effects.
You explain to her that within 1–2 weeks
she will not develop tolerance to which of
the following side effects associated with
opioid administration?
1. Nausea
2. Lethargy
3. Agitation
4. Constipation
140. You explain to Mrs. James that she will

need to begin to take what medication(s)
to help prevent opioid-related
constipation?
1. Antiemetics
2. Stool softener
3. Bowel stimulant
4. Stool softener with stimulant

therapeutic action of bisphosphonates?
1. Bisphosphonates inhibit osteoblast activity.
2. Bisphosphonates inhibit osteoclast activity.
3. Bisphosphonates block osteoclast-mediated
bone resorption.
4. Bisphosphonates are natural inhibitors of
bone mineralization.
142. Mr. Marz has an enlarged spleen and has

been started on corticosteroid therapy.
The primary mechanism of action of this
1. Steroids have a capillary-stabilizing effect.
2. Steroids help to control platelet
sequestration.
3. Steroids help to stimulate rapid platelet
increases.
4. Steroids alter platelet adhesiveness and
allow platelets to be more “sticky.”
D. COMPLEMENTARY AND INTEGRATIVE
MODALITIES
143. Complementary and alternative medicine

(CAM) is defined as:
1. Standard treatment
2. Treatment that should not be used, as it
has not been studied
3. A group of diverse medical and healthcare
systems, practices, and products that are
not considered a part of conventional
medicine
4. A group of diverse medical and healthcare
systems, practices, and products that
should always be used with standard
treatment
144. Complementary therapies that have

demonstrated preliminary evidence in
the treatment of cancer related fatigue
include:
1. Yoga, massage, melatonin, rhubarb
2. Yoga, relaxation, healing touch, ginseng
3. Yoga, St. John’s wort, black cohosh,
vitamin B6
4. Yoga, TENS, Lactobacillus acidophilus,
ginseng
145. Which of the following complementary

and alternative medicine (CAM)
therapies have demonstrated some
benefit to patients in the relief of
menopausal symptoms, including hot
flashes?
1. Barley
2. Black cohosh
3. Evening primrose
4. Soy supplementation
146. A known adverse effect of phytoestrogen

therapy (e.g., black cohosh, soy
supplementation, red clover) is which of
the following?
1. Fatigue
2. Weight gain
3. Sexual dysfunction
4. Endometrial hyperplasia
147. Joan tells you that she feels that her pain
decreases when she listens to music.
Your best response to Joan would be to:
1. Tell her that there is no role in listening to
music to improve pain.
2. She can do whatever she wants to help
manage her pain, but she must maintain
her opioid requirements as ordered.
3. Reassure her that music is pleasant to
listen to, but there is no evidence to
support that listening to music can improve
pain.
4. Reassure her that music is pleasant to
listen to, and there are studies that support
that listening to music can improve pain.
148. A patient who is receiving chemotherapy

tells you that he has heard that ginger
may help control his symptoms of nausea
and vomiting. You tell him that ginger
may help his nausea and vomiting
because:
1. Ginger can stimulate his appetite.
2. Ginger deceases gastrointestinal secretions.
3. Components of ginger are neurokinin-1
(NK1) antagonists.
4. Components of ginger are antagonists at 5-
hydroxytryptamine type 3 (5HT3)
receptors.
149. Complementary and alternative medicine

(CAM) techniques that nurses and
physicians can teach the patient to help
reduce cancer treatment-related nausea
and vomiting include:
1. Reiki
2. Attentional distraction
3. Systematic desensitization
4. Guided imagery and progressive muscle
relaxation
150. The best reason to ask Jeffery, a patient

who is experiencing cancer-related
anorexia, about alternative nutritional
therapies that he may be taking is:
1. To teach him to never use complementary
or alternative nutritional therapies
2. To ensure that any alternative nutritional
therapies do not have an adverse effect on
his current therapies
3. To open the door to communicating about
the issue and to provide reliable sources of
information about these therapies
4. To highlight data on potential harm that
may be associated with complementary and
alternative nutritional interventions
151. Which of the following complementary

and alternative medicine (CAM)
therapies have shown some value
through studies of decreasing anxiety in
patients with cancer?
1. Aloe, phosphates, flaxseed
2. Yoga, music therapy, St. John’s wort
3. Ginseng, physical therapy, vitamin B12
4. Reiki, music therapy, relaxation and guided
imagery
152. According to the Oncology Nursing

Society “Putting Evidence into Practice”
resources, the only complementary
therapy that has been found to be likely
to be effective for cancer-related
depression is:
1. Exercise
2. Massage
3. Reflexology
4. Relaxation therapy
153. The underlying principle of acupuncture

in health care includes which of the
following?
1. Energy enhances healing by alleviating
spiritual blockages.
2. Four secrets of enhancing energy refers to
movements that improve health.
3. Stimulation of the appropriate area helps
the body correct any imbalance in the flow
of energy thereby restoring balance.
4. A therapeutic method that uses pressure to
areas or zones that correspond to areas of
the body to treat physical disorders.
154. Ms. Davis complains of being mildly

depressed and does not want to take
traditional antidepressants. She states
she would like to try St. John’s wort.
Your most appropriate response would
be which of the following?
1. She should only consider conventional
antidepressants.
2. She should see a psychiatrist before
choosing treatment for her depression.
3. Since she is mildly depressed, studies
suggest that St. John’s wort could work for
her.
4. In studies of persons who were severely
depressed, St. John’s wort was not proven
to be superior to placebo.
155. Directing one’s attention away from the

sensations and emotional reactions
produced by pain is known as:
1. Hypnosis
2. Distraction
3. Biofeedback
4. Autogenic relaxation
156. According to research, which of the

following nonpharmacologic measures is
most effective in relieving cancer-related
fatigue?
1. Exercise
2. Conservation of energy
3. Increasing the number of hours resting or
sleeping
4. Motivational strategies to increase self-
efficacy beliefs
157. Rita has lung cancer and wants to try

alternative approaches to nutrition to
help improve her immune system. She is
leaning toward a macrobiotic diet and
asks if there are any adverse effects
associated with this type of diet. The
major problem with a macrobiotic diet is
1. Constipation
2. Fat deficiency
3. Protein deficiencies
4. Deficiencies in vitamin C
158. Mary is being treated with
pharmacologic therapy for her cancer-
related pain. The physician encourages
her to also practice relaxation and
guided imagery to help manage her pain.
Mary asks you to explain why these
interventions for her pain have been
recommended. Your most appropriate
response to her would be:
1. These interventions may interrupt painful
sensory input to the brain.
2. These interventions do not help manage
pain and should not be used.
3. These interventions may help to decrease
patients’ emotional response to pain,
enabling you to deal with the pain more
positively.
4. These interventions help to block the
sensation of pain so that eventually
pharmacologic interventions will no longer
be necessary.
E. PALLIATIVE CARE CONSIDERATIONS
159. While caring for a terminally ill patient

who is receiving high doses of opioids,
you notice nocturnal myoclonus. Which
of the following constitutes an
appropriate therapeutic intervention?
1. Rotate to another opioid.
2. The opioid dose should be reduced.
3. Naloxone should be given to reverse the
opioid effect.
4. Change the opioid, reduce the dose, and
add a benzodiazepine.
160. A patient asks you to explain what

palliative care means. You explain that:
1. Palliative care is focused only on physical
symptoms of patients.
2. Palliative care is focused only on
psychosocial symptoms of patients.
3. Palliative care is focused on improving
quality of life for both the patient and the
family, with a focus on both physical and
psychosocial symptoms.
4. Palliative care is focused on improving
quality of life for both the patient and the
family, with a focus on both physical and
psychosocial symptoms when life
expectancy is less than 6 months.
161. A patient asks you to explain the

difference between palliative care and
hospice. You explain that:
1. Palliative care and hospice are the same
services.
2. Palliative care services can only be provided
in the hospital and hospice is only provided
in the home.
3. Palliative care is only available to patients
with metastatic cancer and hospice is only
available to patients with a life expectancy
of less than 6 months.
4. Palliative care benefits can be offered to
any patient with a high symptom burden
and hospice benefits can be offered to
patients with a life expectancy of less than
6 months.
162. What are considered to be key barriers to

providing palliative care to patients with
cancer?
1. Palliative care can only be provided in the
home.
2. Palliative care can only be provided in the
hospital by palliative care specialists.
3. Palliative care is a fee-for-service model
and there is no insurance reimbursement
for these services.
4. Patients and providers may have
misconceptions about the meaning and
scope of palliative care services.
163. What communication tool may be used

to help guide and increase confidence
during difficult conversations?
1. ALARM
2. SPIKES
3. BETTER
4. PLISSIT
164. When using the SPIKES communication

tool to help guide difficult conversations,
what question could be asked to help
clarify the setting?
1. “I can see that this information is
shocking.”
2. “Is there anyone you would want to have
present when we talk?”
3. “Let me summarize our discussion and
describe the next steps we need to take.”
4. “Are you the kind of person who likes lots
of detail, or would you prefer the big
picture?”
165. When assessing for pain in a patient who

is no longer able to report the intensity
or presence of pain, what are critical
elements to consider about the patient’s
pain?
1. Ask the patient’s family if the patient is in
pain.
2. You cannot assess the patient’s pain unless
they are able to provide a pain score.
3. Ask the patient’s family/significant others
if they think that the patient is in pain,
observe for behaviors that may indicate
pain, and investigate for pathologies that
could produce pain.
4. Ask the patient’s family/significant others
if they think that the patient is in pain,
observe for behaviors that may indicate
pain, and investigate for pathologies that
could produce pain, and initiate a trial of
analgesics.
166. Your 40-year-old patient, Joanne, who
has end-stage liver cancer, has just been
admitted to the hospital for end-of-life
care. She is picking at her clothes and the
bed linen, is talking loudly and
incoherently, and is agitated, and her
family states that this is new behavior.
What do you suspect is the cause of
Joanne’s mental status changes?
1. Delirium
2. Dementia
3. Psychoses
4. Depression
167. Nursing management of Joanne’s

condition includes:
1. Administer 1 mg of lorazepam to calm her
down.
2. Call the patient’s spiritual advisor as she is
likely to imminently die.
3. Restrain the patient as she will likely pull
out an IV if one needs to be inserted.
4. Maintain a safe, quiet environment and
consider treatment with low dose Haldol.
168. What is the most important assessment

for dyspnea?
1. Patient’s self-report
2. Blood gas evaluation
3. Oxygen saturation level
4. Pulmonary function tests
169. Josephine is a 51-year-old patient

admitted with shortness of breath and a
history of lung cancer and is found to
have a pleural effusion. What would you
anticipate to be the most appropriate
actions to help manage Josephine’s
shortness of breath?
1. Administer morphine
2. Administer lorazepam.
3. Position the patient upright in bed.
4. Position the patient with the head of the
bed up, administer morphine and
lorazepam, and prepare her for pleural fluid
drainage.
170. A common concern among patients and

families of administering opioid therapy
even during end-of-life care includes:
1. Fear of addiction
2. Fear of constipation
3. Fear of nausea and vomiting
4. Concern of the cost of opioids
171. Mary is being followed by the hospice
team and is experiencing noisy airway
secretions at the end of her life. What are
appropriate measures to teach the family
about management of this condition?
1. Deep suctioning will help to clear the
secretions.
2. Reposition the patient in the bed with the
head slightly elevated.
3. Encourage the patient to cough frequently
to help clear her secretions.
4. Because death is imminent with this
condition, no measures are likely to help.
172. What is the most common type of

pharmacologic treatment to manage
noisy airway secretions at end-of-life?
1. Opioids
2. Antihistamines
3. Anticholinergics
4. Benzodiazepines
173. What is an important conversation to

approach with a patient with an
implanted cardiac defibrillator who is
admitted to hospice and indicates that he
desires a “Do Not Resuscitate” (DNR)
status?
1. Because of his cardiac defibrillator he
cannot be admitted to hospice care.
2. There is no significant implication of a
patient with an active cardiac defibrillator
in hospice care.
3. Because the cardiac defibrillator will
deliver multiple shocks to the patient
during cardiac arrest, he may want to have
it deactivated.
4. Discussion about the removal of an active
cardiac defibrillator prior to admission to
hospice because of the risk of cardiac
shocks upon cardiac arrest.
174. The family of an actively dying patient

with advanced cancer asks you to start
tube feedings to help “keep the patient
going.” What is your most appropriate
response?
1. There is no role for tube feeding in actively
dying patients and it is unethical to ask for
this treatment.
2. Tube feeding may prolong survival in
patients with advanced cancer but may also
increase the risk of aspiration.
3. Tube feeding does not prolong survival in
patients with advanced cancer and may
increase the risk of aspiration.
4. Tube feeding does not prolong survival in
patients with advanced cancer, but starting
intravenous (IV) fluids may help the family
to feel better.
F. ALTERATIONS IN FUNCTIONING
175. Your patient received chemotherapy 6

days ago and has now called with a fever
of 101.8°F and chills. She has a
productive cough and, except for not
being able to get warm, feels fine. You
send her for a complete blood count and
learn that her absolute granulocyte
count is 500 cells/mm3. You instruct her
to come to the hospital to be admitted.
Your decision is based on which of the
following?
1. She is at risk for bleeding and severe
anemia.
2. She probably has pneumonia and needs to
be observed.
3. She is past her nadir, but cultures need to
be done to determine the source of a
possible infection.
4. When the neutrophil count is 500/mm3 or
less, approximately 20% or more of febrile
episodes have an associated bacteremia.
176. Your patient has a platelet count of

9000/mm3 and has had frequent
nosebleeds. He has an order for a platelet
transfusion, but has acetaminophen, a
corticosteroid, and an antihistamine
ordered prior to the platelet transfusion.
What is the rationale for the
premedications prior to the platelet
transfusion?
1. To prevent fever in the patient
2. To help make the patient more comfortable
3. To prevent the risk of platelet
refractoriness
4. To prevent the risk of a febrile
nonhemolytic transfusion reaction
177. Patient-related risk factors for

thrombosis in patients with cancer
include:
1. Older age, male gender, African American
race, concomitant infection
2. Older age, female gender, African American
race, concomitant infection
3. Younger age, male gender, African
American race, concomitant infection
4. Younger age, female gender, Asian-Pacific
Islander race, concomitant infection
178. According to the National Cancer

Institute Common Terminology Criteria
for Adverse Events (NCI CTCAE) related
to bleeding/hemorrhage, what is
classified as Grade 2 bleeding?
1. Mild, no intervention needed
2. Bleeding requiring transfusion
3. Moderate symptoms requiring medical
intervention
4. Catastrophic bleeding requiring major
intervention
179. Infection in the neutropenic patient is a

serious complication of chemotherapy
and can be fatal in what percentage of
older patients?
1. 15%
2. 30%
3. 60%
4. 75%
180. Margaret is being treated with

chemotherapy for Hodgkin disease and is
monitored weekly for myelosuppression.
Her white blood cell count is 4000
cells/mm3, with 34% segmented
neutrophils and 3% bands. What is her
absolute neutrophil count (ANC)?
1. 48 cells/mm3
2. 480 cells/mm3
3. 1480 cells/mm3
4. 2480 cells/mm3
181. Based on Margaret’s absolute neutrophil

count (ANC), the chemotherapy is
withheld. What answer best describes
why the chemotherapy is withheld?
1. Neutropenia is the most common cause of
life-threatening infections.
2. Neutropenia is the most common risk
factor for the development of oral
candidiasis.
3. Neutropenia always precedes the
development of anemia, which puts
Margaret at risk for extreme fatigue.
4. Neutropenia always precedes the
development of thrombocytopenia, which
puts Margaret at risk for bleeding.
182. Mr. Mendez, who is receiving high-dose

chemotherapy, has developed
neutropenia. The usual symptoms of
infection will likely be absent or muted in
this patient because:
1. The immunoglobulins are reduced.
2. The white blood cells drop rapidly, and
recovery time is slow.
3. Neutrophils are necessary to produce an
inflammatory response.
4. Most infections are due to organisms that
are part of the body’s normal flora.
183. How many days after chemotherapy does

neutropenia typically develop, and what
is the usual time for recovery?
1. Develops 4 weeks after chemotherapy with
recovery in 6 weeks
2. Develops 4–6 days after chemotherapy
with recovery in 2 weeks
with recovery in 6 weeks
with recovery in 3–4 weeks
184. The most common site of infection in the

granulocytopenic patient is which of the
following?
1. Urinary tract
2. Perineal region
3. Respiratory tract
4. Gastrointestinal (GI) tract
185. The National Cancer Institute Common

Terminology Criteria for Adverse Events
(NCI CTCAE): myelosuppression,
identifies Grade 4 neutropenia as:
1. < 500 mm3
2. < 1000–500/mm3
3. < 1500–1000/mm3
4. < Lower limit of normal–1500/mm3
186. The administration of colony-

stimulating factors as prophylaxis
following highly myelosuppressive
chemotherapy is intended to accomplish
primarily which of the following?
1. Prevent pancytopenia.
2. Minimize infection and stomatitis.
3. Maintain white blood cell count above
10,000 cells/mm3.
4. Decrease the number of days that the white
blood cell count is at its nadir.
187. Five days after chemotherapy for lung

cancer, your 72-year-old patient calls
with fever and chills. Blood counts reveal
an absolute neutrophil count of
429/mm3. Which of the following
constitutes appropriate management of
this patient?
1. Begin oral antibiotics, and monitor fever.
2. He needs a chest x-ray to rule out
pneumonia.
3. Arrange for admission to the hospital and
administer antibiotics immediately.
4. He is at the nadir of the white blood cell
count and will gradually improve on his
own.
188. The most common and lethal side effect

of chemotherapy is:
1. Myelosuppression
2. Respiratory distress
3. Increased liver function tests
4. Electrolyte imbalance from nausea,
vomiting, and diarrhea
189. The single most important measure to

prevent infection when caring for the
patient with granulocytopenia is:
1. Providing optimal nutrition
2. Washing the hands meticulously
3. Promptly instituting empiric antibiotics
4. Restricting the presence of live flowers and
plants
190. Recombinant thrombopoietin,

oprelvekin, stimulates the proliferation
and differentiation into what blood cell
type(s)?
1. Platelets
2. Red blood cells
3. White blood cells
4. Multiple blood cell lines
191. A cumulative and delayed

thrombocytopenia has been associated
with which of the following
chemotherapeutic agents?
1. Carmustine
2. Vinorelbine
3. Mithramycin
4. Methotrexate
192. Mr. Jones has a malignant brain tumor

and has been receiving fluorouracil and
carmustine every 6 weeks. His blood
counts today reveal a white blood cell
count of 3000 cells/mm3, hemoglobin of
10 g/dL, and platelet count of 50,000
cells/mm3. His treatment is delayed
today. The best explanation for delaying
his treatment is which of the following?
1. He is moderately anemic.
2. He is moderately to severely
immunosuppressed.
3. He is at severe risk for bleeding due to
thrombocytopenia.
4. He is at moderate risk for bleeding due to
thrombocytopenia.
193. When platelets decrease to 10,000

cells/mm3, the patient is most at risk for
1. Petechiae
2. Epistaxis
3. Concomitant thrombocytopenia
4. Spontaneous central nervous system
bleeding
194. The most common cause of

thrombocytopenia in patients with
cancer is:
1. Infection
2. Hypersplenism
3. Decreased megakaryocytopoiesis
4. Immune-mediated thrombocytopenia
195. Josie has chronic lymphocytic leukemia.

She has immature platelets in the bone
marrow and a platelet count of 45,000
cells/mm3. She has evidence of
petechiae, purpura, and ecchymosis. Her
condition is most likely associated with
which of the following platelet
disorders?
1. Thrombocytosis
2. Hypocoagulopathy
3. Thrombocytopenia
4. Idiopathic thrombocytopenic purpura
196. Your patient just started a new regimen

of chemotherapy including vincristine
and methotrexate 1 week ago. He is
elderly and has historically had some
problems with constipation. Other
significant problems include a platelet
count of 20,000 cells/mm3 and
stomatitis. Nursing actions would
1. Rectal exam to rule out impaction
2. Digital disimpaction if he becomes
constipated
3. Stool softener and a laxative each day as
needed
4. Rectal suppository followed by a tap water
enema
197. Your patient has received multiple

transfusions of random-donor platelets
and is experiencing no increase in his
platelet count. What is this process
called?
1. Refraction
2. Alloimmunization
3. Autoimmunization
4. Hyperimmunization
198. The most important measure in the early

detection of bleeding is:
1. Accurate screening, beginning with a
platelet count
2. Diagnostic testing of the complete
cardiovascular system
3. Observation for subtle diagnostic signals,
such as skin petechiae
4. A family history, focusing on possible
congenital bleeding disorders
199. The typical response of the body to a

reduction in the platelet count, such as
that caused by bleeding, is:
1. Sequestering of red blood cells in the
spleen
2. Increased production of megakaryocytes in
the bone marrow
3. An increase in the fibrinolytic activity of
remaining platelets
4. A release of adenosine diphosphate (ADP)
into the bloodstream, which increases the
oxygen-carrying capacity of available
platelets
200. Bleeding with cancer is most often due

either to the mechanical pressure of
tumors on organs or to:
1. Infection
2. Damage to the spleen
3. Interference with vasculature
4. Hypocoagulability of the blood
201. Acute bleeding that occurs as a result of

tumor-induced structural damage to the
vasculature is best managed by:
1. Radiotherapy
2. Chemotherapy
3. Oral or parenteral iron supplements to
reduce anemia
4. Mechanical pressure (e.g., nasal packing
during epistaxis)
202. The single most significant measure for

predicting bleeding in an individual with
cancer is:
1. Tumor site
2. Platelet count
3. Abnormal platelet function
4. An imbalance in coagulation factors
203. You are monitoring Liza, who is

receiving chemotherapy for acute
myelogenous leukemia, to ensure that
she does not develop complications
associated with leukocytosis. The most
common complication is:
1. Blast crisis
2. Cerebellar toxicity
3. Tumor lysis syndrome
4. Disseminated intravascular coagulation
204. Patients with liver cancer are more at

risk for bleeding due to which of the
following?
1. Abnormal platelet function
2. Altered platelet aggregation
3. Decrease in vitamin K absorption
4. Destruction of platelets by nonimmune
functions
205. Patients with cancers may at times have

bleeding, despite normal platelet counts
and coagulation factors. An example is
bleeding caused by:
1. Hypocoagulability
2. Platelet sequestration
3. Decreased platelet adhesiveness
206. Which of the following coagulation

factors is necessary for both coagulation
and fibrinolysis?
1. Fibrin
2. Thrombin
3. Fibrinogen
4. Prothrombin
207. Grade 1 gastrointestinal (GI) acute-graft-

versus-host disease (GVHD) is
characterized by:
1. Diarrhea > 1000 mL/day
2. Diarrhea > 1550 mL/day
3. Diarrhea < 500 mL/day or persistent
nausea
4. Severe abdominal cramping with or
without ileus formation
208. The following are risk factors in the

development of graft-versus-host disease
(GVHD):
1. Related donor, human leukocyte antigen
(HLA) match, younger age at transplant
2. Unrelated donor, HLA matched, older age
at transplant
3. Related donor, HLA mismatched, older age
at transplant
4. Unrelated donor, HLA mismatched, older
age at transplant
209. Definitive diagnosis of acute

gastrointestinal (GI) graft-versus-host
disease (GVHD) requires:
1. Endoscopy with biopsies
2. Diarrhea < 500 mL/day for 7 days
3. Complaint of persistent nausea for 7 days
4. Complaint of persistent nausea and
vomiting for 7 days
210. Your patient experiences intense nausea

and vomiting from chemotherapy and is
prescribed lorazepam along with her
antiemetics at her next chemotherapy
treatment. She wants to know why she is
given an antianxiety agent when she does
not feel anxious. Your explanation
would include which of the following?
1. The lorazepam is given to reduce
anticipatory nausea and vomiting.
2. Lorazepam can help to prevent motion
sickness, which may be contributing to her
nausea and vomiting.
3. Lorazepam is given to decrease her anxiety
as all patients become anxious while
receiving chemotherapy.
4. The lorazepam is given to induce sleep,
which is an important strategy for
preventing nausea and vomiting with
chemotherapy.
211. Prolonged diarrhea without adequate

management can lead to which of the
following?
1. Renal failure
2. Hepatic failure
3. Circulatory collapse
4. Increased intracranial pressure
212. The National Cancer Institute Common

Terminology Criteria for Adverse Events
(CTCAE) define Grade 2 cancer-related
diarrhea as:
1. Life-threatening consequences; urgent
intervention indicated
2. Increase of < 4 stools/day over baseline;
mild increase in ostomy output compared
to baseline
3. Increase of 4–6 stools/day over baseline;
moderate increase in ostomy output
compared to baseline
4. Increase of > stools/day over baseline;
incontinence; hospitalization indicated;
severe increase in ostomy output compared
to baseline; limiting self-care activities of
daily living
213. A patient is receiving vincristine and

complains of colicky abdominal pain and
abdominal distention. Physiologically,
the patient’s symptoms are most likely
caused by:
1. Decreased colonic transit time with
vincristine
2. The effect of the vincristine on the
gastrointestinal mucosa
3. Cramping and gas pains, which are
common with vincristine
4. Diminished effectiveness of afferent and
efferent nerve pathways
214. Twenty-four hours after taking a

laxative, Mario calls and complains of
nausea and inability to pass gas. He has
not had a bowel movement in 4 days. The
most appropriate approach to this
situation includes which of the
following?
1. The patient needs to have an enema.
2. A stool softener and a laxative should be
recommended.
3. The patient should have a physical exam
and a flat plate of the abdomen because he
could be obstipated.
4. An oil-retention enema and milk of
magnesia should be given and repeated if
there are no results in 24 hours.
215. Opioids affect the gastrointestinal (GI)

tract, contributing to constipation
primarily by which of the following
mechanisms?
1. Histamine release
2. Decreased water absorption due to
increased transit time
3. Increasing the transit of stool through the
colon by increased peristalsis
4. Activation of opioid receptors in the GI
tract and on the central nervous system
216. Opioid-induced constipation is best
managed by which of the following
approaches?
1. Metamucil daily
2. A stool softener with a stimulant
3. Increase fiber to 3–4 grams per day.
4. Increase fluid intake to eight 8-ounce
glasses of fluid per day.
217. Radiation-induced enteritis can cause

significant diarrhea. Which of the
following interventions would be the
most appropriate management of this
problem?
1. A high-residue diet
2. Anti-inflammatories
3. Sandostatin given subcutaneously
4. A liquid diet high in milk and milk products
218. A patient is receiving fluorouracil (5-FU)

and leucovorin weekly for 4 weeks. He
reports abdominal cramping, rectal
urgency, and diarrhea that awaken him
at night. On questioning, he reports four
diarrhea stools on each of the past 3
days, each with a volume of about 1 cup.
Appropriate nursing action would
1. Assess the patient for dehydration,
including orthostatic blood pressures.
2. Encourage him to take loperamide with
each loose stool and to push fluids and
delay treatment for 1 week.
3. Myelosuppression is the dose-limiting
toxicity of 5-FU, so if the counts are good
he should receive treatment.
4. Diarrhea is expected with 5-FU, and he
should receive his chemotherapy with
instructions to take loperamide with each
loose stool.
219. Sophia is receiving chemotherapy and

complains of severe diarrhea for 6 days
and fever for 24 hours and agrees to
come to the outpatient clinic to be
evaluated. The most appropriate initial
nursing action would include:
1. Teach the patient to take nothing by
mouth.
2. Obtain a stool culture to rule out an
infectious process.
3. Teach the patient to eat a low-residue,
high-caloric, high-protein diet.
4. Notify the physician for possible
administration of an antidiarrheal
medication.
220. A patient receiving methotrexate

complains of a fever of 101.5°F for 1 day
and severe diarrhea for 2 days and
requests an antidiarrheal medication.
Which of the following explanations
should be given to the patient regarding
the rationale for not giving him an
antidiarrheal medication?
1. Antidiarrheal agents are only given after 6
days of severe diarrhea.
2. The fever is more important to treat
immediately than the diarrhea.
3. Antidiarrheal agents do not work when the
diarrhea is caused by an infection.
4. Antidiarrheal agents increase the exposure
of the mucosa to the infectious agent.
221. Your patient has recurrent intermittent

bowel obstruction due to advanced
cancer. Which of the following is an
appropriate option to offer this patient
as management strategies for nausea and
vomiting due to bowel obstruction?
1. Pain and antinausea medication
2. No treatment as the patient is nearing the
end of life
3. Surgical placement of a gastrostomy tube
or a percutaneous endoscopic gastrostomy
4. Nasogastric intubation to avoid a surgical
procedure in a patient with advanced
cancer
222. Biliary vomiting is indicative of which of

the following?
1. Progressive constipation
2. Obstruction in the lower ileus
3. Intermittent bowel obstruction
4. Obstruction in the upper part of the
abdomen
223. The two most common complications

related to a prostatectomy include?
1. Pain and infection
2. History of bladder spasms
3. Pain and cardiac arrhythmias
4. Urinary incontinence and sexual
dysfunction
224. Mr. Dulles has undergone a

continent/orthoptic urinary diversion.
Which of the following statements will
help to best educate him to avoid
nighttime incontinence?
1. Drink at least 8 glasses of fluids
throughout the day and evening.
2. Empty the bladder at bedtime (either by
voiding or by self-catheterization).
3. Set the alarm to awaken every 2 hours
during the night to void or self-catheterize.
4. Wear an adult diaper at night as all patients
will experience nighttime incontinence.
225. Mr. Benson presents with some pain and

frequency of urination. During a rectal
palpation, the examiner detects a diffuse
enlargement of the prostate. There seems
to be no mass, however. With no other
information, one might infer that Mr.
Benson is most likely to have:
1. Nephritis
2. Cancer of the prostate
3. Cancer of the bladder
4. Benign prostatic hypertrophy
226. Your patient is being prepped for a

radical prostatectomy and is concerned
about urinary incontinence. Your best
advice to him is which of the following?
1. He should talk to his partner about his
concerns.
2. Urinary incontinence is a major problem in
about 50% of patients.
3. Stress incontinence occurs in about 25% of
patients but it is manageable.
4. The majority of men will gain urinary
control within 1 year following radical
prostatectomy.
227. One of the primary long-term

complications of a cystectomy and
urinary diversion are related to which of
the following?
1. Pain
2. Bowel infection
3. Renal insufficiency
4. Hemorrhagic cystitis
228. Hemorrhagic cystitis is a bladder toxicity

primarily associated with the
administration of what chemotherapy
agents?
1. Fluorouracil and ifosfamide
2. Paclitaxel and ifosfamide
3. Doxorubicin and ifosfamide
4. Cyclophosphamide and ifosfamide
229. Ms. Pang is at high risk for developing

hemorrhagic cystitis in response to high-
dose cyclophosphamide therapy for stem
cell transplantation. You explain that
you will use what drug to help prevent
the development of hemorrhagic cystitis?
1. Mesna
2. Mannitol
3. Amifostine
4. Amino caproic acid
230. A continent urinary diversion is a

surgical method that substitutes the
bowel from portions of the intestine to
function like the original bladder. Which
of the following is a correct description
of this procedure?
1. Two-way valves prevent urinary reflux.
2. An external urinary pouch provides control
of voiding.
3. An intra-abdominal pouch is created for
storage of urine.
4. All continent urinary diversions are
constructed from terminal ileum.
231. Following a radical cystectomy, the

nurse is instructed to irrigate the pouch
regularly to maintain patency. The
patient expresses dismay, stating that he
does not feel he can learn to do this. The
nurse’s best response is which of the
following?
1. “Irrigation is necessary to prevent urinary
reflux.”
2. “Most of the time, the mucus becomes very
thin and easy to pass.”
3. “Has your doctor told you it will be
necessary for you to irrigate the pouch?”
4. “Mucous production will decrease over
time, and irrigation will become
unnecessary.”
232. As you take the history of a patient with

nephrotic syndrome, what signs and
symptoms would you expect to see or
hear reported?
1. Mild hypotension
2. Brown, frothy urine
3. Frank blood in the urine
4. Generalized weight loss with anorexia
233. What are the most important

precipitating factors associated with
myeloma-associated renal failure?
1. Infection, edema, hyperglycemia
2. Infection, dehydration, hypercalcemia
3. Infection, hypertension, hypercalcemia
4. Infection, hypotension, hyperglycemia
234. What is the most common site of

metastatic disease in renal cancer?
1. Lung
2. Bone
3. Liver
4. Adrenal gland
235. When administering everolimus to a

patient with renal cancer, it is important
to emphasize what common side effect?
1. Fatigue
2. Hair loss
3. Hypercalcemia
4. Hypoglycemia
236. With which of the following drugs is the

development of a papulopustular rash
(PPR) most common?
1. Erlotinib
2. Paclitaxel
3. Interleukin-6
4. Interferon-alpha
237. Elise has been receiving erlotinib for the

treatment of non-small cell lung cancer
and has been diagnosed with a grade 3
papulopustular rash (PPR). Based on
clinical guidelines, what will you explain
to her about continuation of treatment?
1. She will continue treatment at full dose.
2. She will continue treatment on a reduced
dose.
3. She will interrupt treatment immediately,
and discontinuation of therapy will be
considered.
4. She will interrupt her treatment for 21 days
or until the PPR is improved to grade 2, and
may restart treatment at full dose or dose
reduced.
238. Significant risk factors for the

development of radiodermatitis in
women undergoing breast irradiation
include:
1. Age under 50
2. Darkly pigmented skin
3. Small breasts with dense tissue
4. Large, pendulous breasts, and multiple skin
folds
239. Which of the following is true regarding

radiation-induced skin reactions?
1. Photons produce greater skin reactions
than electrons.
2. Higher doses given over shorter periods of
time to larger volumes result in more
severe acute skin reactions.
3. When treatment is targeted at areas of skin
apposition, decreased reaction secondary to
warmth and moisture can be expected.
4. Placing tissue-equivalent material on the
skin creates a skin-sparing effect during
radiation therapy, minimizing dose at the
level of the skin.
240. Monique is experiencing

hyperpigmentation. You explain to her
that this may be a reaction to:
1. Cisplatin
2. Paclitaxel
3. Bleomycin
4. Asparaginase
241. Mary is receiving oral capecitabine and

calls the outpatient clinic with a
complaint of mild pain and tingling of
both hands, redness of her hands, and
tenderness to touch. As the nurse, you
would advise her to:
1. Not worry and go get a gentle massage to
help her relax
2. Come to the outpatient clinic to be
evaluated for an allergic reaction.
3. Go to the emergency department as she
may be having a severe allergic reaction.
4. Focus on local comfort measures such as
elevation and cooling of her hands as
palmar-planter erythrodysesthesia (PPE) is
common with capecitabine.
242. Paronychia, or periungual

inflammation, is common in what group
of anticancer drugs?
1. Taxanes
2. Anthracyclines
3. Epidermal growth factor receptor (EGFR)
inhibitors
4. Vinca alkaloids
243. Alicia has metastatic cancer with a grade

2 performance status. She returns today
for her second course of doxorubicin
hydrochloride. Her chief complaint is
not being able to eat, fatigue, and a rash
that has newly formed on her scalp and
spread to her temple just below her left
eye. Appropriate nursing actions would
1. Teach her not to use any harsh soaps or
astringents on her face.
2. Have her see the physician/advanced
practice nurse (APN) to treat her with an
antibiotic.
3. Teach her to not touch the rash and to
wash her hands frequently.
4. Continue with chemotherapy as ordered
because her disease has obviously spread to
her scalp.

agents is most frequently associated with
moderate to severe hair loss?
1. Bleomycin
2. Doxorubicin
3. Methotrexate
4. Mitoxantrone
245. Which of the following is considered

appropriate first-line treatment for
dyspnea?
1. Glucocorticoids
2. Benzodiazepines
3. Morphine sulfate
4. Oxygen therapy
246. Pneumocystis jiroveci pneumonia is

potentially fatal and requires treatment
with:
1. Foscarnet
2. Ganciclovir
3. An aminoglycoside
4. Trimethoprim-sulfamethoxazole
247. When a patient at the end of life

complains of dyspnea, the nurse should
most appropriately focus on which of
the following?
1. Administer bronchodilators as needed.
2. Monitor pulse oximetry to determine need
for oxygen.
3. Administer opioids to lessen the sensation
of breathlessness.
4. Determine degree of dyspnea by assessing
arterial blood gases and pulmonary
function tests.

common presenting symptom of lung
cancer?
1. Cough
2. Sore throat
3. Hoarseness
4. Hemoptysis
249. Which of the following sclerosing agents

is used most commonly to manage
recurrent pleural effusions?
1. Talc
2. Doxorubicin
3. Tetracycline
4. Gemcitabine
250. A chest x-ray reveals that Mr. Stanton

has a large pleural effusion contributing
to his dyspnea and difficulty breathing.
Once the fluid is drained, the physician
instills bleomycin, a sclerosing agent,
into the pleural space. In preparing your
patient for the procedure, you would be
certain to mention which of the
following?
1. The sclerosing agent is given to obliterate
the pleural space.
2. If the fluid reaccumulates, it will be
necessary to evaluate a different treatment
strategy.
3. The purpose of injecting bleomycin into the
pleural space is to kill any cancer cells that
might be there.
4. The procedure is not painful, and therefore
the patient will not require pain medication
before the procedure.
251. Mrs. Frazier, who had an allogeneic stem

cell transplantation and is in the
postengraftment period, develops a
pulmonary infection. You are mindful
that because of prolonged periods of
immunosuppression caused by her
medication, she is at greater risk for
developing:
1. Interstitial pneumonia
2. Idiopathic pneumonia
3. Cytomegalovirus (CMV) pneumonia
4. Respiratory syncytial virus pneumonia
252. The pulmonary function test most likely

to detect chemotherapy-induced
pulmonary toxicity before the onset of
clinical symptoms is:
1. A chest x-ray
2. CO2 binding capacity
3. Pulmonary blood gases
4. The carbon monoxide diffusion capacity
measurement
253. Which of the following agents is most
frequently associated with pulmonary
toxicity?
1. Bleomycin
2. Fluoruracil
3. Doxorubicin
4. Methotrexate
254. Which of the following factors increases

the risk of interstitial pneumonitis, as a
late-onset pulmonary complication of
stem cell transplant?
1. Viral pneumonia
2. High-dose corticosteroids
3. Previous anthracycline therapy
4. Previous cyclophosphamide therapy
255. Malignant pleural effusions are often

associated with a poor prognosis. Which
of the following is an accurate
description of median survival times of
patients with malignant pleural
effusions?
1. Patients with breast cancer with evidence
of a malignant pleural effusion have a
median survival time of 5 months.
2. Patients with lung cancer with evidence of
a malignant pleural effusion have a median
survival time of 3 months.
3. Patients with mesothelioma with evidence
of malignant pleural effusion have a
median survival time of 1 year.
4. Patients with ovarian cancer with evidence
of a malignant pleural effusion have a
median survival time of 2 years.
256. During a thoracentesis procedure, your

patient is placed in an upright sitting
position. As the fluid is being removed,
the patient becomes diaphoretic, pale,
and appears to be fainting. As you
administer care to your patient, you
realize her symptoms are due to what?
1. Needle phobia
2. Pneumothorax
3. A vasovagal reaction
4. Re-expansion pulmonary edema
257. Thoracentesis involves fluid removal

from:
1. The pleural cavity
2. The spinal column
3. The pericardial sac
4. The abdominal cavity
258. The first and most common means of

obliteration of the pleural cavity in a
patient with chronic recurrent malignant
pleural effusions is:
1. Local radiation
2. Pleural stripping
3. Pleuroperitoneal shunt
4. Pleurodesis with a sclerosing agent
259. Cytarabine and mitomycin C can cause

diffuse alveolar damage, resulting in
which of the following pulmonary
disorders?
1. Pneumonia
2. Pleural effusion
3. Obliteration of alveoli
4. Capillary leak syndrome
260. What percentage of pleural effusions are

malignant?
1. 75%
2. 50%
3. < 25%
4. 100%
261. Which of the following differentiates a
malignant pleural effusion from a
nonmalignant pleural effusion?
1. Malignant effusions are hypocellular.
2. Malignant effusions are almost always
clear.
3. Malignant effusions are almost always an
exudate.
4. Malignant effusions are almost always a
transudate.
262. In general, dyspnea most commonly

occurs when which of the following is
present?
1. Chronic pain
2. Physiologic parameters indicating altered
pulmonary function tests
3. An increase in respiratory effort necessary
to overcome obstructive or restrictive
disease
4. A decrease in the amount of respiratory
muscles required to maintain adequate
breathing
263. Management of hemoptysis due to

diffuse alveolar hemorrhage (DAH)
includes which of the following?
1. Antianxiety medications
2. High-dose corticosteroids
3. Thoracentesis to relieve dyspnea
4. Codeine or hydrocodone for cough
suppression
264. Which of the following is considered a

risk factor for lymphedema?
1. Infection
2. Cachexia
3. Colon cancer
4. Breast reconstruction
265. Prevention of lymphedema in a patient

who is at risk for lymphedema includes
which of the following strategies?
1. Education about avoiding obesity
2. Education about the need to avoid any kind
of regular exercise
3. Education about benefits of strenuous
exercise, including weight lifting
4. Education about the use of complete or
complex decongestive therapy (CDT)
266. A patient is going to begin complex

decongestive therapy (CDT) for the
management of lymphedema. What
would be appropriate teaching related to
CDT for this patient?
1. “CDT is a combination of manual
lymphatic drainage and compression
bandaging used only for a short period of
time after lymphedema is identified.”
lymphatic drainage, compression
bandaging, and deep massage used only for
a short period of time after lymphedema is
identified.”
bandaging, exercises, and meticulous skin
care used lifelong after lymphedema is
identified.”
bandaging, exercises, and meticulous skin
care used only for a short period of time
after lymphedema is identified.”
267. Following treatment for ovarian cancer,

your patient calls to complain that her
legs feel heavy, painful, and slightly
numb. Nursing management includes
1. Inform her to elevate her legs and restrict
fluids.
2. Instruct her to come into the emergency
room to rule out deep vein thrombosis.
3. Inform her that her symptoms are likely
due to obstruction of lymph drainage in her
abdomen, and she needs to be evaluated.
4. Reassure her that her symptoms are likely
due to chemotherapy and will improve over
time.
268. Cardiotoxicity associated with

doxorubicin can be minimized by the
administration of which of the following
cardioprotective agents?
1. Digitalis
2. Amifostine
3. Calcium gluconate
4. Dexrazoxane (Zinecard)

be a significant risk factor for cardiac
tamponade?
1. Lung cancer
2. Hyperkalemia
3. Ovarian cancer
4. Hyperphosphatemia
270. James is starting doxorubicin therapy,
without mediastinal radiation. You
explain to him that his lifetime total
cumulative dose of doxorubicin is:
1. 550 mg
2. 600 mg
3. 550 mg/m2
4. 450 mg/m2
271. In the stem cell transplant population,

what drug is reported to cause acute
pericarditis when given in high doses?
1. Epirubicin
2. Bleomycin
3. Trastuzumab
4. Cyclophosphamide
272. Choose the statement that most

accurately describes the degree of
subjective symptoms produced by
malignant pericardial and pleural
effusions.
1. Symptoms tend to be related more to the
rate of fluid accumulation than to the
volume collected.
2. Symptoms tend to be related more to the
volume of fluid collected than to the rate of
the collection.
3. Symptoms are related more to the
underlying disease and length of time the
patient has been diagnosed with cancer.
4. Symptoms correspond directly to whether
the metastatic disease is from microscopic
seeding of the cavities or from local
extension.
273. The most common presenting symptom

of cardiac tamponade in a patient with
cancer is:
1. Nausea
2. Fatigue
3. Dyspnea
4. Chest pain
274. Joan is suspected to be experiencing

cardiac tamponade. As her nurse, what
test(s) will you advise her that she will
likely need to confirm a diagnosis of this
syndrome?
1. Ultrasound of the heart
2. Computed tomography of the heart
3. Two-dimensional echocardiography
4. Magnetic resonance imaging of the heart
275. Mr. Archer has had an implanted port for
4 weeks and recently complained of pain
in his right neck and shoulder, just above
the catheter insertion site. On
examination you notice slight swelling
over the neck, face, shoulder, and arm.
He also complains that his arm is cold at
times and there is some tingling in his
arm and shoulder. What is the most
appropriate action to take?
1. Flush the line with heparin to make sure it
is not clotted.
2. Notify the physician to examine the
patient. A venogram will probably
demonstrate a venous thrombosis.
3. Notify the physician to obtain an order for
alteplase. The patient probably has a fibrin
sheath formation around the tip of the
catheter.
4. These symptoms are normal following port
placement and should resolve in 2–3
weeks. Have him return to the clinic in a
week if he is not better.
276. Thromboembolism (TE) is most

frequently seen with which of the
following?
1. Breast cancer
3. Soft tissue sarcoma
4. Bladder carcinoma
277. The etiology of thromboembolism (TE)

is:
1. Chronic hemorrhage
2. Bone marrow failure
3. Tumor secretion of cytokines, such as
interleukin-1, affecting red cell metabolism
4. The ability of tumor cells to affect systemic
activation of coagulation and to produce
and secrete procoagulant and inflammatory
cytokines
278. The prognosis for a patient with

colorectal cancer is probably poorest if
which of the following exists?
1. High blood pressure
2. Squamous cell involvement
3. Venous and lymph node invasion
4. Location of the tumor above the peritoneal
reflection
279. Erin complains of dyspnea, fatigue,

weakness, and edema in her ankles. She
has a history of left-sided breast cancer
and was treated with surgery and
adjuvant radiation therapy 10 years ago.
What diagnostic test will she likely have
to evaluate her complaints?
1. Electrocardiogram
2. Computed tomography
3. Multigated acquisition scan
4. Magnetic resonance imaging of the heart
280. Which of the following may be effective

in preventing neurotoxicities associated
with oxaliplatin-based therapy?
1. Amifostine
2. Venlafaxine
3. Nortriptyline
4. Pyroxidine (vitamin B6)
281. Davis is taking vincristine. You are able

to discern from his conversation that
although he is familiar with some of
vincristine’s adverse effects, he seems
unfamiliar with its neurotoxic effects.
Thus, you tell him that vincristine is well
known for potential:
1. Encephalopathy
2. Peripheral neuropathy
3. Leukoencephalopathy
4. Acute cerebellar dysfunction
282. Factors that increase the risk of
neurotoxicity with vincristine include:
1. Dose greater than 2 mg and age less than
40 years
2. Dose greater than 6 mg and age more than
60 years
3. Dose greater than 2 mg and severe liver
dysfunction
4. Dose greater than 4 mg and severe liver
dysfunction
283. Your patient is receiving cisplatin

therapy and the advanced practice nurse
has documented that the patient’s
cisplatin-based sensory deficits follow a
“stocking-glove” distribution. This
description means that:
1. Sensory losses are bilateral with
paresthesias of the toes, moving up
through the feet and the fingers, moving up
through the hands.
2. Sensory losses are unilateral with
paresthesias of the toes, moving up
through the hands.
3. Sensory losses are unilateral or bilateral
with paresthesias of the toes, moving up
through the hands.
4. Sensory losses are bilateral with
paresthesias of the feet and hands
accompanied by foot drop and weakness of
distal muscles and leg cramping.
284. A patient receiving paclitaxel has

recently complained that she has some
trouble walking without stumbling. After
examining the patient, the physician
changes her chemotherapy. What is the
most logical explanation for switching
her chemotherapy?
1. The paclitaxel is causing a cerebellar
dysfunction.
2. The cancer could be impinging on the
spinal nerves.
3. The paclitaxel could be causing progressive
peripheral neuropathy.
4. She probably has a brain tumor, and the
chemotherapy is not working.

drugs is associated with arthralgias and
myalgias?
1. Paclitaxel
2. Ifosfamide
3. Fluoruracil
4. Doxorubicin

risk factor for ifosfamide-induced
encephalopathy?
1. High serum albumin
2. Low serum creatinine
3. Hepatic insufficiency
4. Previous taxane therapy
287. Mr. Rogers has a metastatic cancer of

unknown origin. He originally went to
his doctor because of ataxia and lower
extremity weakness. His doctor
described his symptoms as being related
to a paraneoplastic syndrome. Which of
the following statements best describes
the cause of the patient’s weakness?
1. Muscle wasting is common in metastatic
cancer.
2. Chemotherapy is the most likely cause of
the weakness.
3. The cancer is in the brain and is pressing
on the cerebellum.
4. Cerebellar function is impaired because of
the effect of the tumor.
Your patient has a possible brain tumor
288.
involving the frontal lobe. He is unable
to coordinate skilled movements but is
not paralyzed. This clinical
manifestation is called:
1. Apraxia
2. Aphasia
3. Dysphasia
4. Dysreflexia
289. The cause of peripheral neuropathy, as a

result of chemotherapy, is best described
by which of the following?
1. Deep tendon reflexes are lost.
2. Sensory and motor axons are injured.
3. Demyelination reduces nerve conduction
velocity.
4. Nerve cells are damaged by the cytotoxic
effects of the drugs.
290. Jonas has finished his last course of

chemotherapy including carboplatin and
etoposide. He comes for an office visit
complaining of colicky abdominal pain,
constipation, urinary retention, and
impotence. You are concerned because
you know that his symptoms are most
likely due to which of the following?
1. Tumor recurrence
2. A paraneoplastic syndrome
3. Obstipation from chemotherapy
4. The effect of chemotherapy on autonomic
fibers
291. Annie has just completed her 10

treatments of weekly paclitaxel. Over the
last few weeks she has complained of
difficulty buttoning her clothes and asks
how soon it will get better. Your most
appropriate response would be which of
the following?
1. She cannot receive more paclitaxel.
2. Her symptoms will likely improve over
several months.
3. Her symptoms will probably get worse
before they get better.
4. Most symptoms will improve 2–3 weeks
after treatment ends.
292. The risk of ototoxicity from cisplatin

therapy is increased by which of the
following?
1. Rapid drug delivery
2. Previous ear infections
3. Continuous infusion therapy
4. Concomitant radiation therapy
293. Mr. Jones is an elderly gentleman who

has been receiving fluorouracil (5-FU)
and leucovorin weekly as treatment for
his colon cancer. His wife phones you to
say that he is unsteady on his feet and
complains of intermittent double vision.
You encourage her to bring him in right
away because you suspect which of the
following?
1. Acute cerebellar dysfunction due to the 5-
FU
2. Metastatic disease to the brain causing
ataxia and diplopia
3. Dehydration due to severe diarrhea from
the 5-FU
4. Leukoencephalopathy from the cumulative
effect of the drugs
294. After treatment for a brain tumor, Mr.

Jessup begins to experience tingling in
his extremities on the contralateral side
of the tumor as well as progressive motor
loss and changes in the level of
consciousness. You suspect, therefore,
that he might have:
1. Cerebral ischemia secondary to the tumor
2. Cushing’s syndrome, in response to
progressive tumor
3. Increased intracranial pressure due to
increasing tumor size
4. Intermittent pulmonary failure with
cardiac episodes secondary to carotid artery
ligation
295. A patient who is receiving high-dose

cytosine arabinoside for acute
myelogenous leukemia (AML) begins to
experience slight difficulty with
articulation of words. She smiles
apologetically and says, “I guess I didn’t
get enough sleep. My mouth is pretty dry,
too.” Your response is to:
1. Withhold her medication, and check her
renal function tests.
2. Withhold her chemotherapy dose, and do a
neurological evaluation.
3. Do an oral examination, offer mouth care,
and continue chemotherapy.
4. Interview the patient to identify factors
contributing to sleeplessness, which is also
contributing to dry mouth.
296. Allison has been on tapering doses of

steroids over the past week after the
completion of radiation therapy to her
brain for metastatic breast cancer. She is
now sleeping more and seems confused.
The cause of changes in her mental
status is most likely due to:
1. Hypercalcemia
2. Steroid psychosis
3. Tapering of steroids
4. Recurrence of her cancer
297. In most instances, the earliest and most

sensitive indicator of a central nervous
system tumor is a change in:
1. Motor function
2. Sensory function
3. Cognitive ability
4. Level of consciousness
298. In patients with central nervous system

tumors, a Cushing’s triad may be
observed as intracranial pressure
continues to rise. This triad includes:
1. Bradycardia, widening pulse pressure with
systolic hypertension, and alterations in
respiratory pattern from neurogenic to
Cheyne-Stokes to apneic
2. Bradycardia, narrowing pulse pressure with
3. Tachycardia, widening pulse pressure with
4. Tachycardia, narrowing pulse pressure with
299. Due to the potential for the neurotoxic

side effect of pharyngolaryngeal
dysthesia related to the administration of
oxaliplatin, patients are instructed to:
1. Avoid treatment in a hot environment.
2. Avoid treatment in a cold environment.
3. Avoid cold drinks and exposure to cold
immediately after the infusion.
4. Avoid hot drinks and exposure to a hot
environment immediately after the
infusion.
300. John has a lung tumor with a single

brain lesion for which he has received a
full course of radiation therapy. He has
been doing well on paclitaxel and
carboplatin, until he experienced
vomiting that seemed to come on without
warning. Select the most appropriate
advice to give this patient.
1. His vomiting is most likely due to the
chemotherapy, and he should take an
antiemetic and call back if he does not feel
better.
2. He is probably experiencing delayed nausea
and vomiting from the combination of the
radiation and the chemotherapy. An
antiemetic is appropriate.
3. His symptoms could be related to increased
intracranial pressure, and he should come
to the emergency room as soon as possible.
4. His symptoms could be due to
chemotherapy or to increased intracranial
pressure, and he should be advised to take
dexamethasone, which is appropriate in
either case.
301. After amputation, Mrs. Riley reports

pain in the missing lower leg. The nurse
should be aware that this phantom limb
pain:
1. Is likely to worsen with aging
2. Usually occurs immediately after surgery
3. Indicates a patient’s inability to cope with
loss
4. Generally decreases substantially during
the first year
302. Mrs. Geoffry has lung cancer that has

metastasized to her bones. She has
recently completed 3 weeks of radiation
to her thoracic spine. She phones you
with complaints of recent onset of
repeatedly dropping things and radiating
pain from her back to her chest area.
Which of the following best describes the
etiology of her symptoms?
1. Her symptoms are related to the metastatic
disease in her bones.
2. Her symptoms are most likely due to
delayed effects of radiation.
3. Her symptoms are probably related to
metastatic disease in her brain.
4. Her symptoms are new and are most likely
indicative of spinal cord compression at the
level of her thoracic spine.
303. What are the appropriate nursing

actions for Mrs. Geoffry (see the previous
question) based on her etiology?
1. She should see her healthcare provider
immediately for evaluation.
2. She should be cautioned against dropping
items and instructed to take an analgesic
for pain.
3. She should take it easy as she will get
better in a few weeks because that is when
the radiation has its peak effect.
4. She should be fitted for a spinal brace as
the radiation therapy may have weakened
her spine.
304. George has multiple myeloma and has

been confined to bed because of a
pathological fracture. His daughter calls
the nurse because her father is sleeping
more and is becoming difficult to arouse.
The patient’s symptoms are most likely
due to which of the following?
1. Psychosis
2. Hypocalcemia due to multiple myeloma
3. Hypercalcemia due to multiple myeloma
4. Spinal cord compression due to multiple
myeloma
305. Which of the following would be an

appropriate therapeutic intervention for
chronic phantom limb pain after an
above-the-knee amputation?
1. Relaxation to minimize
emotional/psychological stress
2. Morphine sulfate with immediate-release
morphine as needed
3. Prosthetic fitting as pressure from a
prosthesis will decrease the pain
4. A psychiatric consult as phantom-limb pain
is psychosomatic in nature
306. What familial cancer syndrome is

associated with a high risk of the early
development of sarcomas?
1. Cowden syndrome
2. Li-Fraumeni syndrome
3. Familial adenomatous polyposis
4. Multiple endocrine neoplasia type 2
307. Osteosarcoma usually develops between

the ages of:
1. 1 and 20
2. 10 and 30
3. 30 and 50
4. 50 and 70
308. What is the most common site of
metastasis related to an osteosarcoma?
1. Lung
2. Brain
3. Breast
4. Lymph nodes

contraindication to enteral nutrition?
1. Diarrhea
2. Severe weakness
3. Mechanical obstructions
4. Functioning gastrointestinal (GI) tract
310. Which of the following strategies is

effective for managing regurgitation with
gastrostomy feedings?
1. Use large-bore tube.
2. Consider drugs to decrease motility.
3. Place tube distally into jejunum or
duodenum.
4. Measure residuals and withhold feeding if
more than 25–50 cc.
311. While receiving parenteral nutrition,

your patient complains of pain at the site
of the catheter. Appropriate nursing
actions include which of the following?
1. Slow the infusion, and observe for swelling.
2. Stop the infusion, and assess for catheter
patency.
3. Irrigate the catheter with a small-diameter
syringe.
4. Do nothing because slight discomfort is
normal.
312. Mr. Smith, who seems healthy, is

scheduled for surgical resection of an
esophageal lesion. Which route of
administration of nutritional support do
you predict is most likely to be
appropriate for Mr. Smith immediately
after surgery?
1. Enteral nutrition
2. Home total parenteral nutrition (TPN)
3. TPN for 7–10 days
4. Parenteral intravenous fluids for 3–5 days
313. Which of the following patients would

generally most likely be candidates for
home parenteral nutrition (HPN)?
1. Patients with a functional gut
2. Patients with severe enteritis due to
radiation therapy
3. Patients who are terminally ill and unable
to drink fluids
4. Patients with a temporary inability to eat,
such as immediate post-surgery
314. Mr. Cruz is receiving enteral nutrition

every 4 hours and complains of diarrhea
and cramping. The most likely cause of
his discomfort is which of the following?
1. The formula is probably too warm.
2. The formula is probably too concentrated.
3. The formula is probably infused too slowly.
4. The formula probably does not contain
enough fiber.
315. Dysphagia is the most common

presenting symptom of persons with
1. Tracheal cancer
2. Epiglottal cancer
3. Laryngeal cancer
316. Patients with metastatic cancer often

have difficulty maintaining their weight
because of a lack of appetite. Your
patient has just received a prescription
for megestrol acetate, 800 mg per day.
While discussing her new medication,
you are sure to include which of the
following?
1. She may experience muscle wasting or
weakness.
2. The purpose of the medication is to treat
the cancer.
3. Weight gain is likely to occur due to
increase in body fat.
4. She will need to have her blood counts
drawn regularly due to
immunosuppression.
317. Joseph has started radiation therapy to

his left femur for a sarcoma. He
complains of diarrhea and slight nausea
following his radiation treatment. Your
explanation would include which of the
following?
1. His feeling of nausea is probably more
psychological than real.
2. The waste products of tissue destruction
are likely the cause of his symptoms.
3. Because the radiation port does not include
his stomach, it is not likely that his
symptoms are related to the radiation.
4. The field of radiation may include
surrounding pelvic structures that puts him
at risk for gastrointestinal changes, such as
nausea and diarrhea.
318. Anorexia is often characterized by which

of the following?
1. Early satiety
2. Cancer cachexia
3. Visceral and lean body mass depletion
4. Abnormalities of carbohydrate, protein, and
fat metabolism
319. Mary is being treated with chemotherapy

for colon cancer and approaches the
nurse to tell her that she plans to start on
a macrobiotic diet. What is the most
appropriate response to Mary with
regard to this diet?
1. This diet can put her at significant risk for
protein-calorie malnutrition.
2. This is a nutritionally sound diet, and it will
help her to feel stronger during treatment.
3. Because this diet includes coffee enemas,
she should wait to start the diet until her
chemotherapy is complete.
4. This diet requires the use of multiple
dietary supplements, which may be
difficult to manage with her chemotherapy.
320. A newly diagnosed patient with

unresectable gastrointestinal (GI) tract
cancer complains that he has not had an
appetite for many weeks and is
concerned because he is losing weight.
What is the most likely cause of his
weight loss?
1. The chemotherapy and radiation cause
weight loss.
2. Liver disease is most likely causing his loss
of appetite.
3. Anorexia and cachexia are common
manifestations of gastrointestinal cancer.
4. He is probably depressed over his situation
and should improve with treatment.
321. A patient who has been treated with

radiation to the mouth and oropharynx
has developed mucositis. Patient
teaching regarding mucositis
incorporates which of the following?
1. Administering topical analgesics only
2. Encouraging the patient to avoid alcohol
and cigarettes
3. Removing the plaque-like tissue that forms
with mucositis
4. Rinsing the mouth with a dilute alcohol-
based mouth rinse 4 times daily
322. Xerostomia, a decrease in saliva

secretion, is a side effect of:
1. Oral surgery
2. Cisplatin administration
3. Head and neck irradiation
4. Stem cell transplantation
323. Your patient is beginning radiation

therapy to the mandible and is concerned
about how this will affect his ability to
taste and smell. Your teaching would
1. Loss of taste is usually permanent.
2. Bland foods may increase glossodynia.
3. Taste acuity is usually partially restored
within 4 months.
4. If xerostomia occurs, it has little impact on
taste and smell.
324. Jim complains that food does not taste

the same and that everything tastes like
cardboard. He especially dislikes the
taste of red meat. This is best explained
by the fact that persons with cancer
commonly experience which of the
following?
1. Intolerance to bland foods
2. Difficulty digesting their food
3. An increased threshold for sweet, sour, and
salt and a decreased threshold for bitter
foods
4. A decreased threshold for sweet, sour, and
salt and an increased threshold for bitter
foods
325. An example of a chemotherapeutic agent

that may cause a metallic taste during
administration, leading to taste changes,
is:
1. Etoposide
2. Doxorubicin
3. Dacarbazine
4. Cyclophosphamide
326. What are considered to be the single

most important indicator(s) of
nutritional status?
1. Serum albumin
2. Height and weight
3. Midarm muscle circumference
4. Skinfold thickness measurement
327. William asks you for an appetite

stimulant. Keeping in mind that he is on
an extensive chemotherapy regimen, is
diabetic, and has not had problems with
nausea or vomiting, which of the
following drugs is the best possible
intervention for him?
1. Corticosteroids
2. Metoclopramide
3. Megesterol acetate
4. Tetrahydrocannabinol (THC)

regarding cachexia is true?
1. Cachexia is the same as anorexia.
2. Cachexia is the same as starvation.
3. Cachexia is not reversible with appropriate
feeding.
4. Cachexia is due to the tumor consuming
the body’s nutrients.
329. Mr. Thomas has been steadily losing

weight and progressively deteriorating
from his pancreatic cancer. He is
experiencing severe muscle wasting and
energy loss. The appropriate term for
this condition is:
1. Inanition
2. Malnutrition
3. Undernutrition
4. Cancer cachexia
330. You are attempting to choose an

instrument to gain a more complete diet
history from Carlos. He has already told
you that he doesn’t pay much attention
to what he eats, and he has a hard time
remembering what he had for lunch (or
if he had lunch) yesterday. Carlos is very
upset about his recent cancer diagnosis,
and this has changed his eating habits
considerably. However, he is willing to
cooperate with you, and he understands
the importance of being honest in the
things he tells you. Keeping in mind that
Carlos is in the hospital now, but he will
not be for most of his treatment, you
choose:
1. A diet diary
2. A calorie count
3. A 24-hour dietary recall
4. A food frequency record
331. Characteristics of delirium include:
1. An acute onset of cognitive symptoms that
follows a fluctuating course
2. A chronic condition in which cognitive
symptoms get progressively worse
3. A chronic condition which follows a
fluctuating course of cognitive symptoms
4. An acute onset of cognitive symptoms that
follow a steady and progressively worse
course
332. What percent of patients with cancer

report problems with memory, executive
function, and attention during cancer
therapy?
1. 25%
2. 50%
3. 75%
4. 100%
333. Sally has recently completed her

treatment of doxorubicin and
cyclophosphamide for her breast cancer
and states that she feels forgetful and
feels like she has trouble balancing her
checkbook. Your most appropriate
response to Sally is:
1. Don’t worry, you are under a lot of stress
right now and this is a normal feeling.
2. You will need to see the physician or
advanced practice nurse right away as this
may be a sign of disease progression.
3. Many patients experience changes in
cognition related to chemotherapy, and you
may want to see a psychiatrist to help you
cope with the changes.
4. Many patients experience changes in
cognition related to chemotherapy, and
most experience significant improvement
of these changes by 12 to 18 months post
chemotherapy.
334. What is considered to be the most

sensitive test for diagnosing brain
necrosis related to radiation therapy to
the brain?
1. Computed tomography of the brain
2. Magnetic resonance imaging of the brain
3. Positron emission tomography scanning of
the brain
4. Lumbar puncture and evaluation of the
cerebral spinal fluid
335. Risk factors for the development of

leukoencephalopathy and cognitive
dysfunction include:
1. Older age, large-fraction doses, large
volume of irradiated tissue and vascular
conditions
2. Older age, large-fraction doses, localized
conditions
3. Younger age, large-fraction doses, large
conditions
4. Younger age, large-fraction doses, localized
conditions

cognitive dysfunction in patients with
cancer include:
1. High-dose chemotherapy and longer
treatment duration
2. High-dose chemotherapy and shorter
treatment duration
3. Dose-dense chemotherapy and longer
treatment duration
4. Dose-dense chemotherapy and shorter
treatment duration
337. According to the National Cancer

Institute Common Terminology Criteria
for Adverse Events (NCI CTCAE), grade 2
memory impairment is:
1. Mild, not interfering with function
2. Severe, limiting self-care activities of daily
living (ADL)
3. Moderate, limiting instrumental ADL
4. Suicidal ideation or danger to self,
hospitalization indicated
338. Mary is starting on fractionated external

beam radiation for breast cancer. Her
patient education regarding her
treatment and the occurrence of fatigue
includes:
1. She will likely not experience treatment-
related fatigue.
2. She will likely experience the most
significant fatigue after the completion of
her treatment.
significant fatigue 2 weeks after her
treatment begins.
significant fatigue 1–3 days after the
treatment begins.
339. Mary begins to complain of fatigue 3

weeks into her treatment. You explain to
her that the intervention with the highest
level of evidence to improve her fatigue
is:
1. Aromatherapy
2. Acupuncture
3. Physical activity/exercise
4. Cognitive-behavioral therapy
340. Your patient, who is 5 weeks

postradiation therapy for a meningioma
of the brain, complains of increased
daytime fatigue and somnolence. To help
her understand what might be causing
her symptoms, you could say which of
the following?
1. Sleep disturbance generally only occurs
within 30 days of the radiation.
2. Sleep disturbance generally occurs 4–12
weeks after radiation is complete.
3. The incidence of sleep disturbances is 80%
greater in people who receive radiation
therapy to the brain.
4. Her symptoms are not likely due to the
radiation therapy and might be related to
other medications she is taking, specifically
the corticosteroids.
341. Risk factors for cancer-related fatigue
include:
1. Age, gender, marital status, employment
status
2. Age, gender, marital status, cancer
treatment (e.g., chemotherapy, radiation
therapy)
3. Age, cancer treatment (e.g., chemotherapy,
radiation therapy), medications with
sedating effects
4. Advanced/metastatic disease, cancer
treatment (e.g., chemotherapy, radiation
therapy), medications with sedating effects
ANSWER RATIONALES
Management, Fourth Edition, by Connie Henke
Yarbro, Debra Wujcik, and Barbara Holmes Gobel
(Jones & Bartlett Learning, © 2014).
A. ETIOLOGY AND PATTERNS OF SYMPTOMS
1. The answer is d.
Guidelines recommend that erythropoietin
alfa be given in patients being treated with
myelosuppressive chemotherapy with
noncurative intent and who are mildly
symptomatic. Although results may be seen in
2 weeks, an interval of 2–6 weeks may occur
between the time of a dose adjustment and
significant change in hemoglobin, which is the
time required for erythropoiesis and the red
blood cell half-life. Patients with uncontrolled
hypertension should not be treated with
erythropoietin alfa. Erythropoietin-stimulating
agents have also been found to pose an
increased risk for thrombosis in patients with
cancer. CNPP, Pages 509–510, 702–704; CSM,
Page 290.
2. The answer is d.
Infection and sepsis are the most frequent
causes of acute DIC, and can be linked to a
variety of bacterial, fungal, and viral infections.
DIC can be due to liver disease and the use of
prosthetic devices, but are not common causes
of DIC. Thrombocytopenia is an outcome of
DIC. CNPP, Pages 1096–1097; CSM, Page 290.
3. The answer is b.
Skin involvement is the most common clinical
feature of acute GVHD. Chronic GVHD can
also affect the skin occurring 100 days or
longer after stem cell transplant. CNPP, Pages
595–597.
4. The answer is d.
Several factors increase the patient’s risk for
developing GVHD and these include an
unrelated donor transplant, mismatched HLA,
older donor/recipient age, positive
donor/recipient viral seropositivity, increased
donor/recipient parity, mismatched female
donor to male recipient, > 12 Gy of total body
irradiation, a less intensive
immunosuppressive regimen, and no T-cell
depletion of the transplanted stem cells. CNPP,
Page 596.
5. The answer is d.
Ocular GVHD and cataract development are
two of the most common late ophthalmologic
complications seen in HSCT patients. Ocular
GVHD is most often characterized by a dryness
of the eyes with associated gritty/sandy
feelings in the eye. CNPP, Page 602.
6. The answer is d.
VOD or sinusoidal obstruction syndrome
(SOS) is almost exclusive to HSCT and is the
most common nonrelapse life-threatening
complication of preparative regimen-related
toxicity for HSCT. Fungal and virus infections
arise in the liver posttransplant as infections
not as VOD. Patients at risk for developing
VOD include those with hepatitis and
infections before HSCT and those who receive
repeated doses of chemotherapy before
transplant in addition to high-dose irradiation
in pretransplant conditioning regimens. CNPP,
Page 594.
7. The answer is a.
Diarrhea can occur with obstructive jaundice,
and it may be severe and intractable, leading to
fluid and electrolyte imbalance. CNPP, Page
1657.
8. The answer is d.
Paclitaxel has a high potential to cause
hypersensitivity reactions. Corticosteroids are
frequently used when patients are to receive
4–5 courses of paclitaxel to reduce the risk of
hypersensitivity reaction. Corticosteroids are
also commonly used as part of an antiemetic
drug protocols. Corticosteroids commonly
cause sleep disruption, insomnia, restlessness,
and increased motor activity. CNPP, Pages 907,
915.
9. The answer is a.
Viral infections may be characterized by low
continuous fevers. Most patients who have
infection are tachycardic and tachypneic,
except when the infection is so severe as to
cause acidosis. Bacterial infections produce
high spiking fevers with periods of return to
normal. Disseminated fungal infections
usually produce high spiking fevers without
any such return to baseline. Subnormal
temperatures are associated with gram-
negative infections. CNPP, Page 831.

The nadir for high-dose methotrexate is 7–10
days, and diarrhea in the presence of
neutropenia requires the patient be tested for
Clostridium difficile, especially if the patient is
also receiving antibiotics. This bacterium
causes toxin release and is treated with oral
vancomycin or metronidazole. Antidiarrheal
agents should never be used to counteract
diarrhea resulting from infection. CNPP, Pages
465, 513; CSM, Pages 187, 190.

Because it is not possible to distinguish an
acute hemolytic blood reaction from a
nonhemolytic transfusion reaction at the
bedside, the reaction should be managed by
stopping the transfusion, maintaining the line
with normal saline, and working the patient up
for a possible infection or hemolytic
transfusion reaction. Placing the patient in the
Trendelenburg position and administering a
fluid bolus are not ideal because of the
dyspnea. CNPP, Pages 714–715, 718.

Hemolytic transfusion reaction is a rare but
fatal complication following destruction of
donor red cells by recipient antibodies. Acute
hemolytic transfusion reactions occur within
24 hours and are associated with most
hemolytic transfusion-reaction fatalities.

Scalp pain is common approximately 1–2 days
prior to hair loss. The bulb of the follicle swells
as it is about to release the hair. An anti-
inflammatory agent, massage, and/or heat can
be helpful. Skin metastases to the scalp rarely
cause scalp pain. CNPP, Pages 533–534; CSM,
Pages 499, 501.

If a bowel movement does not occur every
other day, a laxative must be taken. His risk
factors are high for constipation (age, opioid
use, vincristine, and change in nutrition), and
it should be emphasized to the patient never to
wait more than 3 days without a bowel
movement before calling the physician. CNPP,
Pages 515–516; CSM, Pages 164–165, 174.
15. The answer if d.

Patients receiving brachytherapy for
gynecologic and prostate cancers are
instructed to maintain a low residue diet and
to take antidiarrheal agents to prevent bowel
movements while implants are in place.
Increased dietary fiber and hydration are
usually sufficient to reverse this side effect.
Not all patients with prostate cancer or on
brachytherapy require opioid therapy. CNPP,
Pages 161–162, 315–318; CSM, Page 165.

Bone marrow failure can occur in heavily
treated patients who have received multiple
courses of chemotherapy, and chronic
microscopic bleeding in patients with primary
or metastatic diseases can result in anemia as
a result of chronic hemorrhage. Tumor
secretion of cytokines, such as interleukin-1,
affect red blood cell metabolism and function
and is a factor associated with anemia of
malignancy. Patients with protein-caloric
malnutrition often have insufficient iron and
folic acid stores, leading to anemia. CNPP,
Page 983.

Patients who are severely immunosuppressed
and have a coagulopathy are most likely to
bleed into the alveoli. The alveoli fill with
blood, prohibiting gas exchange and leading to
hypoxia. Diffuse alveolar hemorrhage (DAH)
has been reported in as many as 12% of
patients who have had hematopoietic stem cell
transplant. CNPP, Page 600; CSM, Pages 294,
303.

This patient’s age puts him at higher risk for
cardiovascular disease and a hemoglobin of 7.7
g/dL increases his risk for angina and
infarction. Anemia manifests as pallor,
hypotension, headaches, irritability, and
fatigue. CNPP, Page 983; CSM, Page 318.

Emesis occurs through several mechanisms,
including stimulation of enterochromaffin
cells in the duodenum, leading to release of
serotonin. Serotonin binds and stimulates the
vagus nerve, which in turn stimulates the
spinal cord, medulla oblongata, and then the
brain’s vomiting center. CNPP, Pages 516–517;

Prior or concurrent radiation may augment the
severity and extent of mucosal injury. Some
drugs, such as dactinomycin and doxorubicin,
potentiate radiation injury to the esophagus,
and others, including 5-FU, hydroxyurea,
procarbazine, and vinblastine, produce an
additive toxic effect with irradiation. CNPP,
Page 357.

Because carcinoma of the thyroid can rapidly
invade surrounding structures, symptoms may
occur that are related to compressive effects of
the enlarging mass on adjacent structures.
Patients may experience dyspnea or stridor
when the trachea is compressed or infiltrated.
Compression of the esophagus may cause
dysphagia. Hoarseness can result from
malignant infiltration or destruction of the
laryngeal or vagus nerves. CNPP, Pages 1490–
1491.

The frequency of oral care should increase
with the severity of the symptoms. A basic
solution such as sodium bicarbonate or
normal saline 4 times daily is recommended
for use. Chlorhexidine is not recommended for
cancer-treatment related mucositis. CNPP,
Page 934; CSM, Pages 411–413.

5-FU is an antimetabolite that contributes to
the development of oral mucositis. Mucositis
is observed more often when it is given to
patients as a bolus dose versus a continuous
infusion. CNPP, Page 924; CSM, Pages 404,
407.

Areas of the oral cavity adjacent to metal tooth
fillings are at greatest risk for increased
reaction due to radiation scatter from the
metal fillings. Mucositis is enhanced and
prolonged in patients who have preexisting
poor oral or dental hygiene, continue to
smoke, use chewing tobacco, consume alcohol,
and have poorly fitting dentures. CNPP, Page
350; CSM, Pages 406–407.

Direct stomatotoxicity results from the
cytotoxic action of drugs on the cells of the
oral basal epithelium, causing a decrease in
the rate of cell renewal. The sequelae include a
thinned atrophic mucosa and initiation of an
inflammatory response (stomatitis). CNPP
Pages, 524–525; CSM, Pages 404–405.

Xerostomia is a drying of the oral mucosa
resulting from loss of saliva due to damage
that occurs to the salivary glands subsequent
to radiation therapy to the head and neck; it
manifests in a thicker saliva. Mucositis is an
inflammatory response of the oral mucosa to
radiation therapy. The oral cavity appears
inflamed, and white patchy areas may be seen.
The patient complains of a sore throat and
mouth. Trismus or jaw hypomobility may
occur if the posterior mandible is included in
the irradiated field. CNPP, Pages 347, 365;
CSM, Pages 421, 423.

Oral pilocarpine has been approved for use as
a stimulant to the exocrine glands. This results
in diaphoresis, salivation, lacrimation, and
gastric and pancreatic secretion. CNPP, Pages
527, 936; CSM, Page 428.

Saliva provides lubrication for oral tissues and
protection from bacterial infections. Saliva
also inhibits enamel decalcification, thereby
greatly increasing the risk of dental caries.
CNPP, Page 936; CSM, Page 423.

Risk factors associated with the development
of radiation induced nausea and vomiting
include female gender, younger age (< 55), low
alcohol intake history, history of radiation
induced nausea and vomiting; as well as
concurrent chemotherapy, previous history of
chemotherapy induced nausea and vomiting,
radiation site, field size, and radiation dose and
frequency. CNPP, Page 349; CSM, Pages 218–
219.

Anticipatory nausea and vomiting generally
occurs after 3 to 4 cycles of chemotherapy in
which the antiemetic control has been
inadequate CNPP, Page 517; CSM, Page 214.

Women experience sexual and reproductive
dysfunction from both single agent and
combination chemotherapy, particularly when
drugs are combined with alkylating agents.
These agents can also cause significant nausea,
vomiting, and diarrhea. CNPP, Pages 1022–
1023, 1628–1631; CSM, Page 510.

Predisposing factors related to cancer-related
sleep disturbance are durable psychological or
biological traits that make a patient more
likely to develop sleep problems during the
course of the cancer experience. Predisposing
factors include female gender, advanced age,
anxiety-prone personality, family or personal
history of insomnia, and genetic factors. The
other answers include precipitating factors and
perpetuating factors that may contribute to
cancer-related sleep disturbance. CNPP, Pages
1055–1056; CSM, Pages 97–98.

Lung cancer, breast cancer, and melanoma
have the highest incidence of brain metastasis,
and therefore are cancers that pose a risk of
increased intracranial pressure with brain
metastasis. CNPP, Page 1170; CSM, Page 439.

Cancer cachexia is a multifactorial syndrome
characterized by anorexia, progressive
involuntary weight loss, and ongoing loss of
skeletal muscle mass (with or without loss of
fat mass) that cannot be fully reversed by
conventional nutritional support. CNPP, Pages
937–938; CSM, Page 351.

The most significant consequence of gram-
negative infection is the potential for
endotoxic or systemic shock. The release of
endotoxins initiates a cascade of events that,
unless interrupted, rapidly lead to death for
the neutropenic patient. CNPP, Pages 1138–
1139; CSM, Pages 138–141.

All of the answers are risk factors for the
development of sepsis in the patient with
cancer, but the presence of granulocytopenia is
the single most important risk factor for
development of sepsis. CNPP, Pages 1137–
1138.

Fever is the cardinal symptom of infection.
The presence of neutropenia may mask the
classic infection-related symptoms of
inflammation, pus formation, and elevated
white blood cell counts. CNPP, Pages 829–831,
1139; CSM, Pages 134–135.

Gram-positive organisms are responsible for
approximately 60%–75% of all infections in
patients with cancer. CNPP, Page 832; CSM,
Page 138.

The skin is the first line of defense against
invading bacteria and subsequent infection.
When a break in the skin occurs,
environmental microbes and those that
normally inhabit hair follicles and sebaceous
glands can enter the body and cause infection.

PMNs make up 35%–76% of white blood cells
and are the first to respond to invading
bacteria. The primary function of PMNs is the
destruction and elimination of
microorganisms through phagocytosis, the
process of engulfing and ingesting foreign
matter. CNPP, Pages 828–829.

Undisturbed endogenous microbial flora exists
as a carefully balanced synergistic
microenvironment within the host. Alterations
in normal flora predispose persons with cancer
to serious opportunistic or nosocomial
infection. A large percentage of infections
developing in cancer patients arise from
endogenous organisms, nearly half of which
are acquired during hospitalization. CNPP,
Pages 828–829; CSM, Page 134.

One of the most common reasons for
unrelieved pain in American healthcare
systems is the failure of staff to routinely
assess pain and pain relief. Many patients
silently tolerate unrelieved pain, especially if
they are not specifically asked about it. CNPP,

Burning, pins and needles, and radiating pain
are all descriptors of neuropathic pain, which
may be related to chemotherapy-induced
peripheral neuropathy. CNPP, Pages 488–489,
792–793; CSM, Page 71.

Neuropathic pain is generally treated with
tricyclic antidepressants, anticonvulsants,
serotonin-norepinephrine reuptake inhibitors,
antiarrhythmic agents, N-methyl-D-aspartate
antagonists, and corticosteroids. CNPP, Pages
792–793; CSM, Pages 83–84.

Critical to establishing a diagnosis of reactive
(situational) depression in patients with
cancer is the evaluation of selected defining
characteristics commonly attributed to
depression among the psychiatrically ill. Some
common characteristics of depression,
however, may also occur in the patient with
cancer as a result of the disease, its treatment,
or its side effects, or they may have existed in
the patient before diagnosis. Therefore, the
primary criteria for assessment of depression
are that the characteristics are a change from
previous functioning, are persistent, occur for
most of the day and on more days than not,
and are present for at least 2 weeks. CNPP,
Performance scales that measure a person’s
functional status are used frequently in the
eligibility criteria for cooperative group clinical
trials and also periodically to evaluate the
effects of treatment and disease. It may be
helpful to interpret a person’s quality and
quantity of life, but it is not a primary
objective of performance status. CNPP, Page
196.

There is general agreement that quality of life
is best evaluated by the patient, rather than by
another observer. There are situations in
which the patient may not be able to provide
the information such as with cognitive
impairment, debilitating fatigue, severe
nausea, severe pain, or other symptoms.
CNPP, Page 218.

The FACT/FACIT instrument is used to
measure the following domains of quality of
life: physical, social/family, emotional,
functional, and overall well-being. CNPP, Page
214.

Risk factors for the development of post-
traumatic stress disorder in patients with
cancer include female gender, younger age at
diagnosis, prior negative life stressors, history
of psychological disturbance, increased
distress subsequent to the diagnosis, lower
education, poor social support, poor social
functioning, reduced physical functioning,
emotional reactive temperament, and avoidant
coping style. CNPP, Pages 768–769.

Cancer pain may be acute, chronic, or
intermittent and often has a definable etiology,
usually related to tumor recurrence or
treatment. In contrast to acute pain, chronic
cancer pain is rarely accompanied by signs of
autonomic nervous system arousal. The lack of
objective signs may prompt the inexperienced
clinician to wrongly conclude the patient is not
in pain. CNPP, Page 784; CSM Pages 70–73.
B. ANATOMICAL AND SURGICAL
ALTERATIONS

The healing process for an allograft may take
up to 1 year. Once healed, the patient will not
be allowed to participate in any high impact
sports as the potential complications include
non-union and fracture at the site of the
allograft. CNPP, Pages 1257–1258.

A graft or flap is indicated when a lesion is
large or located in an area in which insufficient
tissue for primary closure would result in
deformity. Function is preserved in this
manner. A skin flap consists of skin and
subcutaneous tissue that are transferred from
one area of the body to another. A flap
contains its own blood supply, whereas a graft
is avascular and depends on the blood supply
of the recipient site for its survival. CNPP,
Pages 1588–1589.

The nursing actions during a carotid
hemorrhage focus on maintenance of the
airway and control of bleeding. If the patient
has a tracheostomy, the cuff should be inflated
to prevent aspiration. Firm pressure should be
applied to the neck using a towel or dressing
material. If an internal carotid bleed is
suspected, a vaginal pack or fluff dressing
should be used to tightly pack the oral cavity
and oropharynx. The patient is then
transported to the operating room for ligation
of the carotid artery. CNPP, Page 1588.

A significant risk factor in the development of
a carotid artery rupture is if the tumor is
recurrent and the patient has received
previous radiation to the tumor site. Skin flaps
are usually made to cover and protect the
carotid artery. Carotid artery rupture usually is
preceded by a small trickle of blood from the
area. CNPP, Pages 1586, 1588.

When a malignant lesion involves the middle
and left transverse colon, the standard
procedure involves resection of the lesion and
a primary anastomosis. The two- and three-
step procedures are riskier and less often
performed. A right hemicolectomy is
performed on the cecum or ascending colon.

Signs and symptoms of an anastomotic leak
after colorectal surgery include ileus,
abdominal pain, postoperative fever, and an
elevated white blood cell count. CNPP, Page
1445.

For upper and midrectal adenocarcinomas, the
treatment approach of choice is low anterior
resection. This preserves external anal
sphincter control, thus eliminating the need
for a permanent colostomy. Abdominoperineal
resection is usually used for poorly
differentiated adenocarcinoma and more
advanced disease. Laser therapy to the tumor
bed through a colonoscope or flexible
sigmoidoscope is used for smaller tumors of
the colon and rectum, and prophylactic
oophorectomy is recommended for only some
women diagnosed with adenocarcinoma of the
colon and rectum. CNPP, Pages 1466–1467.

The intestine normally produces mucus, and
mucus is almost always present in diversions
using segments of the bowel, causing the urine
to appear cloudy. Excessive mucous may clog
the urinary appliance outlet, and if this occurs,
an appliance with a larger outlet may be used.
CNPP, Page 1236.

An important postoperative nursing function
is assessment of stoma viability to identify
early signs of compromised circulation to the
stoma. A stoma that is dusky, gray, or black
indicates an inadequate blood supply and is
documented and brought to the surgeon’s
attention. CNPP, Page 1469.

Because APR requires a combined surgical
approach through the abdomen and perineum,
a major complication of APR is the occurrence
of perineal and abdominal wound infections.
The type of closure used—primary closure,
partial closure with an incisional drain, or
leaving the wound open and packing it—
determines the necessary postoperative care
and teaching. CNPP, Pages 1466–1467.

Atrial arrhythmias are common in the patient
who has undergone a lung resection because
of irritation to the vagus nerve. Stroke is a
complication of atrial fibrillation. Patients are
monitored closely during the postoperative
period, and beta-blockers are initiated if atrial
fibrillation persists. CNPP, Pages 1700–1701.

Pleural effusion is common following liver
resection and is most often seen after a right
hepatectomy. CNPP, Page 1665.

A common complication after a supraglottic
laryngectomy is aspiration. CSM, Page 387.

Ifosfamide is a chemotherapy agent that
commonly results in alopecia. CNPP, Page 533;
CSM, Page 497.

Chemotherapy-induced hair loss is temporary
and reversible. Hair loss generally occurs 2 to
3 weeks following a dose of chemotherapy, and
complete regrowth may take 1 to 2 years.

Vincristine, as well as the other vinca alkaloids
(vindesine, vinblastine, vinorelbine) can cause
extravasation if the drug leaks out of the vein
into the surrounding tissue. CNPP, Pages 435–
437, 440; CSM, Pages 542–543.

If an extravasation of vincristine is suspected
the nurse should stop the administration of
the drug, gently aspirate any remaining drug,
give 5 separate injections of hyaluronidase
subcutaneous injections into the area
suspected for extravasation, and provide for
local warming of the site for 15–20 minutes 4
times a day. CNPP, Pages 436–437; CSM,
Pages 548–550.

Extravasation can occur with the use of a
central line, including an implanted port. If an
extravasation is suspected when a drug is
being infused in a port, the drug should be
stopped immediately, the residue drug should
be aspirated, the needle should be removed, no
drug should be aspirated from the site (to
minimize damage to the skin surface), and
other local measures should be taken based on
the specific drug. CNPP, Pages 438–441; CSM,
Pages 547–550.

Patients who are at risk for lymphedema must
be aware of the need for meticulous skin care
and to keep the skin clean and supple. A
sunburn can lead to cracking of the skin and
increase her risk for infection and subsequent
lymphedema. CNPP, Page 368; CSM, Pages
560–563.

Because Susan has been taught that an insect
sting may contribute to the development of
lymphedema, she seeks medical care right
away to minimize her risk of this condition.
CNPP, Pages 1312–1313; CSM, Pages 559–561.

Preventive measures to reduce the risk of
lymphedema after a patient has received
radiation therapy to the breast, chest wall, and
axilla include avoiding tight clothing, jewelry,
and elastic bands; avoiding extreme
temperatures; not carrying heavy packages on
the affected arm; taking extra care while
cutting nails or shaving underarms; and
wearing compression sleeves when traveling
on an airplane (even without evidence of
lymphedema). CNPP, Pages 368, 1313; CSM,
Pages 562–563.
While all of the agents listed pose risks for the
development of ocular toxicities; cetuximab,
erlotinib, and gefitinib are associated with
trichomegaly, which is characterized by a
maturation of the hair of the eyelashes and
eyebrows. CNPP, Page 671; CSM, Pages 570,
572, 577.

When a patient experiences trichomegaly
related to cancer therapy, the patient should be
evaluated by an ophthalmologist. The
eyelashes can become overgrown, wiry, and
corkscrew-like and may damage the eye.
CNPP, Page 671; CSM, Pages 570, 572.

Cisplatin is most commonly associated
ototoxicity including hearing loss, tinnitus,
and vertigo. CNPP, Pages 470–471; CSM, Page
571.

Men receiving radiation therapy to the pelvis
experience fibrosis of the blood vessels and the
nerves needed for erection, leading to
increased risks of erectile dysfunction over
time. CNPP, Pages 347, 370; CSM, Page 509.
The alkylating agents are the most common
group of chemotherapy agents to cause
infertility. CSM, Page 510.
C. PHARMACOLOGIC INTERVENTIONS

Contraindications to ambulatory oral
antimicrobial therapy for treatment of fever in
neutropenic patients include hematologic
malignancy, blood and marrow
transplantation, suspected pneumonia, history
of invasive fungal infection, active malignant
disease, serious comorbid health conditions,
and hospital-acquired infections. CNPP, Page
839.

Aggressive antiviral therapy with acyclovir is
commonly used for up to a full year following
stem cell transplant. CNPP, Page 593; CSM,
Page 143.

Patients with HIV and neutropenia, who have
had prolonged treatment with corticosteroids,
immunosuppression should be assessed for
the development of P. jiroveci. Because
symptoms are insidious, a prolonged fever that
is unresponsive to antibiotics and associated
with a nonproductive cough and dyspnea on
exertion may indicate infection. CNPP, Pages
600, 836, 838; CSM, Pages 145–146.

Patients with a T-cell dysfunction should be
treated with trimethoprim/sulfamethoxazole,
or an alternative, as prophylaxis for P. jiroveci
pneumonia. CNPP, Pages 600, 836–838; CSM,
Pages 145–146.

Immunosuppressive medications are aimed at
removing or inactivating T lymphocytes that
attack target organs. Cyclosporine and
methotrexate inhibit T lymphocytes that are
believed to be responsible for acute GVHD and
are the first-line therapy. CNPP, Page 593.

Trimethoprim-sulfamethoxazole may cause a
hypersensitivity reaction that may be
manifested as a macular, itchy rash. CNPP,
Pages 593, 842.

Amphotericin B is the drug of choice for
treatment of systemic fungal infections.
However, it is associated with significant side
effects and toxicity, including fever, chills,
rigors, hypotension/hypertension,
bronchospasms, and occasionally seizures.
Patients are generally premedicated with
antipyretics or steroids to minimize these side
effects. CNPP, Page 843.

Rigors accompanying fever is common with
the administration of amphotericin-B and may
be relieved by covering the patient with warm
blankets and administering IV morphine.
CNPP, Page 843.

Arthralgias and myalgias with the taxanes are
thought to be due to an inflammatory process.
Corticosteroids are effective because of their
ability to reduce the symptoms of
inflammation and inhibit a variety of
proinflammatory genes. Although arthralgias
and myalgias are not associated with muscle
inflammation per se, corticosteroids are
effective in relieving the aches and pains
associated with these symptoms. CNPP, Pages
406, 489; CSM, Pages 20–21.

Flulike symptoms are common side effects
related to IL-2 therapy. Many of these
symptoms can be prophylactically treated with
acetaminophen, a histamine-2 blocker, and
NSAIDs, starting the night before the first dose
of IL-2 and continuing 24 hours after IL-2
administration stops. CNPP, Page 617.

NSAIDs interfere with the synthesis of the
enzyme prostaglandin that blocks the
conversion of arachidonic acid to
prostaglandins. Prostaglandins are known to
sensitize tissues to the effects of inflammatory
mediators such as bradykinin. Inhibition of
prostaglandin synthesis leads to relief of
inflammation and pain. These agents are also
antipyretic. CNPP, Page 800; CSM, Pages 78–
79.

Adverse effects of corticosteroids and NSAIDs
together include hypertension, hyperglycemia,
immunosuppression, and psychiatric
reactions. Although corticosteroids were
previously believed to cause peptic ulcers, this
effect probably occurs more with the
concomitant use of NSAIDs. CNPP, Pages 800,
1181; CSM, Pages 78–79.

Glucocorticoids remain the gold standard
treatment for acute GVHD. Other treatment
strategies include systemic
immunosuppressive therapy and ultraviolet A
irradiation. Fluoride may be used for patients
at risk for dental caries secondary to
xerostomia if the mouth is involved. CNPP,
Page 597.

Hypercalcemia leads to profound dehydration
due to the combined effects of polyuria,
vomiting, anorexia, and defects in the urinary
concentrating ability. Thereby, vigorous
rehydration to rapidly expand the extracellular
fluid volume and increase calcium loss in the
urine is the cornerstone of antihypercalcemic
treatment. Loop diuretics, bisphosphonate
therapy, and corticosteroids may all be used
once the patient is rehydrated. CNPP, Pages
1124–1125, 1129.

Because shorter infusion times and higher
doses of bisphosphonates correlate with a
higher incidence of renal adverse events, doses
of zoledronic acid higher than 4 mg and
infusion times less than 15 minutes are not
recommended. CNPP, Pages 1127–1128.
Osteonecrosis of the jaw is a potentially
serious risk of treatment with bisphosphonate
therapy, such as pamidronate; the longer the
duration of the therapy, the greater the risk.
Prevention strategies include recommending
that patients have a comprehensive dental
examination and necessary dental work
completed prior to initiating bisphosphonate
therapy. CNPP, Pages 1126–1127; CSM, Page
58.

Medications such as phenothiazines, tricyclic
antidepressants, heparin, cimetidine, thiazide
diuretics, and estrogen may suppress platelet
activity, but aspirin is the medication most
commonly associated with platelet
dysfunction. CNPP, Pages 799–800, 859–861;
CSM, Page 289.

NSAIDs inhibit platelet aggregation, thus
inhibits platelet function. CNPP, Pages 800,
861; CSM, Page 289.

The NSAIDs inhibit cyclooxygenase in
peripheral tissues, which prevents arachidonic
acid from converting to prostaglandin. The loss
of the cytoprotective effect of prostaglandin on
the GI epithelium causes the occurrence of the
GI side effects. CNPP, Page 800.

Substance P is the neurotransmitter that acts
at NK1 receptors centrally in the brain and in
the peripheral nervous system. Substance P
has been shown clinically to play a role in both
acute and delayed nausea and vomiting after
highly emetic chemotherapy. Aprepitant
effectively blocks these receptors, thereby
preventing substance P from binding to the
NK1 receptor sites in the medulla, resulting in
inhibition of emesis. CNPP, Pages 516–517,
522–523; CSM, Pages 222, 224.

Delayed nausea and/or vomiting occur more
than 24 hours after chemotherapy
administration. It often peaks 48–72 hours
after chemotherapy and can last 5–7 days.
Serotonin receptor antagonists are effective on
days 1–3, but after that, serotonin levels drop
and substance P, the neurotransmitter that
acts at NK1 receptors, becomes the dominant
mediator of nausea and vomiting. CNPP, Pages
516–517, 523; CSM, Pages 216, 222.
The addition of the serotonin inhibitors, such
as granisetron and odansetron, has improved
the management of chemotherapy-induced
nausea and vomiting. The serotonin
antagonists have a different mechanism of
action (compared to the dopamine antagonists
such as prochlorperazine) so they are ideal to
use in combination antiemetic therapy.
Successful antiemetic regimens interrupt the
stimulation of the vomiting center.
Combination regimens must be individualized
and developed according to the emetic
potential of the chemotherapy regimen,
expected duration of the nausea and vomiting,
and current pattern of symptoms. CNPP, Pages
522–523; CSM, Pages 221–222, 224.

The mechanism of nausea and vomiting is
unclear, but prostaglandin synthesis appears
to play a role. Dexamethasone appears to
inhibit prostaglandin synthesis and therefore
helps to prevent nausea and vomiting. CNPP,
Pages 516–517, 521; CSM, Pages 216, 222, 224.

Despite effective antiemetic regimens, a high
number of patients receiving high dose
cisplatin therapy experience delayed nausea
and vomiting. CNPP, Pages 470–471, 517;
CSM, Page 217.

The combinations of serotonin-receptor
antagonists with steroids have been found to
provide complete control of nausea and
vomiting in up to 100% of patients undergoing
high-dose cisplatin-based regimens. The
combination of ondansetron and
dexamethasone has been found to be more
efficacious than ondansetron alone in
controlling emesis. CNPP, Pages 521, 523;

One of the common side effects of dopamine
antagonists is extrapyramidal reactions,
including akathisia and dystonia. CNPP, Page
520; CSM, Page 222.

Dystonia, including a spasm of the lower jaw,
can usually be reversed by the administration
of diphenhydramine. CNPP, Page 520; CSM,
Page 222.

The vomiting center lies close to the
respiratory center on the floor of the fourth
ventricle and is directly activated by the
visceral and vagal afferent pathways from the
gastrointestinal tract, chemoreceptor trigger
zone, vestibular apparatus, and cerebral cortex.

Serotonin is released from the
enterochromaffin cells in the small intestine.
Serotonin activates 5-HT3 receptors on visceral
and vagal afferents, sending a message to the
chemotherapy trigger zone and the vomiting
center. CNPP, Pages 516–517; CSM, Pages
221–222.

Aprepitant is an example of a newer class of
agents called substance P/NK1 receptor
antagonists that are used in combination with
other antiemetics to prevent acute and delayed
chemotherapy-induced nausea and vomiting.
CNPP, Pages 522–524; CSM, Pages 222, 224.

The effects of 5-HT3 serotonin antagonists are
enhanced by the concomitant use of a
corticosteroid and provide superior antiemetic
treatment in patients receiving high-dose
cisplatin. A neurokinin-1-receptor antagonist
may also be added for additional antiemetic
prophylaxis. CNPP, Page 523; CSM, Pages 221–
223.

Cannabinoids have significant side effects,
including disorientation, dysphoria, and
impaired concentration, especially in the
elderly. CNPP, Page 520; CSM, Page 523.

Meperidine is metabolized into
normeperidine, which is a toxic compound
that can accumulate especially with repeated
doses; in the setting of advanced age or renal
failure, its build up can lead to CNS excitation
and seizures. CNPP, Page 804.

Bisphosphonates such as zoledronic acid and
pamidronate effectively palliate pain in
patients who have metastatic disease,
especially in situations where NSAIDs and
steroids are no longer effective. CSM, Page 84.

Anticonvulsants, including gabapentin, have
become first-line agents in the management of
neuropathic pain. CNPP, Page 800; CSM,
Pages 83–84.

Transdermal fentanyl must first saturate the
subcutaneous tissue, and peak concentration
is usually reached at 72 hours after
administration. CNPP, Pages 802, 807; CSM,
Pages 80–81.

Sedation is a common side effect of opioid
therapy, and there is evidence that
methylphenidate can counteract such
sedation. CNPP, Page 804; CSM, Pages 83–84.

Antidepressants (e.g., amitriptyline,
duloxetine, venlafaxine) control pain by
inhibiting the uptake of neurotransmitters
into nerve terminals. They are used in the
treatment of many types of nonmalignant
pain, such as migraine headaches, but are also
believed to be useful in neuropathic pain that
is due to tumor infiltration of nerves, often
described as having a continuous burning
quality. CNPP, Page 801; CSM, Pages 83–84.

Steroids are efficacious for managing the pain
caused by spinal cord compression. Some side
effects of steroid use, such as mood elevation
and increased appetite, may also be desirable
in some patients. CNPP, Pages 1161–1162;
CSM, Page 83.

Except in a few circumstances, oral pain
medication should be on a fixed-interval basis.

Antidepressants exert their clinical effects
primarily through the increased availability or
reduced degradation of neurotransmitters
integral to the regulation of mood states.
Several tricyclic antidepressants exhibit
varying levels of serotonin and norepinephrine
inhibition. CNPP, Page 801; CSM, Page 83.

Antidepressants are useful for patients with a
neuropathic component to their pain. These
drugs act by inhibiting the uptake of
neurotransmitters into nerve terminals. CNPP,
Page 801; CSM, Page 83.

Lorazepam is a central nervous system
depressant and can cause sedation, amnesia,
and confusion. CNPP, Page 520; CSM, Page
224.

HGFs facilitate the blood cell differentiation
and proliferation process and regulate cell
production in response to demand for certain
cell types. CNPP, Page 698; CSM, Page 142.

Granulocyte and granulocyte-macrophage
colony-stimulating factors decrease
myelosuppression, febrile episodes, and
number of hospital days when given in
conjunction with chemotherapy. CNPP, Pages
699–702; CSM, Pages 142–143.

HGFs activate the production and maturation
of distinctive cell lineages, thereby enhancing
the activity of mature neutrophils:
phagocytosis, oxidative burst, antibody-
dependent cytotoxicity, and chemotaxis. These
actions allow the neutrophils to be more
aggressive and effective in destroying
pathogens. HGFs lessen the duration and
severity of neutropenia, but they do not speed
the onset. CNPP, Pages 699–700; CSM, Pages
142–143.

The most common side effect of myeloid
growth factor therapy is mild to moderate
bone pain, which occurs in 10% to 30% of
patients. CNPP, Page 702.

G-CSFs are appropriate when the risk for
febrile neutropenia is greater than 20%, such
as results from high-dose chemotherapy. It is
not appropriate as routine prevention of
neutropenia. CNPP, Page 702; CSM, Pages
143–144.

Tissue hypoxia is the single most potent factor
in erythropoietin production. In the presence
of hypoxia, the kidneys increase production
and secretion of endogenous erythropoietin.
This in turn stimulates red blood cell
production by the bone marrow, thereby
correcting hypoxia. CNPP, Pages 703–704.

Epoietin alfa is restricted in patients with
uncontrolled hypertension. Erythropoiesis-
stimulating agents (ESAs) have an associated
increased morbidity from cardiovascular
events. If ESAs are used in this setting, blood
pressure should be monitored carefully. CNPP,
Page 703.

HGFs are used as supportive therapy for
patients receiving myelosuppressive therapy
who are at risk for chemotherapy-induced
fever or undergoing a HSCT. CNPP, Page 702.

High-dose IL-2 is FDA approved to treat
metastatic renal cell cancer and metastatic
melanoma. CNPP, Page 615.

Side effects of high-dose IL-2 therapy, such as
generalized edema, hypotension, and
pulmonary congestion are related to capillary
leak syndrome. This syndrome is created by a
shift of fluid from intravascular spaces to
interstitial spaces that induces an increase in
heart rate and a decrease in blood pressure.

The irAEs associated with ipilimumab are
unique and can be severe or even fatal. If
patients experience grade 3 or 4 irAEs with
ipilimumab therapy, patients should be treated
with corticosteroids and the drug should be
permanently stopped. CNPP, Pages 633–636.

The Food and Drug Administration–approved
vaccines against HPV infections, Gardisil and
Cervarix, are most effective at preventing
genital warts, cervical cancers, and pre-cancers
when given prior to sexual activity as they do
not stimulate regression of established
infection. CNPP, Page 640.

Murine monoclonal antibodies, such as
blinatumomab, are derived from mice and
have the highest risk of causing
hypersensitivity reactions. Their names end
with the suffix –momab. The other three types
of monoclonal antibodies are engineered using
less amounts of murine components and more
human components. CNPP, Pages 657, 669;

It is recommended that patients have a
baseline ECG, another ECG at 7 days after
initiation of sunitinib, and then at regular
intervals. This is because the drug is known to
prolong the QT interval and the PR interval,
and to induce bradycardia and ST-T wave
modifications. CNPP, Page 673.

The use of St. John’s wort should be avoided
as it can increase the elimination of the
gefitinib, thereby decreasing the drug’s level
and effects. CNPP, Page 675; CSM, Page 664.

Venlafaxine should not be stopped abruptly as
it can cause a discontinuation syndrome with
symptoms that may include malaise, light-
headedness, dizziness, and lightening-like
pains in the extremities. CSM, Page 553.

Most patients develop tolerance to nausea over
time. Treating the nausea first with an
appropriate antiemetic prior to opioid rotation
is recommended. Tramadol is a weak opioid
receptor agonist not frequently used in cancer
care. CNPP, Pages 804–805; CSM, Page 82.

Low-dose TCAs, gabapentin, lidocaine patch
5%, and tramadol are effective agents for the
treatment of neuropathic pain, diabetic
neuropathy, and postherpetic neuralgia.
Sedation and orthostatic hypotension are
common, which is why TCAs are given at
bedtime and may limit the concomitant use of
opioid analgesics. CNPP, Page 801; CSM, Page
82.

Relief from pruritus from any cause may be
relieved from meticulous skin care, the use of
emollient lotions, and antihistamines. CNPP,

The only side effect that patients do not reach
a tolerance for is constipation. Lethargy and
nausea are common side effects, and patients
will become tolerant of these side effects
generally within 1–2 weeks. CNPP, Page 804;
CSM, Page 82.

Prevention is key to managing opioid-induced
constipation. When opioids are started, a
bowel stimulant and a stool softener should be
started and given regularly. CNPP, Page 804;
CSM, Page 82.

Because bisphosphonates inhibit osteoclast
activity in bone (causes bone breakdown), they
are ideal in the treatment of patients with
bone metastases. When bisphosphonates bind
to bone, they help to stabilize the bone mineral
and inhibit calcium release and further
breakdown. CNPP, Pages 1122, 1125, 1779;
CSM, Pages 58, 77.

Steroids have a capillary-stabilizing effect,
which is important in minimizing the bleeding
potential of thrombocytopenia. CNPP, Pages
872–873.
D. COMPLEMENTARY AND INTEGRATIVE
MODALITIES

CAM is a group of diverse medical and
healthcare systems, practices, and products
that are not currently considered a part of
standard and conventional medicine.
Complementary medicine refers to treatments
that are used with standard treatment.
Alternative medicine refers to treatments that
are used instead of standard treatment. CNPP,
Page 726.

A variety of complementary therapies have
demonstrated preliminary evidence of the
effectiveness in the management of cancer
related fatigue including yoga, relaxation,
healing touch, and ginseng. Most of these
studies are open label with no random
assignment with small sample sizes, making it
difficult to draw strong conclusions about
efficacy. CNPP, Page 745; CSM, Page 36.

Black cohosh is a perennial plant native to
North America that has been found in some
studies to decrease hot flashes. CNPP, Page
745; CSM, Pages 53–54.

Use of phytoestrogens must be weighed
against the understanding that the estrogenic
activity of these substances has the potential
to cause an accumulation of endometrial
tissue, leading to endometrial bleeding. CSM,
Page 53.

You can reassure the patient that music can be
pleasant to listen to and there are studies that
show music therapy may not only improve
pain intensity, but some studies have
demonstrated its ability to decrease opioid
requirements. CNPP, Page 745; CSM, Page 86.

Ginger may decrease chemotherapy-related
nausea and vomiting as several components of
ginger are antagonists at 5HT3 receptors.

CAM techniques that can be taught by nurses,
physicians, social workers, and psychologists
include guided imagery and progressive
muscle relaxation. The other answers require a
trained therapist or psychologist to provide
instruction. CNPP, Pages 738, 745; CSM, Page
227.

Asking questions about complementary and
alternative nutritional therapies opens the
door to communicating about the issue, to
provide reliable sources of information (if
available) to the patient, and to highlight data
on potential harm that may be associated with
complementary and alternative medicine
therapies. CNPP, Pages 728, 734; CSM, Page
365.

Several CAM techniques have been studied in
the relief of anxiety in patients with cancer.
Reiki, music therapy, relaxation and guided
imagery, and acupuncture have all
demonstrated through studies some benefit in
the reduction of cancer-related anxiety. CNPP,

Relaxation therapy is a complementary
therapy that has been identified as Likely to be
effective, for the management of cancer-
related depression according to the Oncology
Nursing Society “Putting Evidence into
Practice” resources. Massage, exercise, and
reflexology have all been found to have
Effectiveness not established. CSM, Page 665.

The underlying principle of acupuncture is
that qi (pronounced chee and translated as
meaning “energy”) is present at birth and
maintained throughout life. Health is a
balance of yin and yang. Disease is a result of
imbalance. Acupuncture results in correcting
any imbalance in the flow of energy, thus
restoring balance. The four secrets of qi gong
means energy cultivation and refers to
movement that are believed to improve health,
longevity, and harmony. CNPP, Page 736;

A number of comparative randomized control
trials have suggested that St. John’s wort is as
effective as pharmaceutical antidepressants for
mild to moderate depression. CNPP, Page 742.

Distraction (e.g., music therapy, breathing
exercises, watching television) directs
attention away from the sensations and
emotional reactions produced by pain and
blocks awareness of the pain stimulus and its
effects. It can be very helpful in reducing pain,
but caregivers must remember that simply
because a patient is effectively distracted from
the pain does not mean that they are pain free.

Meta-analyses of randomized trials support
the benefit of exercise in the management of
fatigue during and following cancer treatment
for patients with breast, colon, and prostate
cancers, young adults with cancer, and those
patients undergoing hematopoietic stem cell
transplantation. CNPP, Pages 890–891; CSM,
Pages 33–35.

Although properly constructed diets are
adequate, many alternative approaches to
nutrition do not provide balanced diets.
Macrobiotic diets are very labor intensive and
low in protein if not planned properly. CNPP,
Nonpharmacologic interventions such as
relaxation and guided imagery do not generally
affect the underlying pathology causing the
pain or alter the perception of pain but may
help to decrease her emotional response to
pain, enabling her to deal with the pain more
positively and proactively. Nonpharmacologic
interventions for pain management are best
used as adjuvants to pharmacologic therapies
and should not be used as substitutes for
pharmacologic therapies. CNPP, Page 809;
CSM, Pages 85–86.
E. PALLIATIVE CARE CONSIDERATIONS

The opioid dose should be changed, dose
reduced, and a benzodiazepine added. This
toxicity is usually due to neuroexcitatory
metabolites of the opioids. Naloxone is not
effective in reversing this toxicity. CNPP, Page
804.

Palliative care is a model of care for people
with advanced illness or high symptom burden
that aims to improve quality of life for patients
and families by focusing on symptom
management, including physical, psychosocial,
and psycho-spiritual symptoms. CNPP, Pages
2066–2068; CSM, Page 700.

Although the definitions of palliative care and
hospice share many similarities, there are
several key differences between them in the
U.S. healthcare system. Key among them is
that palliative care benefits can be offered to
any patient with a high symptom burden
(regardless of disease and life expectancy) and
hospice benefits can be offered to patients
with a life expectancy of less than 6 months.
Palliative care can be offered in a variety of
settings of care. CNPP, Page 2068; CSM, Pages
700–701.

Patients and providers may have
misconception about the meaning and scope of
palliative care services, including
inappropriately equating palliative care with
hospice or very end-of-life care. CNPP, Page
2070.

The “SPIKES” communication tool; which
stands for Setting, Perception, Invitation,
Knowledge, Emotions, and
Strategy/summary; is a communication tool
that can help guide the conversation about
palliative care and hospice and increase patient
and caregiver confidence. The other tools are
used to help guide conversations about sexual
health. CNPP, Pages 2072–2073.

The “setting” in the SPIKES communication
model includes the physical space, participants
in the discussion, and tone of the meeting.
Thus, an appropriate questions to start this
conversation is, “Is there anyone you would
want to have present when we talk?” CNPP,
Page 2073.

Pain assessment in the final days of life can be
complicated when the patient is no longer able
to report the intensity or presence of pain. The
American Society for Pain Management
Nurses suggest the following model: ask the
patient’s family/significant others if they think
that the patient is in pain, observe for
behaviors that may indicate pain and
investigate for pathologies that could produce
pain, and initiate a trial of analgesics to
observe for reduction in behaviors thought to
indicate pain. CNPP, Page 2077.

Acute changes in mental status, indicating
delirium, are common during the final days of
life. Common causes of delirium at the end of
life include medications such as opioids,
corticosteroids, benzodiazepines, and adjuvant
analgesics, as well a variety of metabolic
changes including organ system failure. CNPP,
Nursing management of delirium includes
maintaining a safe, quiet environment,
respecting the patient’s experiences and
supporting family members. It is important to
investigate the underlying cause of delirium,
but pharmacologic therapy may include low-
dose Haldol. Benzodiazepines have been found
to worsen delirium and cognitive impairment.

Dyspnea is a subjective experience and may
not correlate with findings of hypoxia,
hypercarbia, or tachypnea. Thus, the best test
for dyspnea is the patient’s self-report of
dyspnea or shortness of breath. CNPP, Page
2078; CSM, Pages 317, 319–320.

The most appropriate actions to help manage
Josephine’s dyspnea include limiting her
exertion and positioning her in bed with the
head of the bed up, administering morphine
and lorazepam, and preparing her for pleural
fluid drainage. CNPP, Page 2078; CSM, Pages
322–324.

Patient education around the use of opioids for
end-of-life symptoms such as dyspnea is
critical as patients and families may continue
to have a fear of addiction to opioids. CNPP,

Noisy airway secretions become increasingly
more common at end-of-life when patients are
unable to cough or clear their airway of
secretions. Family teaching should include
that they may reposition the patient with the
head of the bed slightly elevated to help
minimize secretions from pooling in the upper
airway, throat, and back of the mouth. Deep
suctioning should be avoided as this may
cause gagging and can be painful for patients.
CNPP, Pages 2078–2079; CSM, Pages 706, 719.

A common palliative care treatment for the
management of noisy airway secretions at end-
of-life includes use of anticholinergics.
Because many patients cannot swallow at this
time, many of these drugs can be given via
other routes than by mouth (e.g., intravenous,
sublingual, transdermal). CNPP, Pages 2078–
2079; CSM, Pages 703–704.
Internal cardiac defibrillator activation during
the active dying phase can cause multiple
cardiac shocks, which are painful and not
consistent with DNR status. Discussion of
deactivation of the device should be
considered, particularly as the patient is closer
to the active dying phase. CSM, Pages 708–
709.

Family members and loved ones may request
the placement of IV lines, total parenteral
nutrition, and tube feedings due to fear that
their loved one is “starving to death.” The most
appropriate response would be that tube
feeding does not prolong survival in patients
with advanced cancer and may increase the
risk of aspiration. CNPP, Pages 2080–2081;
CSM, Page 708.
F. ALTERATIONS IN FUNCTIONING

When the neutrophil count is less than
500/mm3, approximately 20% or more of
febrile episodes have an associated bacteremia
caused principally by aerobic gram-negative
bacilli and gram-positive cocci. CNPP, Pages
511, 832, 838; CSM, Page 135.

Acetaminophen, corticosteroids, and
antihistamines may be given prior to platelet
therapy to minimize the chance of a febrile
nonhemolytic transfusion reaction. CNPP,
Page 715.

Patient-related risk factors for thrombosis
include older age, female gender, African
American race, and comorbidities such as
infection, renal disease, pulmonary disease,
obesity, inherited prothrombotic mutations,
and a prior history of venous
thromboembolism. CSM, Pages 291–292.

According to the NCI CTCAE related to
bleeding, Grade 2 bleeding refers to moderate
symptoms and medical intervention or minor
cauterization is indicated. CNPP, Page 865;
CSM, Page 299.

Infection in the neutropenic patient is always
considered a potentially life-threatening
emergency. Mortality rates in older individuals
with cancer who are neutropenic are about
30%. CNPP, Page 818; CSM, Page 131.

The ANC is calculated by multiplying the total
white blood cell count (4000) by the
differential proportion of combined segmented
neutrophils (34%) and band neutrophils (3%)
in a blood sample. ANC = 4000 cells/mm3 ×
0.37% = 1480 cells/mm3. CNPP, Page 511;
CSM, Page 134.

Neutropenia is not only the most common
dose-limiting side effect of chemotherapy, but
it is potentially the most lethal. CNPP, Pages
511–512; CSM, Page 131.

The patient with neutropenia is unable to
mount an inflammatory response. Fever is
usually the first sign of infection. Choices a, b,
and d are all true, but they explain why the
neutropenic patient is at greater risk for
infection rather than why the usual signs and
symptoms of infection are often absent. CNPP,
Pages 511–512, 829.

Neutropenia typically develops in 8–12 days
after chemotherapy, with recovery in 3–4
weeks. CNPP, Page 511; CSM, Page 133.

The respiratory tract is the most common site
of infection in neutropenic patients. A high
incidence of pneumonia in
immunocompromised patients warrants
thorough assessment of the respiratory tract.
The mouth and oropharynx are also high
incidence sites for infection. CNPP, Pages 511–
512.

Clinically significant neutropenia, Grade 4, is
defined as a neutrophil count of less than 500
cells/mm3. CNPP, Page 504; CSM, Pages 136–
137.
Infections, due to invasion and overgrowth of
pathogenic microbes, increase in frequency
and severity as the absolute neutrophil count
decreases. Risk for severe infections increases
when the nadir persists for more than 7–10
days. The purpose of colony-stimulating
factors is to reduce the number of days that
the nadir is below 500 cells/mm3. CNPP, Pages
699–702, 836; CSM, Page 142.

In the setting of neutropenia, the general
standard of care is a time frame of 1–2 hours
from fever to administration of the first
antimicrobial agent. Chest x-rays are usually
ordered, but the yield is relatively low, and this
step is considered a lower priority than
starting antimicrobial therapy, especially in an
elderly patient. CNPP, Pages 837, 839, 512;

Myelosuppression is the most common and
lethal side effect of chemotherapy. Because
hematopoietic cells divide rapidly, they are
vulnerable to chemotherapy, potentially
resulting in dangerously low levels of red
blood cells, white blood cells, and platelets.
When this occurs, patients are at risk for
bleeding, infection, and circulatory
compromise. CNPP, Pages 509, 511–512; CSM,
Page 131.

Meticulous hand washing, by every person
who enters the room or comes in contact with
the individual at risk, is the single most
important preventive measure against
infection in the patient with granulocytopenia.
Neutropenic individuals are advised of their
risk and are encouraged to remind family,
visitors, and staff about hand-washing
precautions. CNPP, Pages 835, 1141; CSM,
Page 146.

Recombinant thrombopoietin, oprevelkin, is a
colony-stimulating factor that stimulates the
differentiation and proliferation of
megakaryocytes into platelets. It has been
shown to reduce the duration of
thrombocytopenia. CNPP, Pages 699, 701.

A cumulative and delayed onset of
thrombocytopenia has been observed with
carmustine, fludarabine, lomustine,
mitomycin C, streptozocin, vorinostat,
omacetxine, and thiotepa. CNPP, Pages 465,
510; CSM, Page 289.

When platelets are lower than 50,000
cells/mm3, there is a moderate risk of
bleeding, particularly into the central nervous
system in a patient with a brain tumor. As the
platelets continue to decrease below 10,000
cells/mm3, a severe risk exists for fatal
bleeding. CNPP, Pages 510, 856; CSM, Pages
287, 294.

Petechiae and epistaxis may occur as the
platelet count continues to decrease below
10,000 cells/mm3, but a severe risk exists for
spontaneous central nervous system
hemorrhage. CNPP, Page 510; CSM, Page 287.

The most common cause of thrombocytopenia
in patients with cancer is a disorder involving
decreased megakaryocytopoiesis (i.e., platelet
production in the bone marrow). CNPP, Pages
856–857; CSM, Pages 287–289.

Idiopathic thrombocytopenic purpura occurs
most frequently in individuals with
lymphoproliferative disorders such as chronic
lymphocytic leukemia. It is rarely associated
with solid tumors. CNPP, Page 856.

Stool softener and a laxative are important for
preventing constipation in the patient who is
receiving vincristine. Rectal manipulation may
place the thrombocytopenic patient at risk for
bleeding. The use of suppositories or enemas
is contraindicated. CNPP, Pages 869–870;
CSM, Page 303.

Platelet survival is greatly decreased when
alloimmunization to the platelet transfusion
develops. Alloimmunization results when
repeated transfusions of platelets fail to
provide a therapeutic increment in the platelet
count. CNPP, Pages 706–707, 875; CSM, Pages
306–307.

Because diagnostic signals may be subtle (e.g.,
skin petechiae that may be noticed while
bathing the person, traces of blood during
brushing of teeth), it is important for the
nurse to be keenly observant. A family history
and various screening tests may be valuable in
assessment, but they do not substitute for
observation. CNPP, Pages 862–863; CSM,
Pages 293, 295.

Megakaryocytes mature in the bone marrow
and fragment to form platelets, which are then
released into the bloodstream. Under normal
circumstances any reduction in platelet count
—from bleeding, malignancy, chemotherapy,
radiotherapy, or other causes—produces an
increase in the production of megakaryocytes
and platelets in the bone marrow. This activity
is controlled by a regulatory hormone called
thrombopoietin. CNPP, Page 856.

Erosion and rupture of vessels precipitated by
tumor invasion or pressure is the other major
cause of bleeding in persons with cancer. Any
tumor involvement of vasculature tissue or
any tumor lying in close proximity to major
vessels is seen as a threat of bleeding. CNPP,

If acute bleeding does occur, direct methods to
halt the hemorrhage should be instituted
immediately. Another example of the use of
mechanical pressure to stop acute bleeding is
the insertion of an occlusion balloon catheter
into the bronchus. CNPP, Page 305; CSM, Page
872.

The platelet count is the single most important
factor in predicting bleeding in the individual
with cancer. Patients with platelet counts
below 20,000 cells/mm3 have a high risk of
bleeding. Low platelet count
(thrombocytopenia) is also the most frequent
platelet abnormality associated with cancer.
CNPP, Pages 852, 856; CSM, Pages 287–288.

The presence of leukocytosis (white blood cell
count > 30 × 109 cells) is associated with
increased treatment death (˜50% of cases),
most often as a result of tumor lysis
syndrome. CNPP, Pages 1646–1647.

Patients with liver cancer are more at risk for
bleeding because of a decrease in vitamin K
absorption, an increase in prothrombin time
and partial thromboplastin time, and varices
from portal hypertension. Abnormal platelet
function resulting in bleeding occurs most
frequently in hematologic malignancies.
CNPP, Pages 858, 873; CSM, Page 289.

Qualitative abnormalities such as decreased
platelet adhesiveness refer principally to
alterations in platelet function, which may
include a decreased procoagulant activity of
platelets, decreased platelet adhesiveness and
decreased aggregation in response to
adenosine diphosphate (ADP), thrombocytosis
associated with myeloproliferative disorders,
and the coating of platelets by fibrin
degradation products as a result of the
increased activation of coagulation factors.
CNPP, Pages 857, 859–861; CSM, Page 289.

Thrombin, the most powerful of the
coagulation enzymes, is required for both
coagulation and fibrinolysis. CNPP, Page 868.

Grade 1 acute GVHD of the GI system has a
favorable outcome and includes diarrhea <
500 mL/day or persistent nausea. CNPP, Pages
596–597; CSM, Page 189.

Risk factors related to the development of
GVHD include unrelated donor, HLA
mismatched, increased parity of
donor/recipient, older donor/recipient age,
positive donor/recipient viral seropositivity,
mismatched female to male sex match, > 12
Gy of total body irradiation, less intensive
immunosuppressive regimen, and no T-cell
depletion. CNPP, Page 596.

While the patient may be staged as a grade 1
GVHD of the GI system with diarrhea < 500
mL/day or persistent nausea, endoscopy with
biopsies is required for definitive diagnosis of
gastrointestinal graft-versus-host disease.

Anticipatory nausea and vomiting are often
brought about by the patient’s previous
experience with uncontrolled nausea and
vomiting, and lorazepam has been
demonstrated to be effective for anticipatory
nausea and vomiting. Lorazepam acts as an
antianxiety agent but also has some
antinausea effects. Anxiety can occur in
patients receiving cancer treatment, but it is
not a universal problem for patients with
cancer. CNPP, Pages 517, 520; CSM, Page 223.

The degree and duration of diarrhea depend on
the agent, dose, nadir, and frequency of
chemotherapy administration. Patients may
experience abdominal cramps and rectal
urgency with fluorouracil–leucovorin therapy,
which can evolve into nocturnal diarrhea or
fecal incontinence, leading to lethargy,
weakness, orthostatic hypotension, and
fluid/electrolyte imbalance. Without adequate
management, prolonged diarrhea causes
dehydration, nutritional malabsorption, and
circulatory collapse. CNPP, Page 514; CSM,
Page 203.

The CTCAE classifies diarrhea by the number
of stools per day over baseline. The CTCAE
classifies Grade 2 diarrhea as an increase of 4–
6 stools/day over baseline; moderate increase
in ostomy output compared to baseline. CSM,
Page 185.
Rectal emptying is specifically diminished as a
result of chemotherapy-induced neuropathies
that disrupt the autonomic nervous system.

The fact that he is nauseated and not passing
gas means he could be obstipated and needs to
be evaluated immediately. CNPP, Page 515;

Opioids affect the bowel by activation of
specific opioid receptors (primarily on mu,
kappa, and delta receptors) in both the GI tract
and the central nervous system, which
decrease gastric motility. CNPP, Page 804;
CSM, Page 166.

Combining the softening action with the
peristaltic stimulant effect lessens
constipation. Teaching the patient to increase
fiber and fluids will help the action of the
senekot and the colace, but will not by
themselves help opiate-induced constipation.
Metamucil is not recommended for the
treatment of opiate-induced constipation.

Management of severe diarrhea in patients
with radiation-induced enteritis includes
management with sandostatin and a low
residue diet. CNPP, Page 359; CSM, Pages
194–197, 201.

Patients may experience abdominal cramps
and rectal urgency with 5-FU, which can
evolve into nocturnal diarrhea or fecal
incontinence leading to lethargy, weakness,
orthostatic hypotension, and fluid/electrolyte
imbalance. Loperamide is the standard first-
line therapy for chemotherapy-induced
diarrhea, but is given as a loading dose and
then every 4 hours until the patient is
diarrhea-free for 12 hours. CNPP, Page 514;
CSM, Page 200.

Stool cultures should be obtained prior to
administering antidiarrheal medications due
to the potential for infection causing the
diarrhea. CNPP, Page 514; CSM, Pages 193,
195.
If a patient has diarrhea that is due to an
infectious agent such as Clostridium difficile,
the use of antidiarrheal agents can increase
risk for sepsis by increasing exposure to the
mucosa and subsequent absorption of the
toxin because antidiarrheal agents decrease
colonic transit time. CNPP, Page 514.

If the obstruction continues for more than a
few days or is recurrent, a gastrostomy tube is
a much more acceptable and well-tolerated
route for decompression than nasogastric
intubation. Intermittent venting of the
gastrostomy tube allows the patient to
continue oral intake and maintain an active
lifestyle. The two options currently available
are surgically placed gastrostomy and
percutaneous endoscopic gastrostomy. Pain
and antinausea medications may help, but
they cannot replace a venting tube. CNPP, Page
1457.

Biliary vomiting is almost odorless and
indicates an obstruction in the upper part of
the abdomen. CNPP, Page 1457.
The two most common complications related
to prostatectomy include urinary incontinence
and sexual dysfunction. Additional
complications include pain, bleeding, ileus,
infection, myocardial infarction, anesthesia
reaction, pulmonary embolus, and damage to
surrounding organs/tissues. CNPP, Pages
1860–1861; CSM, Pages 266, 268, 509.

Emptying the bladder at bedtime (either by
voiding or by self-catheterization) or setting
the alarm to awaken once during the night
may help to avoid incontinence. Complete
nighttime control returns in the majority of
patients who undergo a continent/orthoptic
urinary diversion surgery. CNPP, Pages 1236–
1237.

The normal prostate on palpation is usually a
rounded structure about 4 cm in diameter that
feels firm. Cancer of the prostate typically
appears as a stony hard nodule, whereas
benign hypertrophy usually results in a diffuse
enlargement of the prostate without masses.
After radical prostatectomy, the majority of
patients achieve urinary control within 1 year.

Primary long-term complications of
cystectomy and urinary diversion include renal
insufficiency, infections, ureteroileal
stenosis/strictures, parastomal hernias, stomal
stenosis, retraction, stone formation, small
bowel obstruction, and metabolic
complications. CNPP, Pages 1235–1236.

The two most common chemotherapeutic
agents associated with the hemorrhagic
cystitis are cyclophosphamide and ifosfamide.

Prevention of hemorrhagic cystitis is the key
to success when administering high-dose
cyclophosphamide, including the
administration of the uroprotectant mesna as
well as aggressive use of hydration and the use
of a Foley catheter. CNPP, Pages 546–548;
CSM, Page 267.

Continent urinary diversion procedures use
bowel from different portions of the intestine
to create an intra-abdominal pouch for storage
of urine. CNPP, Pages 1236–1237.

Continent urinary reservoirs and bladder
substitutes produce much mucus. They should
be irrigated regularly in the early postoperative
period to prevent mucous accumulation.
Mucous production decreases over time, and
irrigation becomes unnecessary. CNPP, Pages
1238–1239.

Signs and symptoms of nephrotic syndrome
include massive proteinuria and brown frothy
urine, as well as facial and peripheral edema,
which may progress to anasarca or edema of
all body tissues. The combined water and
electrolyte retention may cause mild to
moderate hypertension. CNPP, Pages 985–
987.

Infection, dehydration, and hypercalcemia are
the most important precipitating factors in
myeloma-associated renal failure, and they are
found in 50% to 95% of patients with this type
of renal failure. CNPP, Page 1760.

The lung is the most common site of
metastatic disease in renal cancer, seen in
approximately 50% of cases. CNPP, Page 1877.

Fatigue is a common side effect related to the
oral anti-vascular endothelial growth factor
therapies used in the treatment of renal
cancer. Fatigue is often multifactorial and can
be related to the underlying disease,
treatment, concomitant medications, or other
conditions. CNPP, Pages 1885–1886.

PPR is the most common toxicity associated
with both the tyrosine kinase inhibitors and
the monoclonal antibodies, therefore, PPR is
most commonly seen with erlotinib. CNPP,
Pages 588–589; CSM, Pages 666–667.

Patients diagnosed with a grade 3
papulopustular skin rash can expect to
interrupt treatment with the offending agents
for 21 days or until the rash improves to a
grade 2. Once the rash has begun to improve,
treatment may be restarted at full dose or a
reduced dose, especially if there is a recurrent
rash. CNPP, Page 668; CSM, Pages 592–593.

Risk factors for the development of
radiodermatitis in women undergoing breast
irradiation include large, pendulous breasts
with multiple skin folds; combined
chemo/radiation; and certain autoimmune
diseases. CNPP, Page 356; CSM, Page 602.

Factors that determine the degree, onset, and
duration of radiation-induced skin reactions
include the following, among others: Higher
doses given over shorter periods of time to
larger volumes result in more severe acute
skin reactions; electrons produce greater skin
reactions than photons; and placing tissue-
equivalent material on the skin reduces the
skin-sparing effect of radiation therapy,
allowing for maximum dose at the level of the
skin. Finally, when treatment is targeted at
areas of skin apposition, increased reaction
secondary to warmth and moisture can be
expected. CNPP, Pages 340–341.

Hyperpigmentation occurs with bleomycin,
particularly over veins and pressure points.
Other drugs inducing this reaction include
nitrogen mustard, fluorouracil, and etoposide.
CNPP, Page 531.

PPE has been reported with the use of
capecitabine. It may represent a direct toxic
effect on the epidermis and dermal vasculature
or an accumulation of the chemotherapy agent
in eccrine structures, causing erythema of the
palms and soles. PPE is not life-threatening,
but can be comfortable. Treatment should
focus on local comfort measures such as
elevation of the hands or feet and local
cooling. CNPP, Page 532; CSM, Pages 597–599.

Paronychia is an erythematous inflammation
of the nail fold that occurs in 12% to 25% of
patients receiving EGFR inhibitors. CNPP,

Patients should be taught to wash hands
frequently when immunocompromised to
minimize the risk of infection. Persons who
are immunocompromised are at high risk for
activation of varicella zoster virus, which once
activated spreads down the sensory nerve to
skin level. The physician/APN should be
notified immediately if the eye is in close
proximity because ocular dissemination can
result in systemic spread and loss of vision.
Therapy is generally held until the extent of
the spread is known and treatment is
underway. CNPP, Pages 593, 835.

Doxorubicin is frequently associated with
moderate to severe hair loss. Bleomycin,
methotrexate, and mitoxantrone are associated
with mild hair loss. CNPP, Pages 477, 533–
534; CSM, Page 498.

Opioids are the first-line therapy in relieving
dyspnea, as they decrease the intensity of
dyspnea without causing respiratory
depression. Benzodiazepines and
glucocorticoids, along with oxygen, are useful
adjuncts to opioids without fear of respiratory
depression. CNPP, Page 2078; CSM, Page 322.

The treatment of choice is trimethoprim-
sulfamethoxazole. P. jiroveci is a protozoan
that causes infection in children with primary
immunodeficiency disorders, persons with
acquired immune deficiency syndrome, and
those with cancer who are undergoing
immunosuppressive therapy. Untreated, P.
jiroveci is fatal, and even with therapy,
mortality is high. CNPP, Pages 593, 836, 842;
CSM, Page 146.

Opioids are the first-line therapy in relieving
dyspnea, without causing respiratory
depression. Although continuous pulse
oximetry is used widely, patients and family
members often focus on the monitor, which
can increase anxiety and fear. Bronchodilators
can relieve bronchospasm but can also
increase anxiety. CNPP, Page 2078.

Cough is the most common presenting
symptom of lung cancer. Hemoptysis and
hoarseness can be presenting signs of lung
cancer, but are not as common as cough.
CNPP, Page 1690.

Agents used for pleurodesis include talc,
bleomycin, doxycycline, and minocycline.
Tetracycline, formerly the most frequently
used sclerosing agent, is no longer available in
the injectable form. CNPP, Page 1001; CSM,
Pages 335–336.

The purpose of bleomycin is to obliterate the
pleural space and prevent reaccumulation of
fluid. Bleomycin has antitumor activity, but
that is not the primary function when used as
a sclerosing agent. CNPP, Pages 1000–1001;
CSM, Pages 335–336, 338.

CMV pneumonia is the leading cause of
infectious pneumonia during the
postengraftment period after stem cell
transplantation. The incidence of CMV
pneumonia may be higher in allograft-versus-
autograph recipients, specifically because of
prolonged periods of immunosuppression
caused by medication. CNPP, Pages 599–600.

The most sensitive pulmonary function test is
the carbon monoxide diffusion capacity
measurement, which becomes abnormal
before the onset of clinical symptoms. CNPP,
Page 541.

Bleomycin is well known to cause pulmonary
toxicity. The incidence of bleomycin-induced
pulmonary toxicity is 5% for a total cumulative
dose of 400 units and up to 46% of patients
treated with bleomycin. CNPP, Pages 541, 543,
545.

Infectious processes, most often viral in
nature, and prior toxicities related to
chemotherapy or radiation therapy are the
most common risk factors associated with
interstitial pneumonia, as a late-onset
pulmonary complication of stem cell
transplantation. Previous exposure to
anthracyclines and the use of
cyclophosphamide can exacerbate the
complication of pulmonary edema. CNPP,
Pages 599–600, 603.

Median survival times of patients with lung
cancer with evidence of malignant pleural
effusion is 3 months. CNPP, Page 1000; CSM,
Pages 331, 335.
Symptoms of a vasovagal reaction include
diaphoresis and feeling as if loss of
consciousness is imminent. Complications of
the thoracentesis may include bleeding,
vasovagal reaction, pain from re-expansion of
the lung and apposition of pleural surfaces,
and, in approximately 6% of cases,
pneumothorax requiring tube thoracostomy.
CNPP, Page 1000.

Thoracentesis involves pleural fluid removal
by needle aspiration through the chest wall.
Relief of pleural effusion symptoms such as
dyspnea, cough, and dull aching chest pain is a
short-term treatment goal that is usually
achieved when the pleural fluid is
mechanically drained. CNPP, Page 1000; CSM,
Pages 333–334.

Pleurodesis with a sclerosing chemical agent is
the most common method used to obliterate
the pleural space in patients with malignant
pleural effusions. Chemical sclerosing does
not prolong the patient’s life but may enhance
quality of life by relieving symptoms and
reducing the time a patient spends in the
hospital. Shunts and stripping are surgical
methods that become options after other
approaches have been tried and the pleural
effusion remains uncontrolled. CNPP, Pages
1000–1001; CSM, Pages 335–336.

A capillary leak syndrome, involving primarily
the lung, occurs 2–21 days after the first dose
of cytarabine, resulting in pulmonary edema
and respiratory failure. Mitomycin C damage
to the lung presents as diffuse alveolar damage
with capillary leak and pulmonary edema.
CNPP, Page 543.

Approximately 40% to 50% of pleural
effusions are due to malignancy. CNPP, Page
996; CSM, Page 331.

Malignant pleural effusions are almost always
exudates and are blood-tinged or grossly
bloody and hypercellular with leukocytes.
Benign effusions are classified as transudates.

Dyspnea is described as the “invisible” disease
because the patient masks it by resting. So
unless the patient has lung cancer, they are
rarely asked if they are having any difficulty
breathing, and they are reluctant to report this
symptom. Dyspnea occurs when an increase in
the amount of respiratory effort is needed to
overcome obstructive or restrictive disease, an
increase (not decrease) in the amount of
respiratory muscles is required to maintain
adequate breathing, or an increase in
ventilator need. Physiologic parameters are
rarely present with dyspnea. The pain
associated with dyspnea can be a presenting
symptom of pulmonary effusion and is
generally acute rather than chronic. CNPP,
Page 2078; CSM, Pages 317, 319.

High-dose corticosteroids are the primary
treatment for DAH. If hemoptysis occurs,
cough suppression might help because
coughing is an aggravating factor. For treating
substantial hemoptysis, the individual needs
to be kept calm and on bed rest, lying on their
side, with the side of hemorrhage dependent
so as not to cause asphyxiation by draining the
blood into the other lung. CNPP, Pages 599–
600.

The most common causes of chronic or late
lymphedema are prior infection, obesity,
axillary irradiation, tumor recurrence or tumor
enlargement in the axilla, and secondary to
chemotherapy or radiation therapy. CNPP,
Pages 1312–1313; CSM, Pages 556–557.

Evidence suggests that exercise and avoiding
obesity can protect against lymphedema.
Patients who are at risk for lymphedema
should avoid strenuous upper body aerobics or
lifting of weights. CDT is a treatment for
lymphedema. CNPP, Pages 1312–1313; CSM,
Page 559.

“CDT consists of a combination of manual
bandaging, exercises, and meticulous skin care
used lifelong after lymphedema is identified.”

Obstruction of lymphatic drainage from the
abdomen due to ovarian cancer results in
bilateral lower extremity swelling. It can be
painful, and the legs feel heavy. CNPP, Pages
1816–1817; CSM, Pages 557–558.
Dexrazoxane (Zinecard) is currently approved
for patients with metastatic breast cancer who
have received cumulative doses of 300 mg/m2
of doxorubicin and are continuing treatment
with doxorubicin. Zinecard interferes with the
intracellular process responsible for
anthracycline-induced cardiomyopathy. CNPP,
Page 535.

Lung cancer is associated with the highest risk
of cardiac tamponade, through both direct
tumor extension and lymphagenous metastatic
spread to the heart. CNPP, Pages 1076–1077.

The total cumulative dose of doxorubicin is
established at 550 mg/m2, with a decrease in
dose to 450 mg/m2 if mediastinal radiation
has been administered. CNPP, Page 535.

Acute pericarditis has been reported with high-
dose cyclophosphamide therapy (90–270
mg/kg) used in the stem cell transplant
population, with subsequent pericardial
effusion and cardiac tamponade. CNPP, Page
536.
Common presenting signs and symptoms of
malignant effusions are distressing to most
patients. The degree of subjective symptoms
produced by a pleural or pericardial effusion
depends less on the amount of fluid involved
than on the rapidity with which it
accumulates. If fluid accumulation is gradual,
the heart and lungs can accommodate, but
rapid accumulation can trigger an oncologic
emergency. CNPP, Pages 1080–1082.

The most common presenting symptom of
cardiac tamponade in patients with cancer is
dyspnea. Dyspnea is a nonspecific symptom
that can present as dyspnea on exertion to air
hunger at rest. CNPP, Pages 1080–1081.

Two-dimensional echocardiography in
combination with pulsed-wave Doppler
imagining is the recommended technique for
diagnosing cardiac tamponade and considered
the cornerstone of cardiac imaging because it
allows structures of the heart to be moving in
real time in cross section (two dimensions).
Signs and symptoms of a venous thrombosis
are related to impaired blood flow and include
edema of the neck, face, shoulder, or arm;
prominent superficial veins; neck pain;
tingling of the neck, shoulder, or arm; and skin
color or temperature changes. A venogram
with contrast media is used to assess for a
venous thrombosis. CNPP, Pages 457–458.

TE occurs most frequently in patients with
pancreatic cancer, followed by lung, prostate,
stomach, acute leukemia, and colon cancer.
Patients with myeloma, lymphoma, and
leukemias are also at high risk for
thromboembolism. CNPP, Page 982; CSM,
Page 288.

The etiology of TE is the ability of tumor cells
to affect systemic activation of coagulation and
to produce and secrete procoagulant and
inflammatory cytokines. CNPP, Page 983;
CSM, Page 290.

Staging of disease at presentation is the most
important prognostic factor in colon cancer.
Poor prognosis has been associated with
lymph node involvement, venous invasion,
obstructing or perforating carcinomas,
occurrence in young people, location of the
tumor below the peritoneal reflection, hepatic
metastasis, and invasion of the bowel wall.

Erin has signs that could be related to
congestive heart failure. Left ventricular
ejection fraction studies, such as a multigated
acquisition scan, will be ordered to evaluate
and monitor the cardiac condition related to
chemotherapy and radiation therapy. CNPP,
Page 367.

Venlafaxine has been found in studies to
prevent oxaliplatin-induced neuropathy,
compared to placebo. CNPP, Page 540; CSM,
Page 479.

Vincristine is well known for the potential for
causing peripheral neuropathy. CNPP, Page
539; CSM, Page 463.

Factors that increase the risk of neurotoxicity
with vincristine are (1) Frequent drug
administration, such as weekly; (2) Dose
greater than 2 mg; (3) Age greater than 60
years; (4) Concomitant isoniazid, teniposide,
or etoposide therapy; (5) Severe liver
dysfunction; (6) Coadministration of azole
antifungals; and (7) Polymorphisms in
CYP3A5 expression. CNPP, Page 542; CSM,
Page 463.

Sensory deficits predominate with cisplatin
use and early-on, the sensory losses are
bilateral and may take on a “stocking-glove”
distribution where paresthesias of the toes and
feet is an early symptom, followed by
paresthesias of the fingers and hands. CNPP,

Paclitaxel can produce profound peripheral
neuropathy. Symptoms are progressive and
include paresthesia, numbness, loss of sensory
qualities, and a decrease in deep-tendon
reflexes. CNPP, Page 540; CSM, Pages 463–
464.

There are several chemotherapy drugs that can
cause arthralgias and myalgias, but as many as
58% of patients treated with moderate to high
doses of paclitaxel report transient arthralgias
and myalgias. CNPP, Pages 539–540; CSM,
Pages 14–15.

Risk factors associated with ifosfamide
encephalopathy include hepatic insufficiency,
duration of administration, previous cisplatin
use, presence of bulky disease, low serum
albumin, and high serum creatinine. CNPP,
Page 539.

Paraneoplastic cerebellar degeneration (PCD)
is a group of paraneoplastic neurologic
disorders caused by antibodies produced from
the tumor that attack nerve cells, such as
Purkinje cells, resulting in this neurologic
syndrome. CNPP, Page 974.

Apraxia is the condition in which an individual
cannot coordinate skilled movements but is
not paralyzed. CNPP, Page 1360.

The cause of peripheral neuropathy is the
effect of the drug on the microtubules in the
axon transport system that results in axonal
degeneration. CNPP, Page 537; CSM, Pages
458, 461.

Damage to the autonomic fibers can occur
from chemotherapy and cause dizziness,
constipation, abdominal colicky pain, ileus,
impotence, urinary retention, and syndrome of
inappropriate antidiuretic hormone. CNPP,
Pages 537, 542; CSM, Pages 459, 461.

Although mild symptoms may appear 1–3 days
after high-dose paclitaxel of 250 mg/m2 or
greater, resolving 3–6 months after drug
discontinuance, more severe symptoms, such
as loss of fine motor movements, may resolve
only partially. CNPP, Pages 540, 542; CSM,
Pages 460, 464.

Rapid drug delivery, simultaneous
administration of aminoglycosides, and
dehydration seem to increase the potential for
ototoxicity related to cisplatin or carboplatin
5-FU may cause an acute cerebellar
dysfunction, which is usually more common in
the elderly. It is characterized by rapid onset of
gait ataxia, limb incoordination, dysarthria,
nystagmus, and diplopia. CNPP, Page 539.

Numbness or tingling of the extremities on the
contralateral side of the tumor, progressive
motor loss, and changes in the level of
consciousness alert the nurse to possible
increased intracranial pressure related to
tumor growth. CNPP, Pages 1360–1361, 1173–
1174; CSM, Pages 442–445.

The cytosine arabinoside should be withheld
because dysarthria is a symptom of cerebellar
toxicity from the drug. High-dose cytosine
arabinoside can cause cerebellar toxicities that
may be irreversible. A full neurological
examination should be done before each dose,
even in the absence of symptoms. CNPP, Pages
539, 541; CSM, Page 647.

The purpose of the steroids is to minimize
swelling of the brain tissue caused initially by
the tumor and the radiation. When steroids
are tapered or stopped, the swelling may
resume, and the patient can become more
somnolent. CNPP, Page 349; CSM, Page 648.

In most instances, the first, earliest, and most
sensitive indicator of dysfunction is a change
in the level of consciousness. Mental status
and cognitive ability, as well as motor and
sensory function and cranial nerve function,
are also assessed. CNPP, Pages 1353, 1359,
1361; CSM, Pages 638–639.

Late signs of increased intracranial pressure
occur prior to herniation and constitute an
oncologic emergency. These signs include
deterioration in the level of consciousness,
Cushing’s triad, and motor abnormalities.
Cushing’s triad may be observed as
bradycardia, widening pulse pressure with
Cheyne-Stokes to apneic. CNPP, Page 1174;

An acute reversible peripheral neuropathy
related to the administration of oxaliplatin,
pharyngolaryngeal dysthesia, is precipitated by
cold air or cold drinks. Patients should be
instructed to avoid cold drinks and avoid
exposure to cold immediately after the
infusion of the drug. Patients can be taught to
wear scarves over their face/mouth when
entering a cold environment after treatment.
CNPP, Page 540; CSM, Pages 465, 474.

Vomiting as a sign of increased intracranial
pressure may be preceded by nausea, or it may
be sudden, unexpected, and projectile. It is not
related to food ingestion. Paclitaxel and
carboplatin are not usually associated with the
sudden onset of nausea and vomiting,
especially when it has not been a problem
before. CNPP, Pages 1173–1174; CSM, Pages
441–442.

For most individuals, phantom limb pain
usually decreases significantly within the first
year; however, some may be troubled for
years. Although phantom limb sensations (i.e.,
itching, pressure, tingling) are often
experienced shortly after surgery, phantom
limb pain (i.e., cramping, throbbing, burning)
usually occurs within 1–4 weeks after surgery.
Worsening of phantom limb pain may be a
sign of a neuroma or of locally recurrent
cancer in the stump. CNPP, Pages 787, 1259.

Individuals with spinal metastasis may have
radicular pain, paresthesias, heaviness of
limbs, leg buckling, and episodes of dropping
items. Based on these symptoms, compression
of the spinal cord is likely and needs
immediate treatment to prevent progressive
neurological injury. CNPP, Pages 1156–1157.

Compression of the spinal cord is likely and
needs immediate evaluation and treatment to
prevent progressive neurological injury. CNPP,
Pages 1154, 1156–1159.

Mental status changes, particularly with a
diagnosis of multiple myeloma, can be an
initial sign of hypercalcemia, hyperviscosity
syndrome, or drug toxicity. CNPP, Pages 1116–
1117, 1759–1761.

Phantom limb pain is caused by the nerve
pathways that have been transected during
surgery. This transection results in the
transmission of abnormal impulses. Patients
may feel pain, burning, itching, cramping, and
throbbing sensations in the limb. These
sensations can be exacerbated by stress,
fatigue, and emotional stressors and
appropriate interventions may include
relaxation to minimize
emotional/psychological stress, medications
such as muscle relaxants and tranquilizers,
and simple measures like the use of a stump
shrinker that exerts pressure may reduce the
problem of pain. CNPP, Page 1259.

Li-Fraumeni syndrome is a primarily inherited
cancer syndrome that is identified by the early
development of sarcomas. CNPP, Page 1245.

Bone tumors tend to develop in the span of
two decades. Osteosarcomas usually develop
between the ages of 10 and 30. CNPP, Page
1246.

The most common site of metastasis related to
an osteosarcoma is the lungs. CNPP, Page
1267.

A mechanical obstruction that cannot be
bypassed by tube placement is a
contraindication of enteral feedings.
Additional contraindications to enteral
nutrition include severe diarrhea, severe
bleeding, malabsorptive conditions, intractable
vomiting, GI fistulas and inflammatory bowel
processes, and overall health prognosis not
consistent with aggressive nutritional therapy.

Effective strategies for managing regurgitation
with gastrostomy tubes includes place tube
distally (into the jejunum or duodenum);
check tube placement, check residuals, and
withhold feeding if more than 100–200 cc
remains; keep in Fowler’s position; use small-
bore tube, and consider drugs to increase
motility. CNPP, Page 964; CSM, Pages 364–
365, 380.

Catheter dislodgement is a common problem
with parenteral feeding, and the first symptom
of this problem is the patient’s complaint of
pain with infusion. The fluid should be
stopped, and the catheter checked for
placement. CNPP, Page 964.

Because Mr. Smith seems to be very healthy
otherwise, enteral nutrition is the preferred
route, assuming that his gastrointestinal tract
is functioning. TPN for brief periods (7–10
days) may be indicated in a severely
malnourished patient who cannot be fed via
the enteral route. CNPP, Pages 962–963; CSM,
Page 364.

The largest group of patients with cancer
receiving HPN are those with severe enteritis
following curative radiation treatment. CNPP,

Changing the strength or concentration of the
formula may help to reduce the problem of
diarrhea. Other strategies to minimize the
problem of diarrhea include using a
continuous feeding schedule, adding fiber to
the formula, giving the formula at room
temperature, and using a lactose free formula.

Dysphagia and weight loss are classic
symptoms of esophageal carcinoma. CNPP,
Pages 1538–1539; CSM, Page 387.

Benefits of megestrol acetate include increased
appetite, increased caloric intake, weight gain
(due mostly to fat gain), and a sensation of
well-being. Side effects include edema and
thromboembolic events. CNPP, Pages 960–
961; CSM, Page 366.

Some fields for radiation of an extremity, such
as the hip or femur, include surrounding pelvic
structures, thus, the patient is at risk for bowel
sensitivity such as nausea and diarrhea. CNPP,
Pages 347, 358–359; CSM, Pages 218–219.

Anorexia or loss of appetite and declining food
intake involves alterations in food perception,
taste, and smell and early satiety that result
from the effects of cancer or cancer treatment.
Anorexia can be an acute reaction to cancer
and cancer treatment and may not result in
cancer cachexia. Visceral and lean body mass
depletion are common with cancer cachexia,
but body composition changes in anorexia are
primarily related to fat loss. CNPP, Pages 946–
948; CSM, Page 351.

The macrobiotic diet is low in protein and can
lead to protein-calorie malnutrition. This diet
has not been studied extensively enough to be
able to tell a patient that it is a sound
nutritional choice. CNPP, Pages 965–966.

Anorexia and cancer cachexia are common
manifestations of advanced disease. Patients
with cancers of the GI tracts are at particular
risk for undernutrition from mechanical
obstruction and physiologic dysfunction due to
local tumor infiltration; other factors are
contributory. CNPP, Pages 942–943; CSM,
Page 352.

Patients who are undergoing radiation to the
mouth and oropharynx should receive
education on eliminating alcohol and
cigarettes due to the drying nature of these
agents. Time of diagnosis is a difficult time for
patients, thus patients will need support and
guidance in eliminating these agents. CNPP,
Pages 933–936; CSM, Pages 406–407.

Radiotherapy to the head and neck region
destroys taste buds and cells responsible for
saliva secretion, resulting in xerostomia. A
person who is experiencing this effect
produces little saliva, and the saliva that is
produced is viscous, acidic, and high in organic
content. Affected individuals often complain of
decreased taste perception and difficult
mastication. CNPP, Page 355; CSM, Pages 421–
423.

Taste loss during radiation therapy is expected,
given the role of saliva as a mediator of taste.
Taste acuity is partially restored within 60
days and is almost completely restored by 4
months postradiation. A burning tongue
(glossodynia) is triggered after contact with
spicy or acidic foods. CNPP, Pages 352–353,
927; CSM, Pages 422–423.

Physiological increases in the recognition
thresholds for sweet, sour, and salt and
decreases in the recognition levels for bitter
are common. These threshold changes can
lead to meat and other food aversions. CNPP,
Page 947.

A common complaint during intravenous
administration of drugs such as
cyclophosphamide, nitrogen mustard, and
cisplatin is that they cause a metallic taste.
Some individuals become so sensitized to this
taste they become nauseated in anticipation of
their administration. CNPP, Pages 529–530.

Serial measurements of weight and height are
perhaps the single most important indicators
of nutritional status for the clinician. The use
of patient-reported weight and height should
be discouraged. CNPP, Pages 952–953; CSM,
Pages 360–361.

Even though diabetics taking megestrol
acetate must monitor themselves closely, the
drug is indicated in this case because it
increases appetite, causes weight gain, and
improves quality of life. Corticosteroids are
not indicated in William’s case because he is a
diabetic, and both metoclopramide and THC
are indicated for patients experiencing
chemotherapy-induced nausea, which William
is not experiencing. CNPP, Pages 960–961;

Cachexia is not reversible with appropriate
feeding. Cachexia leads to progressive
functional impairment and decreased quality
of life. CNPP, Pages 942, 948; CSM, Pages
351–352.

Inanition is progressive deterioration with
muscle wasting and energy loss. CNPP, Page
942.

A diet diary would provide an extended record
of Carlos’s eating habits that would rely on his
cooperation and honesty, both of which you
believe you can count on. CNPP, Pages 955–
956.

Delirium is a mental disorder that has an acute
onset and is characterized by a disturbance or
awareness in attention that follows a
fluctuating course. CNPP, Page 767; CSM, Page
637.

As many as 75% of patients with cancer
experience problems with memory, executive
functioning, and attention during cancer
therapy, and as many as 35% of survivors
report symptoms in these areas persisting for
months or years. CNPP, Page 767; CSM, Page
638.

Cross-sectional studies of cognition in breast
cancer patients revealed post-chemotherapy
impairment ranging from 17% to 75%, but with
relatively stable or improved performance
evident by 12 to 18 months after the end of
therapy. CSM, Page 639.

MRI is the most sensitive tool available for
diagnosing brain necrosis, a severe reaction to
radiation therapy that affects the white matter
of the brain or spinal cord. CNPP, Page 364;
CSM, Page 645.

The most common late effect of radiation
therapy to the central nervous system is
leukoencephalopathy accompanied by
cognitive dysfunction. The risk factors for this
condition include older age, large fraction
volumes (more than 2 Gy per day), large
volume of irradiated tissue, combined-
modality treatment with chemotherapy, and
vascular conditions such as diabetes and
hypertension. CNPP, Page 364; CSM, Page 641.

Risk factors for the development of cognitive
dysfunction in patients with cancer include
high dose chemotherapy treatment and longer
treatment duration, underlying disease, or
conditions such as dementia or stroke. CNPP,
Page 541; CSM, Pages 639, 642.

According to the NCI CTCAE, grade 2 memory
impairment is moderate, limiting instrumental
ADL. CSM, Page 646.

During fractionated external beam radiation,
fatigue is often cumulative, with the peak of its
severity occurring after the completion of the
treatment course. CNPP, Pages 345, 885.
Physical activity/exercise is the only evidence-
based intervention that has been shown to
consistently improve treatment-related
fatigue. A systematic review of fatigue and its
management demonstrated that regularly
scheduled exercise helps to ameliorate fatigue
in all stages of cancer. Exercise programs
should be individualized. CNPP, Pages 345–
346; CSM, Pages 33–36.

Radiation therapy is commonly associated
with increases in daytime fatigue and
somnolence regardless of whether the
radiation therapy is for primary brain tumors
or for primary tumors in areas other than the
brain. Studies indicate that radiation results in
less sleep efficiency and a higher level of
daytime dysfunction and higher levels of sleep
disturbance in patients further along in their
radiation treatment protocol, generally after
4–12 weeks. CNPP, Page 350.

Although cancer-related fatigue is experienced
almost universally across the continuum from
diagnosis, through treatment, survivorship,
and end-of-life, there is individual variability
in its occurrence and impact on the patient.
Among the several variables that put a patient
at risk for cancer-related fatigue, the following
factors are known to put the patient at risk for
this symptom: advanced/metastatic disease,
cancer treatment (e.g., chemotherapy,
radiation therapy), and medications with
sedating effects. CNPP, Page 885; CSM, Page
29.
CHAPTER 5
Oncologic Emergencies
1. The most common cancer associated

with disseminated intravascular
coagulation (DIC) is:
3. Acute promyelocytic leukemia (APL)
2. The symptoms of disseminated

intravascular coagulation (DIC) seem
paradoxical because:
1. DIC may be both the cause and effect of
malignancy.
2. Thrombosis and hemorrhage may occur
simultaneously.
3. Both platelet function and platelet
numbers are implicated in DIC.
4. Patients may experience fever at the same
time their bodies are hypothermic.
3. The most common cause of acute

disseminated intravascular coagulation
(DIC) associated with cancer is:
1. Infection
2. Anaphylaxis
3. Tumor products
4. Thrombopoiesis

describes the physiologic characteristics
of disseminated intravascular
coagulation (DIC)?
1. All clotting factors are prolonged.
2. The international normalized ratio,
prothrombin time, and partial
thromboplastin time (PTT) are elevated.
3. The platelet count is decreased, the plasma
fibrinogen is low, and the prothrombin
time is prolonged.
4. There is an absence of coagulation, and
therefore, there is widespread hemorrhage.
5. Signs and symptoms of bleeding related
to disseminated intravascular
coagulation (DIC) include:
1. Epistaxis, purpura, petechiae, ecchymoses
2. Focal ischemia, acrocyanosis, superficial
gangrene
3. Anorexia, nausea, vomiting, constipation,
weight loss
4. Elevated temperature, hypotension,
elevated respirations
6. Which of the following tests are specific

and sensitive for the presence of
(DIC)?
1. Fibrinogen level and platelet count
2. International normalized ratio (INR)
3. Plasminogen level and plasmin α-2-
antiplasmin level
4. D-dimer assay and Fibrin Degradation
Product (FDP) titer
7. The only definitive treatment for

(DIC) is:
1. Aggressive antibiotic therapy
2. Treatment of the underlying cancer
3. Administration of platelets and fresh
frozen plasma
4. Reversing the clotting cascade by the
administration of heparin
8. Mary is being treated for acute

promyelocytic leukemia (APL). On the
second day of her chemotherapy, she
complains of shortness of breath, and
you note that she has new bleeding from
her peripherally inserted central catheter
(PICC), as well as hematuria. Her white
blood cell count is 80,000/mm3,
hemoglobin is 9 g/dL, and platelets are
20,000/mm3. What oncologic
emergency is she most likely to be
experiencing?
1. Anaphylaxis
2. Hypercalcemia
3. Tumor lysis syndrome (TLS)
(DIC)
9. The primary treatment for thrombotic

thrombocytopenic purpura is:
1. Vitamin K
2. Plasma therapy
3. Platelet therapy
4. Epsilon-amino caproic acid
10. Mr. Jones, a patient with small cell lung

cancer, develops anorexia, weakness,
and fatigue. At first, these are attributed
to the cancer itself. As his condition
worsens Mr. Jones’s wife calls you in
tears, reporting that he has suddenly
become combative. You tell her that he
must have a serum chemistry as soon as
possible because you suspect:
1. Hyponatremia
2. Hypercalcemia
3. End-stage cancer
4. Paraneoplastic adrenotropic hormone
(pACTH) syndrome
11. Which of the following is indicative of

the syndrome of inappropriate
antidiuretic hormone secretion
(SIADH)?
1. Increased plasma sodium and decreased
urine output
2. Hyponatremia with high serum osmolality
and high urine osmolality
3. Hypernatremia with high serum osmolality
and high urine osmolality
4. Hyponatremia with low serum osmolality,
high urine sodium, and high urine
osmolality
12. Syndrome of inappropriate antidiuretic

hormone secretion (SIADH) is a
paraneoplastic endocrine disorder most
often associated with the ectopic
production of what peptide?
1. Cyclic adenosine 3’,5’-cyclic
monophosphate (cAMP)
2. G protein
3. Adenylate cyclase
4. Arginine vasopressin (AVP)
13. Which of the following is diagnostic for

syndrome of inappropriate antidiuretic
hormone secretion (SIADH)?
1. Absence of edema, euvolemia, decreased
serum osmolality, decreased serum sodium
2. Absence of edema, hypervolemia,
decreased serum osmolality, decreased
serum sodium
3. Presence of edema, hypervolemia,
increased serum osmolality, decreased
serum sodium
4. Presence of edema, euvolemia, decreased
serum osmolality, decreased serum sodium
14. Jason is being treated with
chemotherapy for small cell lung cancer.
His recent lab values demonstrate a
serum sodium of 132 mEq/L. What is the
likely initial treatment for his low
sodium?
1. Administer chemotherapy
2. Hypertonic (3%) saline infusions
3. Administration of intravenous furosemide
4. Free-water restriction to 500 to 1000
mL/day
15. What is the most common adverse event

reported with the use of conivaptan, a
nonselective nonpeptide arginine
vasopressin-receptor antagonist, used to
treat euvolemia and hypervolemic
hyponatremia?
1. Thirst
2. Headache
3. Orthostatic hypotension
4. Mild infusion-site phlebitis
16. Appropriate teaching for the patient

receiving demeclocycline includes:
1. Treatment with demeclocycline allows the
patient to maintain a normal daily intake of
free water and other fluids.
2. Treatment with demeclocycline requires a
strict free water and other fluid intake of
<500 cc/day.
3. Treatment with demeclocycline requires a
strict free water and other fluid intake of
<1000 cc/day.
4. Treatment with demeclocycline requires
intravenous (IV) fluid boluses of 2
liters/day while on treatment.
17. Systemic inflammatory response

syndrome (SIRS) is recognized when two
of the following criteria are met:
1. Temperature >100.4°F or <96.8°F; heart
rate >90 beats per minute; respiratory rate
>20 breaths per minute; white blood cell
count >12,000/mm3, <4000/mm3, or >10%
bands
2. Temperature >100.4°F or <96.8°F; heart
rate >120 beats per minute; respiratory rate
count >12,000/mm3, <4000/mm3, or >10%
bands
3. Temperature >102°F or <96.8°; heart rate
>90 beats per minute; respiratory rate >20
breaths per minute; white blood cell count
>12,000/mm3, <4000/mm3, or >10%
bands
4. Temperature >102°F or <96.8°F; heart rate
>120 beats per minute; respiratory rate
count >12,000/mm3, <4000/mm3, or >10%
bands
18. Sepsis is a common cause of

(DIC). Which of the following conditions
most accurately describes how sepsis
causes DIC?
1. Sepsis causes viruses to thrive, and viruses
cause DIC.
2. Endotoxins released from bacteria activate
the coagulation cascade.
3. Sepsis and bleeding occur simultaneously
in patients who are immunosuppressed.
4. Antiangiogenesis factors are released
during periods of sepsis, which leads to
DIC.
19. Which of the following is considered the

most important prognostic indicator for
septic shock?
1. Prolonged neutropenia
2. Polymicrobial infections
3. Sepsis-induced hypotension
4. The presence of multiple organ dysfunction
syndrome
20. Major fluid volume depletion occurs in

patients with septic shock. Which of the
following pathophysiological
mechanisms of fluid volume depletion is
characteristic of shock?
1. Arterial vasodilation
2. Arterial vasoconstriction
3. Decreased cardiac output
4. Decreased vascular permeability
21. What is the single most important risk

factor for sepsis in individuals with
cancer?
1. Age less than 1
2. Age less than 65
3. Chronic illness
4. Granulocytopenia
22. Septic shock ultimately causes death due

to which of the following?
1. Fever
2. Coagulopathy
3. Tissue ischemia
4. Hypotension
23. The purpose of the Modified Early

Warning Score (MEWS) related to sepsis
is:
1. To act as an algorithm of care
2. To alert physicians when patients are at
risk of sepsis
3. To identify the presence of sepsis in
patients with cancer
4. To facilitate prompt communication
between healthcare providers about early
deterioration in a patient’s condition
24. Jason was just admitted to the hospital

via the emergency department with
suspected sepsis. He has a history of
Hodgkin disease. What is the most
important intervention to initiate
immediately?
1. Steroid therapy
2. Oxygen therapy
3. Antibiotic therapy
4. Intravenous (IV) therapy
25. Jason is started on dopamine when his

blood pressure fails to respond to the
antibiotics and fluid resuscitation. What
is the mean arterial pressure (MAP) that
is targeted to achieve minimal perfusion
pressure and to maintain adequate blood
flow?
1. MAP of 60 mm Hg or less
2. MAP of 60 mm Hg or greater
26. Acute tumor lysis syndrome (ATLS) is

most likely to be seen in which of the
following cases?
1. Colon cancer
2. Burkitt’s lymphoma
27. The metabolic abnormalities that are

characteristic in tumor lysis syndrome
(TLS) include:
1. Hypocalcemia, hypouricemia,
hypophosphatemia, and hypokalemia
2. Hypocalcemia, hyperuricemia,
hyperphosphatemia, and hyperkalemia
3. Hypercalcemia, hyperuricemia,
hypophosphatemia, and hyperkalemia
4. Hypercalcemia, hyperuricemia,
hyperphosphatemia, and hyperkalemia
28. Patients with non-Hodgkin lymphoma

with big, bulky, high-grade disease are at
high risk for acute tumor lysis syndrome
(ATLS). One important aspect of the
nursing care for such patients is:
1. Monitoring urine output for signs of renal
failure
2. Looking for signs of motor incoordination
and cognitive deficits
3. Providing oral or intravenous (IV) agents
that keep blood and urine acidic
4. Discontinuing vinca alkaloid treatment if
signs of severe jaw pain occur
29. Mr. Kramer has chronic myelogenous

leukemia in blastic transformation. He is
considered to have a high tumor burden
and has evidence of lymphadenopathy
and splenomegaly. Which of the
following electrolyte abnormalities
indicate that he is experiencing acute
tumor lysis syndrome (ATLS) ?
1. Hypokalemia
2. Hypercalcemia
3. Hypophosphatemia
4. Acute hyperuricemia
30. A primary physiologic complication of

acute tumor lysis syndrome (ATLS) is:
1. Liver failure caused by a veno-occlusive
disease
2. Tumor lysis, causing release of tissue,
which produces pulmonary emboli
3. Uric acid crystallization in the renal
tubules, causing obstruction and acute
renal failure
4. Tumor cell obstruction of
microvasculature, causing disseminated
intravascular coagulation
31. Tumor lysis syndrome (TLS) results in a

release of a large amount of phosphorus
into the blood and a proportional
decrease in what other serum
electrolyte?
1. Sodium
2. Calcium
3. Potassium
4. Magnesium
32. Which of the following is a key strategy

in the prevention of tumor lysis
syndrome (TLS)?
1. Dialysis
2. Weight bearing
3. Fluid restriction
4. Aggressive hydration
33. Mr. Clay has lymphoma and received

chemotherapy 4 days ago. He has been
doing well but comes in complaining of
fatigue, dizziness, and a “fluttering”
feeling in his chest. Chemistries reveal
potassium, 6 mEq/L; creatinine, 2.7
mg/dL; and calcium, 6 mg/dL. Your
assessment is which of the following?
1. He is dehydrated and needs fluids.
2. He could have a life-threatening
arrhythmia and should be admitted.
3. He is losing calcium and needs magnesium.
4. He is probably anemic and needs a blood
transfusion.
34. Allopurinol is a xanthine oxidase

inhibitor that acts to:
1. Reduce serum uric acid levels
2. Convert uric acid to a more soluble form
3. Decrease deposits of uric acid in the
kidneys
4. Eliminate already formed uric acid deposits
in the kidneys
35. M.T. is admitted to the hospital for

treatment of Burkitt’s lymphoma. Her
lab values on admission to the hospital
demonstrate a potassium level of 4
mEq/L, phosphorus of 3.5 mg/dL,
calcium of 9 mg/dL, and a uric acid of
9.5 mg/dL. Which of the following
medications would you anticipate being
ordered initially to help manage M.T.?
1. Kayexalate
2. Allopurinol
3. Rasburicase
4. Doxycycline
36. Pretreatment risk factors in the

development of tumor lysis syndrome
(TLS) include which of the following?
1. Hypocalcemia
2. Hypophosphatemia
3. Dehydration or renal impairment
4. Decreased lactate dehydrogenase level
37. During his hospitalization, Mr. Clay

develops hyperphosphatemia and is
treated with a phosphate binding,
aluminum-containing agent. Based on
the actions of these agents, what other
medication should be administered
concomitantly?
1. Laxatives
2. Catecholamines
3. Antiarrhythmics
4. Calcium gluconate
38. Mr. Stevens has just begun his first

treatment with rituximab. One hour into
the infusion he complains of fever, chills,
and rigors. Appropriate nursing action is
based on which of the following?
1. The symptoms are expected and are
expected to lessen with each subsequent
treatment.
2. This is an anaphylactic reaction, and the
medication should be permanently
discontinued.
3. The infusion should be maintained; these
symptoms are expected and signal a good
response to therapy.
4. Monitor the blood pressure because
rituximab can significantly raise the blood
pressure, requiring the drug to be
discontinued.
39. Measures to prevent a hypersensitivity
reaction to a monoclonal antibody
1. Administer pretreatment hydration.
2. Administer an opioid before the infusion.
3. Administer acetaminophen and an
antihistamine before the infusion.
4. Speed up the infusion to decrease the
amount of time the infusion takes.
40. Mrs. Howe has just arrived for her first

treatment with trastuzumab, a
monoclonal antibody. As you plan her
teaching about her medication, you are
careful to include which of the
following?
1. If she has fever, chills, or rigors, the
infusion will be turned off, and she will not
receive this medication in the future.
2. If she has fever, chills, or rigors, the
medication will be stopped temporarily and
restarted after her symptoms subside.
3. Fever, chills, or rigors are expected
reactions to trastuzumab and demonstrate
a good response to her treatment.
4. Diphenhydramine and acetaminophen are
often given before the first infusion to
minimize risk of an infusion-related
reaction.
41. Jack is receiving his first infusion of

paclitaxel. Ten minutes into the infusion,
he complains of tightness in his chest
and shortness of breath and begins to
experience wheezing. What are the most
important nursing actions to take?
1. Slow the infusion and monitor the patient
closely.
2. Decrease the infusion by half the initial
rate and treat his symptoms.
3. Stop the infusion, maintain a patent
intravenous (IV) line, and prepare for CPR
as necessary.
4. Stop the infusion, maintain a patent IV
line, and restart the drug when the patient
stabilizes.
42. Alex has an infection of his vascular

access device and is beginning
vancomycin therapy. Twenty minutes
into a 60-minute infusion, you notice his
face and upper torso are flushed and
warm to touch. Appropriate nursing
action includes which of the following?
1. Slow the infusion and administer
morphine.
2. Stop the infusion; he is having an allergic
reaction.
3. Administer Decadron and
diphenhydramine immediately.
4. This is not an antigen antibody reaction;
slow the infusion to 90 minutes.
43. Which of the following drugs is

commonly associated with a
hypersensitivity reaction?
1. Paclitaxel
2. Bleomycin
3. 5-Fluorouracil
4. Cyclophosphamide
44. Which of the following malignancies is

most likely to be associated with
hypercalcemia?
1. Lung cancer
2. Acute leukemia
3. Chronic leukemia
4. Osteogenic sarcoma
45. The most important initial treatment for

hypercalcemia is:
1. Inhibiting bone resorption
2. Treating the primary tumor
3. Inhibiting osteoclast function
4. Improving renal calcium excretion
46. Early symptoms of hypercalcemia in

patients with cancer include:
1. Obstipation
2. Atonic ileus
3. Renal failure
47. The pathophysiology of hypercalcemia

involves a combination of two factors:
bone resorption and:
1. Increased osteoclast activity
2. Increased glomerular function
3. Decreased renal calcium clearance
4. Decreased availability of ionized calcium
48. Factors produced by tumors have been

implicated in malignancy-associated
hypercalcemia. Probably the most
important of these humoral circulating
factors is:
1. Prostaglandin
2. Bisphosphonate
3. Osteoclast-activating factor
4. Parathyroid hormone-related factor
49. A patient is found to have a large tumor

mass associated with high levels of
parathyroid hormone-related protein but
normal levels of 1,25-dihydroxyvitamin D
and normal intestinal absorption rates.
Bone absorption is found to exceed bone
formation. The most likely diagnosis is:
1. Hodgkin disease
2. Multiple myeloma
3. Primary hyperparathyroidism
4. Humoral hypercalcemia of malignancy
(HHM)
50. The symptoms of hypercalcemia in

patients with cancer are best described
as:
1. Numerous, vague, and nonspecific
2. Easily identified but difficult to treat
3. Similar to those of acute renal failure
4. Distinct from those of end-stage disease
51. Patients with severe hypercalcemia are

invariably symptomatic and urgent
intervention is required. What corrected
calcium level is indicative of severe
hypercalcemia?
1. 8.5–10 mg/dL
2. 10.5–11.9 mg/dL
3. 12–14 mg/dL
4. >14 mg/dL
52. Which of the following is used in the

treatment of hypercalcemia?
1. Diuretics
2. Allopurinol
3. Bisphosphonates
4. Fluid intake restriction

common side effect of bisphosphonate
therapy?
1. Extravasation
2. Nephrotoxicity
3. Hypersensitivity
4. Atypical femoral fractures
54. A patient with metastatic squamous cell

lung cancer develops confusion,
disorientation, and hallucinations and
has an elevated serum calcium. Part of
your patient teaching will include the
importance of:
1. Decreasing fluid intake
2. Weight-bearing exercise
3. Taking thiazide diuretics
4. Restriction of salt intake
55. Zoledronic acid is the most potent

bisphosphonate in use in the United
States for the treatment of hypercalcemia
of malignancy. It is recommended that
the dose not exceed 4 mg delivered over
no less than 15 minutes every 3–4 weeks.
The rationale behind this
recommendation is which of the
following:
15 minutes increase liver toxicity.
15 minutes increase renal toxicity.
15 minutes increase nausea and diarrhea.
4. Does higher than 4 mg given in less than 15
minutes increase bone marrow
suppression.
56. Malignant pericardial effusions:

1. Are extremely rare
2. Are not easily detected because many
patients are asymptomatic
3. Are easily detected by tachycardia, low
blood pressure, and shortness of breath
4. Occur in 50% of all patients with cancer,
especially the hematologic malignancies
57. Possible early signs of cardiac

tamponade include:
1. Hypotension, bradycardia, and fatigue
2. Tachycardia, fatigue, and shortness of
breath
3. Hypotension, cough, and narrowing pulse
pressure
4. Hypertension, bradycardia, and widening
pulse pressure
58. Which of the following tumor types is

commonly associated with pericardial
effusion and tamponade?
1. Lung cancer
2. Colon cancer
4. Gastrointestinal cancer
59. Which of the following is a significant

risk factor for the development of
cardiac tamponade?
1. Hyperkalemia
2. Hyperuricemia
3. Radiation to the pericardium
4. Pericardial fluid accumulation of 100 cc
60. Your patient is suspected to have a

cardiac tamponade. What test is
considered to be the most sensitive
method for diagnosing this oncologic
emergency?
1. Chest radiograph
2. Electrocardiogram (EKG)
4. Two-dimensional echocardiogram
61. J.T. has metastatic lung cancer and has

been diagnosed with hemodynamically
unstable cardiac tamponade. What
treatment do you anticipate that J.T. will
imminently need to undergo to treat his
cardiac tamponade?
1. Radiotherapy
2. Chemotherapy
3. Pericardiectomy
4. Pericardiocentesis
J.T. has been readmitted to the hospital
62. with a recurrent malignant pericardial
effusion and is scheduled to undergo a
pericardiocentesis with sclerosis with
cisplatin. You explain to J.T. that the
sclerosing agent acts to:
1. Treat the cancer cells in the pericardium
that are causing the effusions
2. Relieve pain in the pericardial space caused
by the malignant pericardial effusion
3. Create inflammation and cause additional
space between the pericardial layers to
allow more space for the fluid to drain
4. Create inflammation and cause adhesions
between the pericardial layers to obliterate
the space and prevent reaccumulation of
fluid
63. Which of the following is used as a

sclerosing agent for the management of
recurrent cardiac tamponade?
1. Rituximab
2. Bleomycin
3. Gemcitabine
4. Doxorubicin
64. A side effect of most sclerosing agents

that should be treated proactively
includes:
1. Pain
2. Hypotension
3. Vasovagal response
65. You will soon begin work in a clinic that

specializes in the detection and
treatment of spinal cord tumors. You are
aware that the most common presenting
symptom of a spinal cord tumor is:
1. Pain
2. Weakness
3. Numbness and tingling
4. Uncoordinated ataxic gait
66. The most common cause of spinal cord

compression is:
1. Chronic steroid use
2. Carcinomatosis meningitis
3. Metastasis to the vertebral column
4. Primary disease of the vertebral column
67. The most common cancer associated

with spinal cord compression is:
1. Breast cancer
2. Gastric cancer
3. Multiple myeloma
4. Hepatocellular cancer
68. Mrs. Johnson has been treated for lung

cancer, and she has complained of back
pain for 2 months and now presents with
weakness. Which of the following helps
to explain her symptoms?
1. Back pain is rarely a symptom of spinal
cord tumors.
2. Back pain and weakness are classic
symptoms of spinal cord tumors.
3. Back pain and weakness are likely caused
by her chronic steroid use.
4. Back pain and weakness are likely caused
by inactivity related to fatigue from her
lung cancer treatment.
69. Mark is being discharged from the

hospital. His prostate cancer involves
bone metastases to the spine and pelvis.
Which of the following development is
likely to indicate a need for emergent
radiation therapy?
1. Inability to walk
2. Motor weakness
3. Bowel incontinence
4. Bladder incontinence
70. A woman with breast cancer and known

bone metastases is currently on
pamidronate. Her primary complaint is
weakness in both arms. She has back
pain, but it is unchanged from the
previous week. The most logical
explanation for her symptoms and the
correct nursing action is which of the
following?
1. Weakness in arms and legs is common
with pamidronate, and she should increase
her use of the arms to avoid losing muscle
strength.
2. She has known bony metastasis that is no
worse; the pamidronate will help the bone
to heal, so it is appropriate to monitor her
symptoms.
3. If she has bony disease in her spine, she
should have an emergency magnetic
resonance image (MRI) to rule out spinal
cord compression.
4. She should be encouraged not to cough,
strain, or lift heavy objects because she
could have osteoporosis and is at risk for
disc disease.
A man with a history of lung cancer calls
71. his doctor to report the following
symptoms: dyspnea; headache; swollen
face, neck, and arms; and dilated chest
veins. Which of the following best
identifies what he is describing?
1. Possible pneumothorax
2. Possible superior vena cava (SVC)
obstruction
3. Possible local recurrence with brain
metastasis
4. Telangiectasia and complications of prior
radiation therapy
72. Which of the following is characteristic

of superior vena cava syndrome (SVCS)?
1. Late symptoms include cough and dyspnea.
2. An increase in venous pressure causes
venous hypotension.
3. Late symptoms include hoarseness and
edema in the face, neck, and arms.
4. As the superior vena cava (SVC) is
compressed, there is reduced venous return
to the right atrium.
73. Early warning signs of superior vena

cava syndrome (SVCS) include:
1. Respiratory distress, stridor, and cyanosis
2. Swelling of the head, neck, and upper torso
3. Bradycardia, shortness of breath,
abdominal distention
4. Distant, muffled heart sounds, diminished
apical pulse, decreased cardiac output
74. What is the most likely initial treatment

of choice for a quickly progressing
superior vena cava syndrome (SVCS)
caused by non-small cell lung cancer
(NSCLC)?
1. Chemotherapy
3. Radiation therapy
4. Administration of anticoagulants
75. What is the best surgical intervention for

superior vena cava syndrome (SVCS) to
provide rapid relief of symptoms prior to
a tissue diagnosis?
1. The compressed portion of the vena cava is
removed.
2. A bypass graft is fashioned to redirect blood
flow around the obstruction.
3. Percutaneous placement of an
endovascular stent to bypass the
obstruction.
4. The portion of the vena cava that is being
compressed is repositioned surgically
following resection of the tumor.
76. Which of the following cancers is

responsible for more than 75% of all
cases of superior vena cava syndrome
(SVCS)?
1. Lung cancer
2. Breast cancer
3. Kaposi sarcoma
4. Hodgkin disease

common cause of superior vena cava
syndrome (SVCS)?
1. Mediastinal fibrosis
2. Thoracic aortic aneurysm
3. Thrombus formation from intravascular
devices
4. Malignancy in the mediastinal area causing
obstruction of upper venous blood flow to
the heart
78. A patient with a suspected superior vena

cava syndrome (SVCS) will likely have
what diagnostic studies?
1. Echocardiography
2. Standard chest x-ray
3. Positron emission tomography (PET)
4. Computed tomography (CT) with contrast
79. What is the most likely treatment for a

patient with non-Hodgkin lymphoma
and an associated superior vena cava
syndrome (SVCS)?
2. Radiation therapy
3. Chemo-immunotherapy
4. Administration of anticoagulants
80. In most instances of central nervous

system tumors, the earliest indicator of
increased intracranial pressure (ICP)
includes:
1. Vomiting
2. Change in vital signs
3. Motor and sensory function
4. Change in level of consciousness and
cognitive ability
81. Other early signs of increased

intracranial pressure (ICP) include:
1. Headache
2. Decorticate posturing
3. Widening pulse pressure
4. Increased systolic blood pressure
82. Late clinical manifestations of increased

intracranial pressure (ICP) include the
Cushing’s Triad. What symptoms
constitute this triad?
1. Irregular respirations, systolic hypotension,
tachycardia
2. Irregular respirations, systolic
hypertension, tachycardia
3. Irregular respirations, systolic hypotension,
bradycardia
4. Irregular respirations, systolic
hypertension, bradycardia
83. Which of the following is a risk factor for

the development of increased
intracranial pressure (ICP)?
1. Liver cancer
2. Colon cancer
4. Primary brain tumors
84. In balancing intracranial pressure (ICP),

the mechanism that specifically
maintains a normal ICP despite
fluctuations in arterial pressure and
venous drainage is:
1. Compensation
2. Autoregulation
3. Cerebral blood flow
4. Cerebrospinal fluid displacement
85. The most commonly used imaging

technique to evaluate increased
intracranial pressure (ICP) is:
1. Brain scan
2. Lumbar puncture
3. Computed tomography (CT), contrast
4. CT, non-contrast
86. J.K.’s intracranial pressure (ICP) is

acutely elevated after tumor resection. In
acute situations like his, the drug of
choice is:
1. Dilantin
2. Carmustine
3. Vincristine
4. Dexamethasone
87. What nursing measures should be

included in the care of the patient with
increased intracranial pressure (ICP)?
1. Place the patient prone and keep the head
in a neutral position.
2. Elevate the head of the bed and keep the
head in a neutral position.
3. Place the patient in a supine position with
the head in a neutral position.
4. Place the patient in a Trendelenburg
position with the head in a neutral
position.
88. In the setting of increased intracranial

pressure (ICP), what is the evidence-
based recommendation for maintaining
the cerebral perfusion pressure (CPP)?
1. 40 to 60 mm Hg
2. 50 to 60 mm Hg
3. Above 120 mm Hg
4. At or above 70 mm Hg
89. To obtain a definitive diagnosis of a

ureteral obstruction, the nurse should
expect to prepare a patient for what
procedures?
1. Cystoscopy
2. Computed tomography (CT) of the rectum
3. CT of the ureters
4. Cystoscopy and retrograde pyelogram
90. John M. is diagnosed with a ureteral
obstruction and is scheduled to have
ureteral stent placements. What action
of the nurse is appropriate for this
procedure?
1. Ensure that the patient signs the consent
for surgery.
2. Explain to the patient that the ureteral
stents can help to establish patency and
prevent further compression by the tumor.
3. Explain to the patient that if the ureteral
stent becomes blocked that he will have to
undergo placement of a percutaneous
nephrostomy tube.
4. Explain to the patient that the ureteral
stent placement is a surgical procedure and
that he will be recovered in a post-
anesthesia care unit.
91. Which of the following is a risk factor for

the development of a bowel obstruction?
1. Advanced liver cancer
2. Advanced breast cancer
3. Advanced colon cancer
4. Advanced pancreatic cancer
92. The presence of foul-smelling, fecaloid

vomiting can be the first sign of an:
1. Obstruction of the large bowel
2. Obstruction of the gastric outlet
3. Obstruction of the ileal or colon
4. Obstruction of the small intestine
93. Signs and symptoms of a bowel

obstruction include:
1. Fever, abdominal pain, progressive
constipation, absence of bowel sounds over
the affected area
2. Nausea, vomiting, abdominal pain,
progressive constipation, absence of bowel
sounds over the affected area
progressive constipation, increase in bowel
progressive constipation, decrease in bowel
94. Mary K. develops a bowel obstruction

due to advanced colon cancer. What
procedure will the nurse prepare Mary
for initially?
1. Surgical exploration of the obstruction in
the colon
2. Nasogastric insertion and administration of
parenteral fluids
3. Gastrostomy tube insertion and
administration of parenteral fluids
4. Surgical exploration of the obstruction in
the colon and the placement of a
percutaneous endoscopic gastrostomy tube
95. Late effects of total body irradiation

include:
1. Osteopenia
2. Pneumonitis
3. Muscle weakness
4. Permanent hair loss
96. Pneumonitis may be associated with

which of the following chemotherapy
agents used in preparative regimens for
stem cell transplantation?
1. Cyclophosphamide, busulfan, and
carmustine
2. Cyclophosphamide, busulfan, and
carboplatin
3. Cyclophosphamide, doxorubicin, and
etoposide
4. Cyclophosphamide, doxorubicin, and
carmustine
97. Susan is a 54-year-old patient who
completed radiation therapy for non–
small cell lung cancer 5 months ago. Her
husband calls your clinic and states that
she has been complaining of shortness of
breath and a nagging cough for the past
24 hours. You explain to him that he
should bring Susan to the clinic to
evaluate her, as you are primarily
concerned about:
1. Pneumonia
2. Cardiac complications such as heart failure
3. Graft-versus-host disease involving the
lungs
4. Respiratory complications such as
pneumonitis
98. Susan is diagnosed with radiation-

induced pneumonitis. The nurse can
expect to begin teaching about what
treatment for this complication?
1. Steroids
2. Antibiotics
3. Biotherapy
4. Chemotherapy

agents is classified as a non-irritant
agent?
1. Cytarabine
2. Docetaxel
3. Vincristine
4. Doxorubicin
100. Which of the following agents is

classified as a vesicant agent?
1. Fludarabine
2. Gemcitabine
3. Doxorubicin
4. Mitoxantrone

extravasation include:
1. Small, fragile blood vessels
2. Prominent, easily accessed blood vessels
3. Staff experienced in chemotherapy
administration
4. Previously untreated patients who have not
had repeated venipuncture
102. Marvin comes to the clinic 2 days after

administration of doxorubicin with
complaints of pain, swelling, and
induration at the site of the
venipuncture. What do you suspect is the
cause of Marvin’s complaints?
1. Flare reaction to the doxorubicin
2. Extravasation of the doxorubicin
3. Vessel irritation due to the doxorubicin
4. Venous shock related to the doxorubicin
103. The nurse is going to begin a continuous

vesicant infusion. What steps can the
nurse take to minimize the risk of
extravasation?
1. Avoid the dorsum of the hand, wrist, and
antecubital; check for a brisk blood return
every 2 to 5 mL and secure the intravenous
(IV) line to the skin by using a clear
dressing.
2. Avoid the dorsum of the hand, wrist, and
antecubital; check for a brisk blood return
prior to initiating the infusion and secure
the IV to the skin by using a clear dressing.
3. Use only an IV that is new or has been
started in the previous 24 hours; avoid the
hand, wrist, and antecubital; check for a
brisk blood return prior to initiating the
infusion.
4. Use only a central venous access device
(CVAD) to administer a continuous
vesicant infusion, check for a brisk blood
return at the port closest to the patient and
ensure that the dressing covering the
insertion site is transparent.
104. The patient in the above question is

taught to notify the nurse immediately if
which of the following symptoms
occurs?
1. Pain or swelling at the infusion site
2. Pain, burning, leaking, or other changes in
sensation at the infusion site
3. No symptoms, as it is the responsibility of
the nurse to identify a possible
extravasation
4. No symptoms, as the infusion will not
extravasate since it is going through a
central venous access device (CVAD)
105. The nurse is administering an

intravenous (IV) push vesicant drug and
suspects an extravasation. What are the
symptoms that would indicate an
extravasation?
1. Pain and swelling at the site
2. Ulceration at the IV insertion site
3. Wheal formation along the vessel
4. Red streaks or blotches along the vessel
106. What are the steps that the registered
nurse should follow if she suspects that a
patient is experiencing an extravasation
related to a vesicant drug?
1. Stop the infusion immediately, remove the
peripheral intravenous (IV) device or port
needle, assess and treat suspected
extravasation.
2. Stop the infusion immediately, infuse
normal saline through the IV line, remove
the peripheral IV device or port needle,
assess and treat suspected extravasation.
3. Stop the infusion immediately, leaving the
IV tubing in place attempt to aspirate
residual fluid from the IV line, remove the
peripheral IV device or port needle, assess
and treat suspected extravasation.
4. Stop the infusion immediately, disconnect
the IV tubing from the IV device, attempt
to aspirate residual fluid from the IV
device, remove the peripheral IV device or
port needle, assess and treat suspected
extravasation.
107. The appropriate antidote to be given if an

extravasation of an anthracycline is
suspected is:
1. Dextrazoxane
2. Hyaluronidase
3. Sodium thiosulfate
4. Sodium bicarbonate
108. The nurse suspects that the patient is

experiencing an extravasation related to
the administration of vincristine. What
medication antidote would be
appropriate for a vincristine
extravasation?
1. Dexrazoxane
2. Hyaluronidase
3. Sodium thiosulfate
4. Sodium bicarbonate
109. After treating the vincristine-related

extravasation with the appropriate
medication antidote, what step(s) should
next be taken?
1. Elevate the area for 48 hours.
2. Apply cold packs to the site and elevate the
area for 48 hours.
3. Apply warm packs to the site and elevate
the area for 48 hours.
4. Apply frozen packs to the site and elevate
the area for 48 hours.
Answer Rationales
Answer Rationales sections refer to the textbooks
Management, Fourth Edition, by Connie Henke
Yarbro, Debra Wujcik, and Barbara Holmes Gobel
(Jones & Bartlett Learning, © 2014).
1. The answer is c.
DIC can be associated with a number of
cancers, including leukemia and solid tumors.
The most common cancer associated with DIC
is APL. APL cells express a variety of
procoagulant substances including tissue
factor (TF) and cancer procoagulant (CP).
2. The answer is b.
DIC always results from an underlying disease
process that triggers abnormal activation of
both thrombin and plasmin formation.
Thrombin is both a powerful coagulant and an
agent of fibrinolysis. Thus, small clots may be
formed in the microcirculation of many organs
at the same time that clots and clotting factors
are being consumed. The excess circulating
thrombin also assists in the conversion of
plasminogen to plasmin, causing fibrinolysis.
The result is hemorrhage because the body is
unable to respond to vascular or tissue injury.
3. The answer is a.
The most common cause of acute DIC is
infection and sepsis associated with cancer. It
is believed that bacterial endotoxins, which are
released from gram-negative bacteremia,
activate factor XII of the clotting cascade. This
factor can initiate coagulation as well as
stimulate fibrinolysis. DIC can also be linked
to fungal and viral infections. CNPP, Page
1097.
4. The answer is c.
DIC represents the most common serious
hypercoagulable state in individuals with
cancer. Tests generally done to help support
the diagnosis of DIC include prothrombin time
(prolonged), platelet count (decreased), and
the plasma fibrinogen level (decreased). CNPP,
Pages 1099–1101.
5. The answer is a.
Bleeding is the most obvious sign of a
hemorrhagic disorder. Signs and symptoms of
bleeding may include epistaxis, purpura,
petechiae, and ecchymoses. B are signs of
thrombus formation. C are signs of
hypercalcemia. D are signs of sepsis. CNPP,
Pages 1099–1100; CSM, Pages 291–296.
6. The answer is d.
The laboratory tests that are both specific and
sensitive for the presence of DIC include the
D-dimer assay and the FDP titer. The other
tests help to support the diagnosis of DIC, but
are not specific for DIC. CNPP, Pages 1099–
1101.
7. The answer is b.
Treatment of the underlying malignancy is
vital in the patient with a hypercoagulability
abnormality, because the tumor is the ultimate
stimulus. All other therapy, although effective
on a short-term basis, provides only an
interval of symptomatic relief. CNPP, Pages
1101–1102; CSM, Pages 304–306.
8. The answer is d.
APL is the cancer most commonly associated
with DIC. Symptoms related to DIC correlate
to where fibrin clots have lodged. Bleeding is
the most obvious sign of a hemorrhagic
disorder and can occur from any orifice or
opening on the surface of the skin or organ. A
low platelet count is a nonspecific but frequent
finding in DIC. CNPP, Pages 1096–1097.
9. The answer is b.
Plasma exchange is the primary treatment for
thrombotic thrombocytopenic purpura.
Platelet therapy is contraindicated unless
required for life-threatening bleeding
complications. CSM, Page 291.

Mr. Jones most likely has hyponatremia
secondary to syndrome of inappropriate
antidiuretic hormone secretion (SIADH).
SIADH is primarily associated with small cell
lung cancer. Water intoxication accounts for
the signs and symptoms seen with SIADH. The
early symptoms, such as nausea, weakness,
anorexia, and fatigue, can be easily attributed
to the cancer. However, as the hyponatremia
worsens, symptoms may progress to include
altered mental status, confusion, and
combativeness. CNPP, Pages 1198, 1201–1203.

SIADH results from ADH secretion by the
tumor. The symptoms include hyponatremia,
high urine sodium, high urine osmolality, and
low serum osmolality, characterized by mental
status changes, lethargy, seizures, and
confusion. CNPP, Pages 1198–1201.

In cancer, SIADH typically results from tumor
secretion of AVP. G protein, adenylate cyclase,
and cAMP are all part of the cascade of effects
related to SIADH in the renal collecting ducts.

The criteria for the diagnosis of SIADH
includes: decreased serum osmolality,
decreased serum sodium, increased urine
osmolality, increased serum sodium,
euvolemia, decreased level of uric acid,
decreased or normal blood urea nitrogen,
absence of edema; and normal renal, adrenal,
and thyroid function. CNPP, Pages 1201–1202.

The initial treatment for most patients with
syndrome of inappropriate antidiuretic
hormone secretion (SIADH) is to restrict free-
water to 500 to 1000 mL/day. Hypertonic
saline infusions along with administration of
intravenous furosemide are generally initiated
for severe hyponatremia. Chemotherapy is
often an offending agent that can cause SIADH
and thus is not the treatment of choice for this
syndrome. CNPP, Pages 1199, 1202–1204.

Mild infusion-site phlebitis is the most
common adverse event related to the
intravenous (IV) use of conivaptan. All of the
other choices (thirst, headache, orthostatic
hypotension) are less common adverse events.
CNPP, Page 1204.

Treatment of syndrome of inappropriate
antidiuretic hormone secretion (SIADH) with
demeclocycline allows the patient to maintain
a normal daily intake of water and other fluids.

SIRS is a part of a continuum of escalating
responses to a variety of severe clinical insults,
as manifested by two or more specific physical
or laboratory findings: Temperature >100.4°F
or <96.8°F; heart rate >90 beats per minute;
respiratory rate >20 breaths per minute; white
blood cell count >12,000/mm3, <4000/mm3,
or >10% bands. CNPP, Page 1136.

Risk of bleeding and DIC increases during
periods of febrile neutropenia. This is due to
the activation of the coagulation cascade by
endotoxins released from bacteria. DIC is a
dangerous sequel of sepsis. This is most
frequently seen in gram-negative sepsis due to
the endotoxins released from the bacteria.

When sepsis progresses to a state of organ
dysfunction, hypoperfusion, or hypotension,
severe sepsis is present. Multiple organ
dysfunction syndrome, which is defined as the
presence of altered organ function in an
acutely ill patient such that homeostasis
cannot be maintained without intervention, is
the final common pathway for the critically ill
patients. The presence of multiple organ
dysfunction syndrome is an important
prognostic indicator for septic shock. CNPP,
Pages 1136–1137.

The principal feature of sepsis is arterial
vasodilation. Major fluid volume depletion
occurs in patients with septic shock due to
decreased venous tone, vascular pooling,
capillary leak, and third spacing of fluid; which
is then compensated by a normal to increased
cardiac output. The hallmark of septic shock is
profound hypotension. CNPP, Pages 1138–
1139.

Granulocytopenia is the single most important
risk factor in the development of sepsis in the
patient with cancer. Age less than 1, age
greater than 65, and chronic illness are risk
factors in the development of sepsis. CNPP,
Pages 1137–1138.

The clinical picture of septic shock illustrates
the cumulative effects of coagulopathy,
hypotension, hypoperfusion, and, ultimately,
tissue ischemia involving failure of all body
systems. CNPP, Pages 1139–1140.

The purpose of the MEWS is to facilitate
prompt communication between nursing and
medical staff when deterioration in a patient’s
condition first becomes apparent. The authors
of this scoring system intended for the MEWS
to result in earlier intervention in the general
medical setting so that transfer to a critical
care setting is either prevented or occurs
without unnecessary delays. CNPP, Pages
1141–1143.

The most important intervention in the
management of septic shock is immediate
treatment with antibiotic therapy. According to
the sepsis resuscitation bundle, antibiotics
should be administered within 1 hour from the
time of identification of sepsis. The use of
steroids for the treatment of sepsis in the
absence of shock is not recommended. Oxygen
therapy and IV fluid therapy are both indicated
in the treatment of shock, but antibiotic
therapy must be the immediate focus. CNPP,
Pages 1143–1145.

If fluid resuscitation fails to restore organ
perfusion, the use of vasopressors is required.
Ideally, the MAP should be maintained at 65
mm Hg or greater to achieve the minimal
perfusion pressure and to maintain adequate
blood flow. CNPP, Page 1147.
ATLS is a complication of cancer therapy that
occurs most commonly in patients with
tumors that have a high proliferation index
and are highly sensitive to chemotherapy.
ATLS is most commonly seen in patients with
high-grade lymphoma (such as Burkitt’s
lymphoma), acute myelogenous leukemia,
acute lymphocytic leukemia, and non-Hodgkin
lymphoma. ATLS is less common in solid
tumors and chronic lymphocytic leukemia.
CNPP, Page 1208.

The metabolic abnormalities that are
characteristic in TLS include hypocalcemia,
hyperuricemia, hyperphosphatemia, and
hyperkalemia. These metabolic abnormalities
occur when a cell is lysed because of
chemotherapy or other precipitating event and
the intracellular electrolytes are released into
the vascular system. CNPP, Pages 1208, 1211–
1212.

ATLS generally occurs when the patient is
initially treated. Tumor cells spill their
contents into the general circulation, causing a
metabolic disturbance. Renal failure and death
may occur. The treatment of choice is
prevention, including hydration, and IV or oral
allopurinol and/or rasburicase to prevent
hyperuricemic nephropathy. CNPP, Pages
1209, 1211–1217.

ATLS is most often characterized by the
development of acute hyperuricemia,
hyperkalemia, hyperphosphatemia, and
hypocalcemia with or without acute renal
failure. CNPP, Pages 1208, 1211–1212.

Uric acid crystallization in the renal tubules,
causing obstruction, decreased glomerular
filtration, and/or acute renal failure, is a major
complication of ATLS. CNPP, Pages 1012–1214.

In TLS there is an inverse relationship
between phosphorus and calcium, whereby if
one mineral increases, the other decreases in
the same proportion. CNPP, Pages 1212, 1214.

Aggressive hydration is needed to help prevent
acute TLS, to at least 3 liters of fluid per day,
with adequate urinary output and using
diuretics to promote excretion of the
electrolytes that have been released from lysed
cells to prevent renal tubular damage. Fluid
restriction in the management of acute TLS is
contraindicated. Dialysis may be considered
for patients with evident acute kidney injury.

An increase in phosphate, potassium, uric acid,
blood urea nitrogen, and creatinine or a 25%
decrease in calcium within 4 days of
chemotherapy is indicative of tumor lysis
syndrome (TLS) and places the patient at risk
for life-threatening arrhythmias. CNPP, Pages
1211–1214.
34. Then answer is c.

Allopurinol prevents the formation of uric acid
by inhibiting xanthine oxidase and interfering
with purine metabolism. Allopurinol acts by
decreasing deposits of uric acid already formed
in the kidneys. Because allopurinol reduces
the incidence of obstructive uropathy caused
by uric acid precipitation, it works most
effectively in patients who are at risk for
developing tumor lysis syndrome (TLS), and is
less effective in patients with existing
hyperuricemia. CNPP, Page 1216.
A diagnosis of Burkitt’s lymphoma puts M.T.
at high risk for tumor lysis syndrome (TLS).
Based on M.T.’s lab values, she is already
experiencing hyperuricemia. Rasburicase is
indicated for the initial management of
elevated plasma uric acid levels in adults with
leukemia, lymphoma, and solid tumors
receiving anticancer treatment expected to
result in TLS. CNPP, Pages 1208–1209, 1217.

Pretreatment risk factors in the development
of TLS include dehydration or renal
impairment; large, bulky tumors with
significant adenopathy; hyperkalemia,
hyperphosphatemia, hypocalcemia,
hyperuricemia; and an elevated lactate
dehydrogenase level. CNPP, Page 1215.

Phosphate-binding, aluminum-containing
medications used for the treatment of
hyperphosphatemia can cause significant
constipation and therefore patients should be
concomitantly treated with laxatives. CNPP,
Page 1221.

An infusion-related symptom complex
consisting of fever, chills, and rigors, asthenia,
and headache occur in most patients during
the first infusion with rituximab. The
symptoms will generally decrease with
subsequent infusions. Rituximab causes
hypotension, not hypertension. CNPP, Pages
908, 913; CSM, Pages 119–120.

Infusion reactions to monoclonal antibodies
are generally prevented by the pretreatment
with acetaminophen and an antihistamine.
Anaphylactoid reactions have most commonly
occurred with monoclonal antibody therapy.
Most of these reactions occurred at the
beginning of therapy administration to
patients with lymphoma or leukemia or when
administered by rapid infusion. CNPP, Pages
913, 915–916; CSM, Page 120.

Fever, chills, or rigors related to the
administration of trastuzumab indicate an
infusion reaction. Acute side effects that occur
during infusion are most commonly fever,
chills, rigors, malaise, myalgia, nausea, and
vomiting. The symptoms often resolve if the
medication is stopped and restarted at a slower
rate. CNPP, Pages 909, 913; CSM, Pages 119–
120.

Jack may be experiencing an anaphylactic
reaction to the paclitaxel. Whenever
anaphylaxis is suspected, the initial nursing
actions would include stopping the infusion,
maintaining a patent IV line with normal
saline, and preparing for CPR as necessary.
Whether or not a patient is rechallenged with a
chemotherapy drug after an anaphylactic
reaction is dependent on the severity of the
reaction. CNPP, Pages 916–917; CSM, Pages
124–126.

While flushing is a symptom that may be seen
with an allergic reaction, vancomycin causes
release of histamine from the mast cells,
which causes vasodilation and the appearance
of an allergic reaction. The red neck, or red
man syndrome, is common with vancomycin
and improves with slowing to a 90-minute
infusion. CNPP, Pages 909–911, 916–917;

Paclitaxel has a high potential to cause
hypersensitivity reactions. Hypersensitivity
reactions due to bleomycin, 5-flurouracil, and
cyclophosphamide are rare. CNPP, Pages 906–
907; CSM, Page 117.

Hypercalcemia is common in patients with
squamous cell lung cancer. Patients with lung
and breast cancer account for the highest
percentage of malignancy-induced
hypercalcemia. Hypercalcemia is rare in the
acute and chronic leukemias and osteogenic
sarcoma. CNPP, Page 1108.

Before excessive bone resorption can be
treated, impaired renal calcium excretion must
be improved, usually by correcting dehydration
and removing factors that may exacerbate
hypercalcemia, including thiazide diuretics.
Oral or intravenous (IV) hydration with
normal saline may be required. CNPP, Pages
1121–1124.

Nausea and vomiting are part of a
constellation of early clinical manifestations of
hypercalcemia related to cancer. Atonic ileus,
obstipation, and renal failure are all late
manifestations of hypercalcemia. CNPP, Pages
1116–1117.

Hypercalcemia is characterized by excess
extracellular calcium. This condition results
from bone resorption—the release of skeletal
calcium into serum—and from the failure of
the kidneys to clear extracellular calcium. As
calcium levels rise, symptoms of
hypercalcemia appear. CNPP, Pages 1109–1113.

Malignancy-associated hypercalcemia is a
complex metabolic complication in which bone
resorption exceeds both bone formation and
the kidney’s ability to excrete extracellular
calcium. Humoral circulating factors include a
parathyroid hormone-related factor and 1,25-
dihydroxyvitamin D. Hypercalcemia that
develops in patients with solid tumors but
without bone metastases is thought to be
caused by parathyroid hormone-related factor.

In HHM, patients secrete high levels of
parathyroid hormone-related protein but have
low or normal levels of 1,25-dihydroxyvitamin
D and normal intestinal absorption rates.
Osteoblastic and osteoclastic activities are
“uncoupled” so that bone resorption exceeds
bone formation. Hypercalcemia and
hypercalciuria thus occur. CNPP, Pages 1113–
1116.

Hypercalcemia symptoms are numerous,
vague, and nonspecific, and may be difficult to
distinguish from disease- or treatment-related
side effects. CNPP, Pages 1116–1118.

Patients with corrected serum calcium
concentrations of more than 14 mg/dL are
invariably symptomatic and the situation can
be life-threatening. Without proper
intervention, almost 50% of patients will die
because of renal failure, coma, or cardiac
arrest. CNPP, Page 1120.

Hydration, increasing fluid intake, forced
diuresis after rehydration, and bisphosphonate
therapy are all used to treat hypercalcemia.
Allopurinol blocks the conversion of xanthine
and hypoxanthine to uric acid and thus is used
to help prevent tumor lysis syndrome (TLS).

Nephrotoxicity is the most common side effect
of bisphosphonate therapy and patients
receiving these therapies require close
monitoring of renal function during treatment
and rigorous hydration. There are reports of
atypical femoral fractures in patients receiving
bisphosphonate therapy for osteoporosis.

Paraneoplastic hypercalcemia often presents
as confusion, disorientation, and
hallucinations. Mobilization and weight-
bearing exercise is encouraged to decrease
bone resorption. Thiazide diuretics decrease
renal excretion of calcium, which may
potentiate hypercalcemia and thus should be
avoided. CNPP, Pages 1121–1124.

Because shorter infusion times and higher
doses of bisphosphonates correlate with a
higher incidence of renal adverse events, doses
of zoledronic acid higher than 4 mg and
infusion times of less than 15 minutes are not
recommended. CNPP, Pages 1127–1128.

A malignant pericardial effusion is the most
common cardiac complication associated with
cancer and indicates a poor prognosis.
Malignant pericardial effusions are not easily
detected by routine tests because most
patients are asymptomatic. Often, clinical
manifestations are vague or attributed to other
causes. CNPP, Pages 1003, 1005; CSM, Pages
340, 343.

The signs and symptoms of cardiac tamponade
are variable and depend on the rate and
amount of pericardial fluid accumulation,
etiology of the tamponade, and the patient’s
age. If fluid accumulation occurs slowly, the
early signs may include tachycardia, fatigue,
nausea, vomiting, diarrhea, and shortness of
breath. CNPP, Pages 1076, 1080–1084; CSM,
Pages 342–343.

Lung cancer, breast cancer, and hematologic
cancers are the tumor types most commonly
associated with pericardial effusions and
cardiac tamponade. CNPP, Pages 1002, 1076–
1078; CSM, Pages 338–339.

Radiation therapy to the pericardium poses a
significant risk factor for the development of
cardiac tamponade. Small amounts of fluid in
the pericardium do not usually cause
symptoms related to cardiac tamponade.
Hyperkalemia and hyperuricemia are
electrolyte abnormalities associated with
tumor lysis syndrome (TLS). CNPP, Page 1078.

Two-dimensional echocardiogram is the most
sensitive and precise method for the diagnosis
of cardiac tamponade. Findings on
electrocardiography are nonspecific. A chest
radiograph is not a definitive diagnostic
method for cardiac tamponade. MRI has
limited usefulness in the diagnosis of cardiac
tamponade. CNPP, Pages 1003, 1084–1086.

Echocardiogram-guided pericardiocentesis is
the treatment of choice for patients with
cardiac tamponade and hemodynamic
compromise. Chemotherapy and radiotherapy
may be used for symptomatic relief of patients
with cardiac tamponade, but not when a
patient’s hemodynamic status is compromised.
Pericardiectomy is generally reserved for
patients with recurrent malignant pleural
effusions and an expected survival of 1 year or
more. CNPP, Pages 1088–1092; CSM, Pages
1041–1043.

Sclerosing agents are introduced into the
pericardial sac to create inflammation and
cause adhesions between the visceral and
parietal layers; these adhesions obliterate the
pericardial space, thereby preventing fluid
reaccumulation. CNPP, Pages 1089–1090;
CSM, Page 342.

Bleomycin, doxycline, and cisplatin are
chemotherapy drugs that are used as
sclerosing agents for the management of
recurrent cardiac tamponade. CNPP, Page
1189.

The most common side effects of sclerosing
agents include pain, fever, and arrhythmias.
Patients should be treated proactively for pain
prior to a pericardiocentesis with the
administration of sclerosing agents. CNPP,
Pages 1089–1090.

Pain is the most common presenting symptom
of a spinal cord tumor. Weakness is the most
readily identified objective finding and may
follow the appearance of sensory symptoms.
Specific sensory deficits depend on where the
tumor is on a cross section of the spine. A
lateral tumor affects pain and temperature,
causing numbness and tingling. Anterior
tumors lead to weakness and an
uncoordinated ataxic gait. CNPP, Page 1156.

Spinal cord compression is now referred to as
a skeletal-related event or a consequence of
bone metastasis, reflecting the fact that almost
90% of cases are due to involvement of the
vertebral column with metastatic disease.
67. Then answer is a.

Any cancer has the potential to cause spinal
cord compression, but of all cancer types,
breast, lung, and prostate cancers are the most
likely to do so. CNPP, Page 1154.

Weakness is the most readily identified
objective finding for spinal cord tumor and is
an indication that her lung cancer has spread
to her spine. Back pain is the most common
presenting symptom of spinal cord
compression. CNPP, Pages 1156–1158.

All patients with bone metastasis are at risk
for spinal cord compression. Urinary and
bowel incontinence are signs of autonomic
dysfunction and are poor prognostic signs, and
will not likely respond to radiation therapy.
The degree of neurological impairment prior to
initiating treatment is predictive of recovery
post-treatment. Worsening back pain,
weakness of the lower extremities, or sensory
deficits require immediate medical attention:
usually radiation therapy to control tumor
impingement on the spinal cord. CNPP, Pages
1156–1158.

Imminent spinal cord compression should be
suspected in individuals who have known bone
metastases, progressive back pain associated
with weakness, paresthesias, bowel or bladder
dysfunction, or gait disturbances. CNPP, Pages
1156–1159.
Obstruction of the SVC is a common
complication of lung cancer. Dyspnea is the
most common symptom. The clinical picture
can include edema of both eyelids, arms, and
hands; cough; and dilated collateral chest
veins. CNPP, Page 1190.

Increased venous pressure in the upper body,
resulting from the obstruction of the SVC,
reduces blood flow and determines the clinical
manifestations of SVCS. Initial symptoms of
SVCS include dyspnea; cough and stridor;
hoarseness; edema in the face, neck, and arms;
and neck and chest vein distention. Increased
venous pressure also results in hypertension.

Due to the increased venous pressure in the
upper body, the most common early signs of
SVCS include swelling of the head, neck, and
upper torso. Respiratory distress, stridor, and
cyanosis are late symptoms related to SVCS.
CNPP, Page 1190.

Radiation therapy is the treatment of choice
for SVCS caused by NSCLC because NSCLC
does not respond well to chemotherapy.
Radiation therapy is also the choice in patients
without a histologic diagnosis. CNPP, Pages
1192–1194.

Percutaneous placement of an endovascular
stent to bypass the obstruction provides rapid
relief of symptoms until the etiology is
determined. Surgical bypass has a limited role
in the management of SVCS and is used only
when other management techniques have
failed to relieve the symptoms of SVCS. CNPP,
Pages 1193–1194.

Lung cancer is responsible for more than 75%
of all cases of SVCS. Small cell carcinoma of
the lung is the most common histologic type,
followed by squamous cell carcinoma of the
lung. CNPP, Page 1188.

A malignancy in the mediastinal area causing
obstruction of upper venous blood return to
the heart is the most common cause of SVCS.
Thrombus from intravascular devices, thoracic
aortic aneurysm, and mediastinal fibrosis are
nonmalignant causes of SVCS. CNPP, Page
1188.

The most useful imaging for evaluating a
suspected SVCS is a CT with intravenous (IV)
contrast. PET may be done after a chest CT to
provide additional information on the extent
of the disease involvement in patients with
lung cancer or lymphoma. CNPP, Pages 1190–
1191.

Complete relief of symptoms related to SVCS
can be obtained in the majority of patients
with non-Hodgkin lymphoma with chemo-
immunotherapy. Multiagent or combination
chemotherapy is the standard. CNPP, Pages
1192–1193.

In most instances, the earliest indicator of
increased ICP is a change in the level of
consciousness and cognitive ability. Motor and
sensory function, vomiting, and vital sign
changes occur, but not early on. CNPP, Pages
1173–1174; CSM, Pages 441, 443, 447.

Headache is a common presenting symptom of
increased ICP. Decorticate and decerebrate
posturing, widening pulse pressure, and
increased systolic blood pressure are all signs
that occur late in the course of increased ICP.

Cushing’s Triad, seen in late stages of
increased ICP include irregular respirations,
systolic hypertension, and bradycardia. CNPP,
Pages 1173–1174; CSM, Page 441.

Increased ICP is commonly observed in
patients with primary brain tumors, central
nervous system lymphoma, and primary
leptomeningeal gliomatosis. CNPP, Page 1170;
CSM, Page 442.

In balancing ICP, autoregulation is the
mechanism that specifically maintains a
normal ICP, despite fluctuations in arterial
pressure and venous drainage. CNPP, Pages
1171–1172.

The most commonly used imaging technique
to evaluate ICP is a non-contrast CT scan. This
scan can rule out hemorrhagic bleed as an
etiology for increased ICP and can provide
preliminary information on the presence of
primary or metastatic masses or
hydrocephalus. CNPP, Page 1178; CSM, Page
447.

In situations in which ICP is acutely elevated,
corticosteroids and careful fluid management
are required. CNPP, Pages 1180–1181; CSM,
Pages 447, 449.

Raising the head of the bed to 30° acts to lower
ICP by improving jugular venous drainage.
Keeping the patient’s head in a neutral
position also promotes jugular venous
drainage. CNPP, Pages 1179–1180; CSM, Pages
446–447, 451.

Current evidence-based guidelines recommend
maintaining the cerebral perfusion pressure at
or above 70 mm Hg. Episodic dips below this
CPP will increase ICP. CNPP, Pages 1080–
1081.

A cystoscopy and bilateral retrograde
pyelogram are the most reliable diagnostic
tools for determining ureteral obstruction.
These exams can also determine whether the
obstruction is intrinsic to the ureter, or
extrinsic. CNPP, Page 1470.

Urinary stents can be inserted into the ureters
to establish patency and prevent further
compression by the tumor at the time of the
retrograde pyelogram. If the stents become
occluded, they can usually be changed via
cystoscopy. CNPP, Page 1470.

Although bowel obstruction can happen at any
time with colon cancer, it is more common and
may evolve more rapidly in patients with
advanced disease. CNPP, Page 1454.

The presence of foul-smelling fecaloid
vomiting can be the first sign of an ileal or
colonic obstruction. Biliary vomiting is almost
odorless and indicates an obstruction in the
upper part of the abdomen. CNPP, Pages 1454,
1457.

Signs and symptoms of bowel obstruction
include nausea and vomiting, abdominal pain,
and the absence of bowel sounds over the
affected area. CNPP, Pages 1454, 1457.

The initial usual treatment for symptom
control for a bowel obstruction is placement of
a nasogastric tube with decompression and
administration of hydration fluids. If the
obstruction continues for more than a few
days, a gastrostomy tube is a more acceptable
and better tolerated route for decompression.
CNPP, Page 1457.

Late effects of total body irradiation include
pneumonitis and fibrosis, decreased growth
and development in childhood survivors,
gonadal dysfunction and infertility,
development of cataracts, and development of
secondary malignancies. CNPP, Page 370.

Pneumonitis may be associated with the
following agents given as part of the
preparative regimen for stem cell transplant:
etoposide, fludarabine, and mitoxantrone.

Radiation pneumonitis is an inflammatory
response to the lungs due to radiation injury to
the lung tissue. It presents as a delayed
response to the treatment from 2 weeks to 6
months after completion of therapy. Patients
will often complain of shortness of breath and
a nagging cough related to pneumonitis. CNPP,
Page 1702.

If radiation pneumonitis is suspected, steroids
are the treatment of choice and are often
effective almost immediately upon
administration. CNPP, Page 1702.

Cytarabine is considered to be a non-irritant
drug if it extravasates outside of the vessel
wall. CSM, Page 542.

Doxorubicin is considered to be a vesicant,
which can cause tissue damage if it
extravasates outside of the vessel wall. CNPP,
Pages 437, 477; CSM, Pages 541–542.
Risk factors for the development of
extravasation include patient related factors,
procedural factors, and equipment/material
factors. A significant patient related factor
includes small, fragile veins. CNPP, Page 436;

Pain, swelling, and induration at the insertion
site of a doxorubicin infusion are indicative of
an extravasation of the doxorubicin. These
symptoms can intensify over time. CNPP,
Pages 438–440; CSM, Pages 545–547.

Vesicants may be administered as a
continuous vesicant, but only through a CVAD.
Blood return should be checked by aspirating
with a syringe at the port closest to the patient,
and the dressing over the CVAD insertion site
should be transparent. CNPP, Pages 436–438;

Extravasation can occur with the use of a
CVAD. Thereby, a nurse should teach a patient
receiving a continuous infusion of a vesicant
to notify the nurse or other healthcare
clinician if they experience any pain, burning,
leaking, or other changes in sensation at the
infusion site. CNPP, Pages 438–440; CSM,
Pages 547–548.

Common symptoms that are indicative of an
extravasation include pain, burning or a
stinging sensation at the insertion site,
redness in the area of the venipuncture site,
and swelling. Blood return is not present in
most cases of extravasation. CNPP, Page 438;

When an extravasation is suspected it is
critical to always stop the infusion
immediately. Once the infusion is stopped,
then disconnect the IV tubing from the IV
device, attempt to aspirate residual fluid from
the IV device, remove the peripheral IV device
or port needle, and assess and treat suspected
extravasation. Treatment may include
administration of medication antidotes,
depending on the drug that has extravasated.
CNPP, Pages 437, 440; CSM, Pages 548–549.

Dexrazoxane is administered intravenously as
three 1- to 2-hour infusions if an extravasation
of an anthracycline is suspected. CNPP, Pages
436–438, 440; CSM, 549–551.

Hyaluronidase is administered as 5 separate
injections if an extravasation to a plant
alkaloid, including vincristine, is suspected.

After treating the vincristine-related
extravasation with the appropriate medication
antidote, the nurse should apply warm packs
for 15 to 20 minutes at least 4 times per day
for 24 to 48 hours, and should then elevate the
area for 48 hours to minimize swelling. CNPP,
Pages 436–438; CSM, Pages 548–550.
CHAPTER 6
Psychosocial Dimensions of
Cancer Care
A. CULTURAL, SPIRITUAL, AND RELIGIOUS
DIVERSITY
1. Respect for cultures other than one’s

own and for people’s specific beliefs and
behaviors that emanate from their
cultural background is known as:
1. Multiculturalism
2. Cultural sensitivity
3. Ethnoculturalism
4. Developing rapport
2. As you plan your interventions for

assisting a family on the imminent death
of a loved one, you consider the
following approach in your plan of care:
1. You will assess their coping mechanisms
during a family conference after the
patient’s death.
2. You will review the patient and family
assessment after the patient’s death to
discern what is important for the family
and determine their needs.
3. You will be aware of the family’s cultural,
social, and religious requirements related
to the death and aftercare of their loved
one.
4. You will begin preparations for
bereavement support.
3. Afterdeath care includes preparing the

body so that loved ones can see the
patient in as natural a state as possible.
Your major consideration in afterdeath
care for Mr. Smith, a practicing Muslim,
is:
1. Not moving the body for several hours to
allow the spirit to leave without becoming
confused
2. Provide immediate postmortem care.
3. Allow the family to clean and redress the
patient.
4. Assign a male nurse to clean and redress
the patient.
4. Spirituality refers to that dimension of

being human that:
1. Represents and expresses one’s life
principles
2. Is one of the most important components
of quality of life, at the end of life
3. Involves reviewing and reflecting
systematically about right conduct and how
to live as a good person
4. Represents one’s religion and world beliefs
5. Regardless of one’s beliefs about

religion, studies have shown which of the
following activities is most directly
correlated with spiritual well-being?
1. Church-related activities
2. Meditation
3. Prayer
4. Spiritual imagery
6. Helping patients find meaning in cancer

through spirituality is best accomplished
by which of the following?
1. Help patients to accept their diagnosis and
prognosis.
2. Support patients to find meaning amidst
their illness.
3. Counsel patients and families to find
spiritual support.
4. Promote religiosity among patients and
families.
7. Research into spirituality and death

reveals many aspects of the relationship
between spiritual issues and preparation
for death. Which of the following is the
best assumption regarding spirituality
and preparation for death?
1. Greater spiritual quality at life’s end is
associated with dignified dying.
2. The closer individuals get to death, the
more they will become aware of personal
spirituality.
3. Individuals with advanced cancer who
believed in divine intervention were more
apt to have an advanced directive.
4. Religious or spiritual coping was associated
with less need for life-sustaining measures.
8. Mr. Allen is distressed over his wife’s

apparent anger and rejection of God due
to the recent discovery that her breast
cancer has recurred. Your efforts to
counsel him are based on which of the
following cognitive strategies?
1. Individuals assume that traumatic events
such as cancer strengthen one’s belief that
there is meaning and worth.
2. Individuals whose world is shattered will
work to reconstruct their world view so
that it includes a rationale for God’s
failings.
3. Individuals use strategies such as making
comparisons to another situation to make
the event meaningful.
4. The nurse helps to construct for the
individual a possible meaning for this
event.
9. Spiritual distress is best defined by which

of the following components?
1. A disturbance in the belief or value system
that provides strength, hope, and meaning
to life
2. Negative religious coping
3. Changes in spiritual practices
4. No interactions with family and friends
10. Individuals who are at risk for spiritual

distress are:
1. Older adults with cancer
2. Younger adults with cancer
3. Newly diagnosed patients
4. Patients whose religious beliefs provide
meaning
11. In evaluating a patient’s journey through

spiritual distress, the nurse must
consider the following:
1. She will be able to assist the patient to
overcome spiritual distress through
empathic listening and allowing the patient
to discuss spiritual concerns.
2. She will be able to assist the patient by
discussing difficulties praying and help
them to reflect on coping abilities.
3. She will have no control over the patient’s
outcome of spiritual distress.
4. She will complete the assessment for
spiritual beliefs and practices required by
The Joint Commission and refer results to
the chaplain or patient’s clergy.
12. Although it is true that oncology nurses

hold diverse perspectives about
challenging issues such as palliative
sedation, nurses’ attitudes regarding
end-of-life decisions and participation in
palliative sedation are most significantly
influenced by which of the following?
1. Professional integrity
2. Sanctity of life
3. Personal religious beliefs
4. Patient autonomy
13. Research has demonstrated that when

confronted with a life-threatening
illness, spirituality helps patients to
accomplish which of the following before
dying?
1. Define the role of religion in their lives.
2. Find a sense of meaning despite the illness.
3. Find trust in their caregivers.
4. Confirm their belief in a higher power.
B. FINANCIAL CONCERNS
1. The Patient Protection and Affordable

Care Act (PPACA) represents a major
opportunity for:
1. Disease prevention and enhancement of
public health
2. Achievement of universal health coverage
3. Coverage of costs for patients entered on
clinical trials
4. Decreased cost of health insurance
2. The Patient Protection and Affordable

Care Act (PPACA) covers:
1. Treatment for obesity
2. Tobacco cessation counseling
3. Coverage of costs for patients entered on
clinical trials
4. Nutrition counseling
3. Research indicates the risk of incurring a

financial burden is:
1. High for spouse caregivers of cancer
patients
2. High for spouse caregivers of patients with
a chronic condition
3. High for caregivers of patients with stage I
disease
4. High for caregivers of patients with
continuing phase of cancer treatment
4. Mr. Jones requires a hematopoietic stem

cell transplant (HSCT), however, he is
concerned about costs as he is not sure
his insurance will cover this procedure.
Your best response is:
1. An insurance evaluation must occur and a
member of the healthcare team will assist
with this evaluation.
2. If he doesn’t have insurance, he will not be
able to have a HSCT.
3. He must raise his own funds for the HSCT
if the insurance doesn’t cover his HSCT.
4. It is common for institutions to provide
care at a capitated fee regardless of actual
cost incurred.
5. The Family Medical Leave Act of 1993

guarantees:
1. All states to provide a cash allowance to
persons who are eligible for Medicaid’s
personal care benefit so they can purchase
their own care or hire friends or family to
provide care
2. Unpaid leave to a family member to care
for a spouse, son, daughter, or parent
3. Payment for family members to provide
care to a spouse, son, daughter, or parent
terminally ill with cancer
4. Payment for a family member to relocate to
a geographical area closer to the patient to
accommodate for caregiving
responsibilities
C. ALTERED BODY IMAGE
1. Most empirical studies dealing with the

relationship of cancer to body image and
quality of life have focused on:
1. The total self-appraisal of cancer patients,
both men and women
2. The effects of various treatments on
relationships of cancer patients with
significant others
3. Women with gynecologic or breast cancer
or males with testicular or prostate cancer
4. The interaction of variables such as age,
depression, and activity status on the
psychosocial aspects of sexual health
2. Albert is about to undergo chemotherapy

with a regimen that includes
cyclophosphamide, doxorubicin,
vincristine, and prednisone, and is
known to cause significant hair loss.
Which of the following will be part of
your patient education plan for Albert?
1. Chemotherapy-induced alopecia occurs
slowly and may not occur for several
months after the treatment.
2. Once chemotherapy is complete, regrowth
is visible in 4–6 weeks.
3. Mild hair loss is associated with this
regimen.
4. In situations involving very high doses of
alkylating agents, it may take more than 2
years for regrowth.
3. Following four courses of chemotherapy,

Albert shows you that his fingernails
have developed transverse white lines or
grooves. You explain to Albert that this
symptom:
1. Is a response to cyclophosphamide because
pigmentation has been deposited at the
base of the nail
2. Indicates a reduction or cessation of nail
growth in response to cytotoxic therapy
3. Reflects a cytotoxic reaction to
cyclophosphamide
4. Is a partial separation of the nail plate
called onycholysis and is a reaction to
fluorouracil (5-FU) therapy
4. Because of the staging of her cancer, the

size of the tumor, and a number of other
factors, Marcia will undergo immediate
breast reconstruction after her surgery.
Her surgeon has explained that the
procedure most likely to be used in her
case is the transverse rectus abdominis
(TRAM) flap. You explain to Marcia that
this will involve removing tissue from
her and tunneling it to the
mastectomy site.
1. Abdominal muscle
2. Latissimus dorsi muscle
3. Lower abdomen
4. Buttocks
5. Sally asks you if there is anything she can

do to prevent hair loss with
chemotherapy. Which of the following
would be an appropriate response?
1. Use a hair dryer on a low setting after
shampooing.
2. Use Minoxidil, an oral active vasodilator.
3. Use vitamin D to help prevent hair loss.
4. Use only protein-based shampoos and
conditioners and avoid daily shampooing.
6. A woman with breast cancer is being

treated with six courses of intravenous
(IV) docetaxel, doxorubicin, and
cyclophosphamide. She is very upset
about the possibility of losing her hair.
The most appropriate response to her
concerns regarding hair loss would
1. Reassure her that although she will have
significant hair loss, it will grow back.
2. Assure her that it is likely she will not lose
any hair at all.
3. Inform her that hair loss is gradual over
the next 2 months, and she will require a
wig sooner rather than later.
4. Let her know that her hair will likely thin,
but she will probably not require a wig.
7. A patient being treated with radiation to

an abdominal field is concerned about
hair loss that she expects to experience
following radiotherapy. You can best
reassure her by telling her that:
1. Hair follicles are relatively radioresistant
due to their low rate of growth and mitotic
activity.
2. Radiation response is seen mostly in
tissues and organs that are within the
treatment field.
3. Alopecia is permanent only when radiation
is administered in low doses over an
extended period of time.
4. Alopecia is more closely associated with
brachytherapy than with teletherapy.
D. LEARNING STYLES AND BARRIERS TO
LEARNING
1. Susan has been assigned to teach

nursing students the importance of
family caregivers. As a part of her class,
she reviews the key reasons why families
of patients with cancer need help and
support. Of the reasons below, which is
the most important reason that they
need support?
1. They lack preparation for the complex care
that they are expected to provide.
2. To reduce the burden of care and help them
maintain their well-being
3. Long-term care is most often provided in
the home by family caregivers.
4. Lack of effective professional–family
communication in healthcare settings
2. Which of the following strategies for

designing an effective culturally sensitive
patient program is most important?
1. Prepare the program and materials at a
fifth-grade reading level.
2. Evaluate the cultural aspects of the needs
of family members for program
development.
3. Present the program to nursing colleagues
for their advice and support.
4. Prepare programs and materials that are at
a comprehension level and culturally
appropriate for the patient audience.
3. Helen is preparing to review treatment

options with a patient who speaks only
Spanish. Helen speaks only English. If
given a choice, Helen will probably want
to choose the use of:
1. A professional interpreter
2. A family member as interpreter because
the family is an integral part of treatment
delivery and involvement in most Hispanic
cultures
3. A friend as interpreter because of the
emotional support friends lend in a
Hispanic extended-family social structure
and because a friend is more likely than
family to relay the complete message
4. Any of the above, as long as the interpreter
is fluent in both languages
4. The most common means of reducing
uncertainty for patients and their family
members is:
1. Providing preparatory information and
education
2. Referring them to a professional therapist
3. Protecting the individual from all negative
information
4. Encouraging them to maintain an
optimistic outlook
5. Research concerning cognitive changes

associated with systemic cancer
treatment demonstrates that people who
received systemic cancer treatment
demonstrated impairment in which of
the following areas?
1. Information processing
2. Spatial skill
3. Verbal memory
4. Attention deficit
E. SOCIAL RELATIONSHIPS AND FAMILY
DYNAMICS
1. The basic unit of society is the:

1. Family
2. Social structure
3. Religious structure
4. Relationship of ethnicity and culture to
role assignment
2. During the initial family assessment,

which of the following is most likely to
be considered during the evaluation?
1. What are the health and religious beliefs of
the family?
2. Who is the primary family caregiver?
3. What are the social obligations of family
members?
4. Does the family have a history of physical
or mental health problems?
3. On conducting a family assessment, the

nurse identifies conflict among the
family members caring for the patient.
Upon inquiry, the nurse learns that the
conflict is “not new” and has existed “for
years.” Using this information, the nurse
establishes a plan of care that:
1. Attempts to change the behavior among the
family members because the patient is
upset by the conflict
2. Involves having psychological services
counsel the “conflicting members”
3. Schedules family meetings about how the
conflict is affecting the patient and what
can be done to resolve it
4. Is sensitive to the feelings of the members
in conflict but does not attempt to treat the
causes of the conflict
4. The psychosocial dimension of cancer

care focuses on both the unique needs of
the individual at risk for or with cancer
and the:
1. Unique needs of other individuals in
society
2. Clinical training of healthcare professionals
3. Social groups affected by that individual
4. Role of specific therapies in cancer
treatment
5. Which of the following strategies

influence an individual’s capacity to
adjust and adapt to a cancer diagnosis?
1. Family-level teaching with respect to the
disease, treatment, rehabilitation, and/or
prognosis
2. Anticipatory guidance, positive reframing,
and planning
3. Mobilization of community resources such
as support groups
4. All members of the individual’s support
system
F. COPING MECHANISMS AND SKILLS
1. Deterioration in communication
patterns between individuals with cancer
and their family is most predictable
under which of the following
circumstances?
1. When the cancer is first diagnosed
2. When the individual is reluctant to discuss
prognosis
3. When the professionals give most
information to the patient and not the
family
4. When professionals give more information
to the family than the patient
2. Which of the following nursing action is

most effective with cancer patients
experiencing anxiety?
1. Helping the patient learn new coping
strategies through anxiety-reducing role
playing
2. Helping the patient focus on the perceived
threat and appraise the stimuli in a
different way, thus reducing anxiety
3. Helping the patient identify stimuli that
have resulted in a loss of self-esteem
4. Therapeutic communication and
assessment
3. You are working with Mr. Jones and his

family, who have just discovered not only
that his lung cancer has recurred, but
also that it is terminal this time. Which is
likely to be true regarding the
psychosocial needs of Mr. Jones and his
family?
1. When coping with a difficult disease like
lung cancer, it is the discovery of meaning
in the disease that gives one a sense of
mastery.
2. His family is likely to develop depressive
symptoms and will need appropriate
interventions.
3. Often the fear of dying is not as profound
as the fear of suffering in the process.
4. Patients who are allowed to indulge
excessively in expressing their fears,
concerns, and wishes regarding death are
more prone to morbid depression.

effective coping and healthy lifestyle
behavior is true?
1. Use of denial or behavior disengagement as
coping strategies is associated with a
poorer psychological well-being.
2. Psychosocial responses to cancer can be
clearly identified as either adaptive or
maladaptive.
3. A perception of uncertainty in a situation
results in an appraisal of danger.
4. Distancing behaviors of health
professionals are helpful in preventing
overinvolvement.
5. Which of the following statements most

accurately describes the relationship
between family responses to a diagnosis
of cancer and the responses of patients
themselves?
1. Family responses are similar to patient
responses.
2. Responses of anxiety and depression are
less common among family members than
among patients.
3. Responses of hopelessness and altered
sexual health are less common among
family members than among patients.
4. Family responses generally are not similar
to patient responses.
G. SUPPORT
1. It is not uncommon for the spouse of a

patient with cancer to be unwilling to
discuss his or her concerns with the
patient because of fears that it might be
distressing to the patient. This type of
communication is referred to as:
1. Privileged communication
2. Filtered communication
3. Balanced communication
4. Protective buffering communication
2. Levels of social support have been

associated with individual coping
capabilities. The most beneficial finding
of studies on social support for patients
with cancer is:
1. Attendance and use of support groups
2. Cognitive-emotional therapy and relaxation
therapy
3. Opportunity to discuss thoughts and
feelings with an attentive, empathetic,
professional listener
4. Supportive-expressive group therapy
43. There are barriers that can limit family
members’ ability to obtain information
and support from nurses and other
health professionals. The most common
barrier is:
1. Lack of clarity about who is responsible for
helping family members
2. Lack of value placed on the support of the
family in the care of the patient
3. Lack of effective professional–family
communication
4. Lack of time and the constraints that exist
in the healthcare system
44. When providing support for Ms.

Wiggins, a 47-year-old African
American, who was just diagnosed with
breast cancer, which of the following
considerations is most important?
1. The woman of the family is generally
charged with the responsibility for
protecting the health of family members.
2. The family assumes the responsibility for
making treatment decisions on the
patient’s behalf.
3. Patients may not give consent for
treatment until permission is obtained
from the mother or grandmother.
4. The nuclear family is very important, and
men assume dominant roles and decision-
making.
45. Problems that patients with cancer

experience, such as anxiety and
depression, can be reduced through:
1. Counseling
2. Referral to a mental health professional
3. Participation in support groups
4. Pharmacologic management
46. Patient education along the cancer

continuum should be individualized
based on:
1. The type of information available by the
healthcare provider
2. The patient’s IQ level of understanding
3. The patient’s learning style
4. The patient’s socioeconomic and reading
level
47. Research has shown that African

American breast cancer survivors valued
support groups that considered:
1. Their specific type of cancer they were
living with
2. Involvement of their family unit
3. Providing counselors in addition to the
support group
4. Their cultural, socioeconomic positions,
with emphasis on spirituality and religion
H. PSYCHOSOCIAL CONSIDERATIONS
48. Depression can be a short-term or long-

term effect for patients with cancer and
responses to a perceived loss of self-
esteem may be affective, behavioral, or
cognitive. Which of the following is an
example of a behavioral response
associated with depression?
1. Lack of energy
2. Guilt
3. Indecisiveness
4. Suicidal ideation
49. A 68-year-old woman recently diagnosed

with metastatic cancer confesses that she
has no one to talk to and feels extremely
depressed. She has a history of
depressive disorder but is currently not
taking any medication. Which of the
following is a diagnostic criteria for
major depressive disorder?
1. Disorientation, impaired memory, rapid
heartbeat, elevated blood pressure
2. Impairment in social functioning
3. Recurrent thoughts of death or suicide
4. Emotional symptoms in response to a
stressor (e.g., treatment)
50. Cancer patients who are most likely to

exhibit psychosocial distress are:
1. Those who have been successful in
resolving past stress situations
2. Those who are dealing with stressors
simultaneously
3. Those who receive minimal support from
the healthcare team
4. Those who cope principally through
adaptive defense mechanisms
51. Your patient seems detached from

decision-making and tends to shy away
from social situations. He says he is
depressed regarding his diagnosis. After
talking to him for a while about this, you
conclude that which of the following
could be an appropriate approach to
management?
1. Pharmacologic intervention for his
depression is a logical approach.
2. Reassure him that depression is expected
and will improve with time without
medication.
3. Ignore his symptoms because talking about
it could make it worse.
4. Encourage the doctor to place him on
suicide precautions.
52. Unlike anxiety and depression, which of

the following statements is true of
hopefulness as a response of patients to
the cancer experience?
1. It involves a combination of affective,
behavioral, and cognitive responses.
2. It has not been implicated in the
development of cancer or in the quantity
and quality of life after diagnosis of cancer.
3. It can be clearly distinguished from other
similar concepts using the accepted
defining characteristics.
4. It has been associated with a higher quality
of life.
53. What is one major reason that a

diagnosis of depression among patients
with cancer is often complicated?
1. Some cancer patients had preexisting
depressive symptoms before the diagnosis
of cancer.
2. Instruments have yet to be developed to
measure depression among cancer patients.
3. Symptoms of depression are often identical
to those of anxiety.
4. The signs and symptoms of cancer are
markedly different from those of
depression.
54. A nursing intervention for the treatment

of patients with cancer-related distress
that deals with the patient’s affective
responses is:
1. Negotiating goals for increasing
independence in self-care and decision-
making
2. Giving permission to safely discuss
thoughts and feelings
3. Contracting short-term goals of care that
the patient can achieve
4. Encouraging physical mobility
55. Laryngectomy patients have been

reported to be at increased risk of
psychosocial stressors, depression, and
suicide. A major reason for this is which
of the following?
1. Functional impairment of chewing and
swallowing
2. Speech intelligibility
3. Mobility disorders
4. Inability to cope with day-to-day living
56. For the person with cancer who is

experiencing anxiety, which of the
following interventions is most
commonly used?
1. Problem-focused or emotion-focused
coping strategies
2. A prescription for an antianxiety agent
3. Relaxation tapes and exercises
4. Referral to a psychiatrist specializing in
behavioral disorders
57. Which of the following symptoms is

diagnostic of anxiety in the person with
cancer?
1. Anorexia
2. Weight loss
3. Fatigue
4. Restlessness
58. Anxiety is defined operationally as an

increased level of arousal associated with
vague, unpleasant, and uneasy feelings
that occur in response to a perceived
threat. What is the source of this
perceived threat?
1. A nonspecific external stimulus
2. A specific external stimulus, often a
physical threat
3. A nonspecific internal or external stimulus
4. A specific internal stimulus, usually pain or
inflammation
59. Why are cognitive and behavioral

techniques such as hypnosis,
biofeedback, progressive muscle
relaxation, or music therapy helpful in
the treatment of anxiety related to
cancer?
1. These techniques restore or enhance a
sense of self-control.
2. They provide temporary emotional
distraction from the reality of the situation.
3. Channeling anger makes it less
threatening.
4. Cognitive techniques promote effective
denial.
60. As an individual patient with cancer

faces imminent death, certain losses and
changes are experienced. The
individual’s response to these losses and
changes is usually due to which of the
following?
1. Search for immortality
2. Search for meaning
3. Search for acceptance
4. Search for forgiveness
61. In a discussion of the patient’s prognosis

for which the patient has requested, the
patient and her husband begin to sob
softly. Your most appropriate nursing
action would be which of the following?
1. Ask them if you have said something that is
upsetting to them.
2. To facilitate hope, you encourage them not
to cry because there are options available
and describe what those are.
3. Stop talking, temporarily allowing them to
express their grief.
4. Reschedule the appointment because they
are not prepared for what you have to say.
62. On his most recent visit, your patient,

who is suffering from lung cancer,
appears anxious but denies difficulty
breathing. He complains of inability to
sleep and believes this is due to
depression related to his illness. The
most appropriate pharmacologic
intervention for him might be which of
the following?
1. Chlordiazepoxide (Librium)
2. Selective serotonin-norepinephrine
reuptake inhibitors (SSNRIs)
3. SSNRI plus a short-acting benzodiazepine
4. Lorazepam (Ativan)
63. Which of the following individuals are at

higher risk for depression?
1. Men with prostate cancer
2. Women with breast cancer who were
abused as a child
3. Young adult with testicular cancer
4. Patient with altered immune system
64. When assessing patients for depression,

it is important to be aware of certain
misconceptions regarding psychological
distress in the patient with cancer.
Which of the following statements is a
myth and unsubstantiated by empirical
data?
1. Depression is a natural by-product of the
cancer experience.
2. Patients with cancer hide their negative
emotions to protect their family.
3. Obtaining psychological counseling is
regarded by cancer patients as an indication
of their inability to cope.
4. Depression affects the course of cancer by
increasing morbidity and hospital stays.
65. When screening for depression in

individuals with cancer, which of the
following questions has the highest
sensitivity and specificity for correctly
identifying depression?
1. “Are you depressed most of the day nearly
every day?”
2. “Have you lost interest in all or almost all
activities?”
3. “Do you often feel sad or low?”
4. “How is your distress on a scale of 0 to 10?”
66. A person who experiences cancer-related

symptoms processes information about
these symptoms in which of the
following ways?
1. By evaluating the symptom and obtaining
feedback
2. Cognitively and emotionally
3. Intellectually and socially
4. By its presentation and controllability
67. Which of the following “directions”

provides patients who are at risk for loss
of decision-making ability the best
chance of having their healthcare wishes
carried out?
1. Power of attorney for health care
2. Verbal instructions to the attending
physician
3. A living will
4. A do-not-intubate/ventilate order on
admission
68. Mr. Jones has completed his treatment

and expresses a reluctance to return to
work because he feels concerned about
what others may think about his
diagnosis of cancer. Your best advice to
him is:
1. Consider legal action if he is discriminated
against.
2. Keep a diary of any objectional events that
occurred.
3. Talk to your supervisor or human
resources manager to be sure they know
you have cancer.
4. Contact cancer survivor organizations for
advice.

regarding decision-making in reference
to treatment decisions is correct?
1. Patients who take a passive role in making
the final selection of treatment cope better
with side effects.
2. Patients who actively participate in
decisions have improved function, sense of
well-being, and perform effective self-care.
3. Patients whose family controls decision-
making have improved quality of life.
4. Patients who allow the physician to make
the final treatment decisions have
improved quality of life.
70. Your patient states “A small part of me

died when I was diagnosed with cancer.”
What type of grief is this patient
exhibiting?
1. Anticipatory grief
2. Preparatory grief
3. Complicated grief
4. Prolonged grief
71. Complementary therapies are widely

used by patients with cancer, but the role
of complementary approaches in
managing depression is limited. Of the
interventions below, which is likely to be
effective for depression based on weight
of evidence evaluated by the Oncology
Nursing Society?
1. Reiki
2. Massage
3. Relaxation therapy
4. Exercise
I. SEXUALITY
72. According to research, the ability to

conceive or father a child after stem cell
transplantation is most likely to be
related to which of the following?
1. Initial treatment for the cancer
2. Whether or not total body irradiation is
used
3. The use of colony-stimulating factors
4. The presence of graft-versus-host disease
73. Your patient, Melissa, is beginning her

treatment for osteogenic sarcoma and is
concerned that the chemotherapy and
radiation therapy might cause congenital
abnormalities in her future offspring. An
appropriate response would include
1. Explain that she should be thinking about
her own situation instead of dwelling on
what might never be.
2. Explain that this is a legitimate concern,
and reassure her that research has found
no higher incidence of congenital
malformation in the children born of
women who have had treatment for cancer
than in the general population.
3. Explain that it is difficult to answer her
question because there is a much higher
incidence of miscarriage in women who
have been treated for cancer.
4. Explain that you understand how she feels,
and refer her for genetic counseling.
74. While teaching your 41-year-old female

patient about the side effects of high-
dose chemotherapy, she asks you about
the possibility that she may become
menopausal. Your discussion is based on
which of the following research findings
regarding risk of menopause as it relates
to high-dose chemotherapy?
1. Because the treatment is dose dense,
lasting only 9 weeks, she is not likely to
experience permanent menopause.
2. High-dose chemotherapy is associated with
a high rate (90%) of ovarian failure.
3. She has a 55% risk of permanent
menopause.
4. Data are not available to address this issue
with certainty.
75. Your 36-year-old patient with testicular
cancer is completing a course of curative
chemotherapy and begins to inquire
about his ability to father children, and
whether or not they might have a higher
risk of birth defects as a result of his
treatment. Your most appropriate
response would include which of the
following?
1. Men with azoospermia immediately after
chemotherapy will not recover a sperm
count.
2. Chromosomal abnormalities have been
observed in survivors and could result in
miscarriages or still births, so he should
not pursue fathering a child.
3. It is recommended that men wait at least 6
months after the end of cancer treatment
before attempting to conceive children.
4. It is recommended that men wait at least 2
years after the end of cancer treatment
before attempting to conceive children
because most recurrences occur in that
time period.
76. After 18 months of intensive

chemotherapy, a 32-year-old woman
with breast cancer reveals to you her
concern regarding the effects of cancer
chemotherapy on her future children.
Your counsel to her would include which
of the following?
1. There has been an increased incidence of
birth defects in the offspring of women
previously treated with chemotherapy.
2. There has been an increased risk of first
pregnancy miscarriages.
3. There has been no increased risk of
nonhereditary cancers among offspring.
4. There has been an increased risk of
hereditary cancers among offspring.
77. Both chemotherapy and radiation

therapy are known to have teratogenetic
effects on the fetus, causing spontaneous
abortion, fetal malformation, or fetal
death. These complications are most
likely to happen during which trimester?
1. First
2. Second
3. Third
4. The risk to the fetus is equal among the
three trimesters.
78. Janie is 7 months pregnant and has

recently had a lumpectomy for breast
cancer. She is scheduled to begin
chemotherapy followed by radiation. She
is debating whether to start her
chemotherapy or delay it until after she
has her baby. She is concerned about the
effect of the chemotherapy on her baby.
Your comments and counsel are based
on which following statement regarding
the effect of chemotherapy on a
developing fetus?
1. Chemotherapy during the second and third
trimesters does not cause premature birth
or low birth weights.
trimesters is not associated with a higher
incidence of congenital abnormality
compared with the normal pregnancy
incidence.
trimesters is associated with a higher
incidence of congenital abnormality
compared with the normal pregnancy
incidence.
4. Alkylating agents and antimetabolites are
not associated with fetal malformations
during the third trimester.
79. The fertility of which of the following
patients is most likely to be affected by
chemotherapy?
1. Kevin, who is 7 years old
2. Dan, who is 60 years old
3. Pamela, who is 15
4. Elaine, who is over 30
80. What is the best advice you would give to

the cancer patient who becomes
pregnant?
1. Most cancer treatments do not adversely
affect a pregnancy.
2. In general, pregnancy may adversely affect
the outcome of your cancer.
3. Therapeutic abortion has been shown to be
of benefit in altering disease progression.
4. Treatment options will be evaluated as
though you were not pregnant, and therapy
instituted when appropriate.
81. Invasion of a cervical carcinoma into

underlying tissue is found in a woman
during the third trimester of her
pregnancy. Which of the following
treatments is most likely to be followed?
1. Fetal viability is awaited, and appropriate
therapy is given after delivery of the baby
by cesarean section.
2. Surgery or radiation therapy, without
therapeutic abortion, is undertaken
immediately.
3. A radical hysterectomy and pelvic node
dissection are performed and combined
with radiation therapy.
4. Therapeutic abortion is performed
immediately and followed by standard
treatment for advanced disease.
82. Evaluation of the placenta for evidence

of metastasis to the fetus is most likely to
be carried out under which of the
following situations?
1. When the mother has received
combination chemotherapy during the
third trimester of pregnancy
2. When the mother has received low doses of
radiation during the first trimester of
pregnancy
3. When the mother has breast cancer or
invasive cervical cancer
4. When the mother has melanoma
83. Which of the following is most likely to
involve risk to the fetus whose mother is
being treated for cancer?
1. Pelvic surgery on the mother during the
second trimester of pregnancy
2. Low doses of radiation associated with
diagnostic x-rays
3. Chemotherapy during the first trimester of
pregnancy
4. The use of anesthetic agents during surgery
on the mother during the second trimester
of pregnancy
84. In a support group you are conducting

for expectant mothers with breast
cancer, the following question is raised:
“How likely is cancer to spread from the
mother to the fetus?” You explain that
only a few cancers spread from the
mother to the fetus. Which among the
following cancers mentioned by the
group is most likely to spread from the
mother to the fetus?
1. Cervical
2. Non-Hodgkin lymphoma
3. Ovarian
4. Breast cancer
85. Methods have been identified that may
preserve fertility during cancer
treatment. The best method to
recommend is:
1. Treatment of men with gonadotropin-
releasing hormone (GnRH) analogs
2. Treatment of women with GnRH analogs
3. Shielding of the testes or ovaries from the
radiation field
4. Birth control pills for women
86. The American Society of Clinical

Oncology developed recommendations
for fertility preservation for women with
cancer. A standard of care recommended
for women is:
1. Ovarian tissue cryopreservation
2. Ovarian tissue transplantation
3. Embryo and oocyte cryopreservation
4. Gonadotropin-releasing hormone (GnRH)
analogue ovarian suppression
87. For patients who undergo surgery for

gastrointestinal cancer, possible organic
sexual dysfunction is most closely
associated with which of the following?
1. Placement of a colostomy
2. Removal of rectal tissue
3. Changes in body image
4. Responses by family and friends
88. Assessment of a patient’s alteration in

sexual function includes information
regarding medical, psychologic, and
psychosexual status. One method for
assessing sexual dysfunction includes
the use of the ALARM model. ALARM is
an acronym for which of the following?
1. Assess, Learn, Arousal, Relearn, Medical
data
2. Assess, Libido, Activity, Relearn,
Meditation
3. Activity, Libido, Arousal, Resolution,
Medical data
4. Arousal, Libido, Action, Resolution,
Meditation
89. Which of the following has been

implicated in sexual dysfunction in both
men and women receiving
chemotherapy?
1. Depletion of the germinal epithelium
2. Treatment with estrogens
3. Combination chemotherapy, including an
alkylating agent
4. Treatment with androgens
90. Marcia, a patient of yours, will be

starting chemotherapy with gemcitabine
and cisplatin in 2 weeks. She asks you to
explain to her the risks and side effects of
chemotherapy that may affect her sexual
function. You explain to her that she
may experience the following as a result
of her chemotherapy:
1. Vaginal dryness
2. Irregular menses
3. Decreased libido and ovarian dysfunction
4. Hot flashes and night sweats
91. The traditional radical prostatectomy

results in:
1. Permanent erectile dysfunction
2. Impaired ability to experience a normal
orgasm
3. Decreased libido and loss of testosterone
4. The loss of antegrade ejaculation and
infertility
92. The most common sexually transmitted

disease (STD) in the United States is:
1. Hepatitis A virus (HAV)
2. Hepatitis B virus (HBV)
3. Human papillomavirus (HPV)
4. Human immunodeficiency virus (HIV)
93. Premature menopause is one of the most

common complaints of cancer survivors.
Research related to induced early
menopause is showing:
1. An increased risk of premature morbidity
and mortality
2. An increased number of survivors seeking
sexual counseling
3. An increased number of survivors taking
hormonal therapy
4. An increased number of survivors
undergoing hysterectomy and being placed
on hormonal therapy
94. In breast cancer survivors, 50% to 75%

have sexual dysfunction related
to .
1. Vasomotor symptoms
2. Hot flashes
3. Urogenital dysfunction
4. Alteration in mood and depression
95. Your patient is suffering from vasomotor
symptoms, primarily hot flashes, and
asks you what she could do to provide
some relief? You recommend:
1. Exercise
2. Ginseng
3. Soy supplement
4. Relaxation techniques
96. A critical component of your sexual

assessment of lesbian, gay, bisexual, and
transgender (LGBT) patients with cancer
is to:
1. Involve a mental health professional.
2. Use the ALARM model of assessment.
3. Use the 5A Sexual Health Adaptation
model of assessment.
4. Use the ASK framework for assessment.
97. What grade is complete loss of sexual

interest according to the National Cancer
Institute (NCI) Cancer Terminology
Criteria of Adverse Events (CTACE)?
1. Grade 1
2. Grade 2
3. Grade 3
4. Grade 4
98. A commonly prescribed intervention to
enhance intimacy and sexual contact is:
1. To use sensate focus touching techniques
2. To focus on intercourse techniques
3. To focus on creating an ambient
atmosphere
4. To use lubricants and sexual devices
Answer Rationales
Cancer Nursing: Principles and Practice (CNPP),
Eighth Edition, by Connie Henke Yarbro, Debra
Wujcik, and Barbara Holmes Gobel (Jones &
Bartlett Learning, © 2018) and Cancer Symptom
Gobel (Jones & Bartlett Learning, © 2014).
A. CULTURAL, SPIRITUAL, AND RELIGIOUS
DIVERSITY
1. The answer is b.
Cultural sensitivity is having respect for
cultures and the beliefs connected with those
cultures other than your own. CNPP, Page
2081.
2. The answer is c.
Important considerations that should be
addressed in advance of the death is an
understanding of the family’s cultural and
religious considerations, both during and
immediately after the patient’s death. CSM,
Pages 713–714.
3. The answer is d.
Cultural practices need to be considered in
afterdeath care. For Muslims, a male patient
can only be cared for by another male. In
Buddhism, the body should not be moved for
several hours to allow the spirit to leave
without becoming confused. Jewish and
Muslim families may refuse autopsies on the
belief that the body belongs to God or Allah.
CNPP, Page 2081.
4. The answer is b.
Spirituality has been found to be one of the
most important components of quality of life,
particularly at the end of life. Greater spiritual
quality at life’s end is associated with greater
coping with disease-related symptoms, better
psychosocial well-being, and dignified dying.
Reviewing and reflecting on one’s life is not
uncommon and can lead to spiritual suffering.
Religion is the representation and expression
of spirituality. Ethics involves reflecting
systematically about right conduct and how to
live as a good person. CNPP, Page 2080; CSM,
Page 683.
5. The answer is c.
Regardless of one’s beliefs about religion,
patients report that prayer is a significant
source of comfort during illness. CSM, Page
688.
6. The answer is b.
The process of deriving meaning in illness has
been described as assisting individuals with
recognizing positive outcomes from negative
experiences, such as life reviews, meaning-
centered therapy, and dignity therapy. CSM,
Page 688.
7. The answer is a.
Greater spiritual quality at life’s end is
associated with better psychosocial well-being
and dignified dying. Individuals with advanced
cancer who believed in divine intervention and
had strong spiritual well-being were less apt to
have an advanced directive. CNPP, Page 2080.
8. The answer is c.
Individuals generally assume that the world is
meaningful and that they have worth.
Traumatic events such as a cancer diagnosis
can shatter these assumptions. When this
happens, people work to reconstruct their
worldview so it includes assumptions about
the event that are wiser and more mature. The
cognitive strategy used is a meaning-focused
strategy, for example, “It could be worse.” The
individuals must construe their own meanings
for life’s traumas. The nurse cannot do this
cognitive work for them. CNPP, Page 773.
9. The answer is a.
Spiritual distress is an accepted nursing
diagnosis that refers to a disturbance in the
belief or value system that provides strength,
hope, and meaning to life. CSM, Page 683.

Younger adult cancer patients may be at higher
risk for spiritual distress than older adults.
Some cultural groups (e.g., African American,
Latino) may be at more risk for spiritual
distress if their spiritual practices are
disturbed by illness. CSM, Page 686.

Spiritual distress cannot be fixed, cured,
solved, or manipulated as it is an outcome over
which a nurse has no control. Rather, the
nurses’ spiritually sensitive care for this
symptom must be one that seeks to
accompany, support, and nurture. The Joint
Commission does require an assessment for
the spiritual beliefs and practices of the
patient. CSM, Pages 686–689.

Religious and moral beliefs may not be
consistent with participation in palliative
sedation. Staff should have an opportunity to
withdraw from participation. CSM, Page 708.

Spirituality greatly affects a patient’s journey
through a life-threatening illness and provides
a sense of meaning despite the illness. It has
been found to be one of the most important
components of quality of life at the end of life.
CSM, Page 683.
B. FINANCIAL CONCERNS

The PPACA represents a major opportunity for
prevention of disease and enhancement of
public health as it established the National
Prevention Strategy, which provides new
funding for prevention and public programs
and promotes the use of preventive clinical
services. It also aims to achieve near-universal
health insurance and improve insurance
affordability. CNPP, Page 103.

The PPACA requires that all health plans must
cover tobacco cessation counseling. Obesity
screening and counseling for children and
adults are covered but not treatment for
obesity. Only routine patient costs associated
with clinical trials are covered by the PPACA.

The economic burden for family caregivers, is
substantial especially during the continuing
phase of treatment. More than 13% of patients
with cancer had high total economic burdens
in contrast to 10% of those with other chronic
conditions and 4% of those without chronic
conditions. CNPP, Page 2052.

The cost of HSCT are substantial and
preauthorization for insurance coverage is
required. The team will assist with this
evaluation. However, it is common for
institutions to provide care at a capitated fee
and this is a more positive response for him.
In some cases, the patient has to raise their
own funds unless the institution provides
charity care, which is rare. CNPP, Page 567.

The Family Medical Leave Act guarantees only
unpaid leave to care for a seriously ill spouse,
son, daughter, or parent. Only a few states will
provide a cash allowance to Medicaid eligible
persons to provide care. CNPP, Page 2053.
C. ALTERED BODY IMAGE

Most empirical studies dealing with the
relationship of cancer to body image and
quality of life have focused on women with
gynecologic or breast cancer or on men with
testicular or prostate cancer. Additional
empirical data are needed on the issues of
perception of significant others’ responses to
the physical and psychological sequelae of
cancer; the interaction of other variables, such
as age, depression, and activity status; and the
physical as well as psychosocial aspects of
sexual health. CNPP, Pages 209, 1013–1019;

Chemotherapy-induced alopecia occurs rapidly
and usually starts 2–3 weeks following a dose
of chemotherapy. After discontinuation of the
epilating drugs, regrowth is visible in 4–6
weeks, but complete regrowth may take 1–2
years. In situations involving high doses of
alkylating agents, hair may not regrow. CNPP,
Beau’s lines indicate a reduction in or
cessation of nail growth in response to
cytotoxic therapy. CNPP, Page 534; CSM, Page
601.

The TRAM flap procedure is sometimes known
as the “tummy tuck” because the muscle and
fat are tunneled from the abdominal muscle to
the mastectomy site. CNPP, Page 1314.

Recommendations to minimize hair loss
include using mild protein-based shampoos
with conditioners, and avoiding daily
shampooing. Hair should be allowed to dry
naturally and not use a hair dryer. Minoxidil or
Vitamin D have not been shown to prevent
hair loss. CNPP, Page 534; CSM, Page 501.

Docetaxel, doxorubicin, and cyclophosphamide
will likely cause hair loss but it will grow back.
Encourage the patient to purchase a wig and
she may consider cutting her hair short before
hair loss begins. CNPP, Page 533; CSM, Page
497.

Radiation response is seen mostly in tissues
and organs that are within or adjacent to the
treatment field (i.e., they are site specific).
Thus, an individual treated in the abdominal
field does not lose scalp hair from radiation.
CNPP, Page 342.
D. LEARNING STYLES AND BARRIERS TO
LEARNING

Families are the bedrock of chronic care in the
United States with over 44 million informal
family caregivers. Patients are leaving the
hospital sicker and sooner than ever before
and their long-term care is most often
provided in the home by family caregivers who
assume multiple roles. CNPP, Page 2046.

Program preparation and materials should
consider the comprehension level and the
cultural perspectives of the patient audience to
be most effective. Reading level must be
considered but also needs to include cultural
perspectives. CNPP, Pages 105, 2047.

The use of professional interpreters, if
available, is the optimal choice. Family and
friends may be used, but the correct or
complete message may not be relayed. CSM,
Page 74.
Education assists patients and family
members in reducing their sense of
helplessness and inadequacy. The most
common means of reducing uncertainty is to
provide preparatory information about the
specific aspects of the cancer experience faced
by the individual. Preparatory information also
prevents or alleviates treatment-related
symptoms. CNPP, Page 2056.

Individuals who received systemic cancer
treatment were impaired in executive
functioning, verbal memory, and motor
functioning. CNPP, Page 767.
E. SOCIAL RELATIONSHIPS AND FAMILY
DYNAMICS

The basic unit of society is the family. Cultural
values can determine communication with the
family, the norm for the family size, and the
roles of specific family members. CNPP, Page
2046.

A detailed family assessment is important,
particularly with regard to the functional
abilities of the caregiver, pattern of authority,
and support mechanisms available. Families
are categorized as supportive, ambivalent, or
hostile, and they generally continue to act as
they did in previous crises. CNPP, Page 2053.

Family units can be identified as supportive,
hostile, or ambivalent, with their behavior
described in terms of cohesion, adaptability,
and communication. When crisis occurs or
families are faced with the serious and difficult
implications of cancer and its treatment, their
behavior usually does not change and in some
cases can intensify. Therefore, if a family were
dysfunctional, hostile, or in conflict, it is very
likely that their behavior will continue. The
nurse’s primary concern is to support and care
for the patient. The chances are high that the
nurse will be unable to change the behavior of
the family members in conflict. CNPP, Pages
2056–2057.

Each individual brings to the cancer
experience unique personality traits and a
personal socialization pattern different from
all others. Understanding the uniqueness of
the individual is achieved only through study
of the commonalities of the personality and
social psychological (psychosocial) aspects of
illness. CNPP, Pages 212–213.

The individual’s coping abilities and the
availability to receive support from significant
others influences the capacity to adjust and
adapt to a cancer diagnosis and treatment.
CSM, Page 625.
F. COPING MECHANISMS AND SKILLS

Communication deteriorates the most when
information is given to the family but not the
patient; this is privileged communication.
When communication is just to the patient
and not the family, it can be misinterpreted
when the patient passes it to the family; this is
filtered communication. The family receives
the information, but the best communication
is balanced communication when the health
professional communicates with both the
patient and family. CNPP, Page 2046.

The two most important nursing actions with
respect to anxiety are communication that is
therapeutic and develops a trusting
relationship; and assessment across the cancer
illness trajectory. Loss of self-esteem is more
commonly a symptom of depression. In
general, nursing interventions that focus on
anxiety are based on helping the patient to
recognize various manifestations of anxiety,
determining whether the patient desires to do
anything about the response, and activating
coping strategies to control anxiety levels.
CSM, Page 629.

The recurrent and advanced phase of cancer is
a difficult time for the patient and family.
Researchers have reported that family
caregivers reported more depression than the
patients themselves. Additionally, caregivers
are less likely to seek help for their depression.
CNPP, Page 2049.

Denial or behavior disengagement are
avoidant coping strategies that are associated
with poorer psychologic well-being.
Psychosocial responses cannot be clearly
identified as either adaptive or maladaptive;
this depends largely on the situation and on
the adaptive potential of the particular
response in that situation. A perception of
uncertainty can result in an appraisal of
danger or opportunity, depending on the
individual’s definition of the situation.
Distancing behaviors by health professionals
enhance patients’ sense of loneliness and fear.
Over involvement with patients can be
countered through supportive collegial
relationships. CNPP, Page 2058.
Family responses of anxiety, depression,
hopelessness, and altered sexual health in
response to a diagnosis of cancer have been
shown to be similar to those of the patients
themselves. CNPP, Page 2048.
G. SUPPORT

This communication is referred to as
protective buffering, where the family member
attempts to keep the patient from incurring
further distress. CNPP, Page 2050.

Central to the beneficial findings in research
associated with levels of social support with
individual coping capabilities is the
opportunity for patients to safely discuss
thoughts and feelings with an attentive,
empathetic, professional listener. Cognitive-
emotional therapy, relaxation therapy,
aromatherapy, and support groups are
important as well. CNPP, Page 773.

The most common barrier to helping families
of patients with cancer is the time constraints
in the healthcare setting. CNPP, Pages 2046–
2047.

Assessment of cultural values and beliefs are
most important. African American women are
generally charged with the responsibility for
protecting the health of family members.
Whereas the family of Asians or Pacific
Islanders exert an extremely powerful force in
the patient’s life and the needs of the patient
are often secondary. Native Americans may
not give consent for treatment until
permission is obtained from the mother,
grandmother, or aunt. The nuclear family is
very important in Hispanics, and men assume
dominant roles and decision-making. CNPP,
Page 2047.

A number of studies have shown that
problems that patients experience, such as
anxiety and depression, can be reduced
through participation in support groups as the
patient receives emotional and social support.
Counseling may be useful but considerations
must be given to insurance and availability.

Patient education should be individualized
based on the patient’s preferred style of
learning (e.g., oral, written, group, or
individual). It should be the amount of
learning desired by the patient and not the
healthcare provider. Consideration should also
be given to any factors that could impede
learning such as pain or fatigue. CSM, Page
625.

Research has shown that African American
breast cancer survivors valued support groups
that considered their unique cultural and
socioeconomic positions, with emphasis on
spirituality and religion resulting in a better
quality of life. CNPP, Page 2021.
H. PSYCHOSOCIAL CONSIDERATIONS

Choice b is an affective response; other
affective responses include worthlessness,
hopelessness, and sadness. Choices c and d are
cognitive responses; another cognitive
response is a decreased ability to concentrate.
Other behavioral responses include change in
appetite, sleep disturbances, withdrawal, and
dependency. CNPP, Page 768; CSM, Page 656.

Disorientation, impaired memory, rapid
heartbeat, and elevated blood pressure are not
a part of the diagnostic criteria for major
depressive disorder. Choice b and d are
symptoms of an adjustment disorder. CNPP,

Distress related to the cancer experience
comprises a combination of multidimensional
stressors that strain the patient and family
along the cancer continuum. Psychological
distress frequently goes undetected because
patients are reluctant to report to healthcare
providers, thus distress remains untreated.
CNPP, Page 760.

People with cancer who also suffer from
depression are as likely to benefit from its
treatment as anyone else. The idea that
depression is to be expected in cancer patients
is not supported by empirical data. Cancer
patients are no more likely to develop
depression than other medical-surgical
patients. It is a myth that suicide is a logical
choice for all cancer patients. With attention to
the problems such as depression, unmanaged
pain, or other symptoms, suicide is not
common. CNPP, Pages 773–774; CSM, Page
663.

The ability to stay hopeful or optimistic has
been associated with lower distress and a
higher quality of life. Patients need
encouragement to be optimistic and to accept
negative feelings as a normal part of the cancer
experience, as well as continue to find ways to
restore and maintain hope. CNPP, Page 2057.

Many of the symptoms related to depression,
such as fatigue and insomnia, are also
common in cancer patients and associated
with their disease or treatment. Thus, the
coexistence of signs and symptoms of disease
are similar to those of depression and make
the diagnosis of cancer-related distress
difficult. CNPP, Pages 760–763; CSM, Page
656.

The other interventions listed are cognitive or
behavioral in approach. Before these
interventions are attempted, it is important for
the nurse to acknowledge the patient’s feelings
associated with depression, including
hopelessness, despair, anger, and guilt. The
nurse can do this in many ways, starting with
giving the patient permission to discuss those
feelings and then demonstrating acceptance of
them by attentive listening and by exploring
methods for the patient to deal positively with
them. CSM, Page 666.

Healthcare providers commonly perceive
disfigurement, loss of voice, and disease
control as the most relevant issues
postoperatively for laryngectomy patients.
However, patients may be able to meet
rehabilitation goals (talk and eat) but cannot
cope with day-to-day living (relationships,
finances, work, and performance). CNPP, Page
1595.

There is evidence that cognitive behavioral
interventions targeting either problem-focused
or emotion-focused coping strategies are most
common interventions for depression and
anxiety. CNPP, Page 773; CSM, Pages 626–656.

The diagnosis of anxiety in healthy persons is
made based on somatic symptoms, including
anorexia, fatigue, and weight loss, which in
cancer are often symptoms of the disease itself
and its treatment. The symptoms of worry,
distractibility, restlessness, and fearfulness are
more important for diagnosing anxiety among
cancer patients. CNPP, Page 768.

Anxiety is most likely to occur when an
individual experiences a nonspecific internal
or external stimulus that is perceived as a
threat to certain beliefs, values, and conditions
essential to a secure existence. CSM, Page 619.
Cognitive and behavioral techniques are well
suited to the treatment of anxiety because the
techniques are often effective not only in
symptom control but also in restoring or
enhancing a sense of self-control. CNPP, Pages
772–773; CSM, Pages 626–629.

Both patients and family caregivers seek
meaning as a way of trying to make sense of
such a negative experience. CNPP, Page 2052.

Allow the patient or family members the
opportunity to express their emotional
response to bad news. Allow the patient or
family member to cry and wait for them to
stop on their own. This may be an appropriate
time for silence. It is important to
acknowledge their grief, and tears are an
appropriate expression of grief. Only if crying
is protracted or hysterical should you consider
resuming your discussion at a later time.

SSNRIs target a second neurotransmitter,
norepinephrine, that plays a role in triggering
the fight-or-flight reaction. These medications
work well for those patients who have anxiety
with an overlay of depression. Because these
medications take up to 2 weeks to work, the
short-acting benzodiazepines may be used
until they take effect. CNPP, Page 774; CSM,
Pages 628, 663.

Although the incidence of psychological
distress varies by type of cancer and stage of
disease, individual life circumstances play a
significant role in the experience of
depression. Findings have reported that
women breast cancer survivors who were
abused as a child have more cancer-related
psychological distress. CNPP, Page 763; CSM,
Page 656.

Patients with cancer often believe that
depression is normal in those with cancer,
which is erroneous. Studies have documented
that depression affects the course of cancer by
increasing morbidity and hospital stays and
negatively impacts treatment compliance and
possibly prognosis and mortality. Patients feel
a need to protect the family by masking their
negative emotions; counseling is viewed as an
indication of weakness and inability to cope.

The distress of all patients with cancer should
be assessed by asking “How is your distress on
a scale of 0 to 10?” The distress management
assessment tool developed by the National
Comprehensive Cancer Network (NCCN) is a
useful resource to assess distress in the
patient with cancer. Research has found that
scores of 4 or higher on this tool are associated
with high levels of emotional distress. CNPP,

Patients process information about their
symptoms in two ways. They process
cognitively, using a problem-focused approach,
which assists in their making a plan for
addressing the symptom. They also process
information emotionally. Emotional
processing can affect planning for self-care.
CNPP, Page 773.

A living will may be applicable only when it
pertains to a terminal illness but not for a
patient whose health is declining for medical
reasons other than those that can be classified
as terminal or if the patient is in a vegetative
state. In general, the power of attorney for
health care is more useful than the living will.
The living will does not identify another
person who can act as the agent for a disabled
patient. Verbal instructions are of little value if
a family member or anyone else chooses to
argue against what has been reportedly
communicated verbally. Written instructions
are necessary. An order that instructs not to
intubate does not address any other
interventions that might be suggested. CNPP,
Pages 2072–2073.

Talking to your supervisor or human
resources, and speaking to other coworkers
who have tread this path before is a first
course of action. Also, help from organizations
that regularly help cancer survivors can be
beneficial. CNPP, Page 2042.

Patients who actively participate in treatment
decisions have improved functional status,
sense of well-being, and perform effective self-
care. Including the family as a part of the
decision-making process promotes better
communication and mutual support. CNPP,
Pages 499–500.

Anticipatory grief is a reaction that occurs in
advance of death. It has three foci of time:
past, present, and future. This patient is
anticipating grief related to the loss of future
events. CSM, Page 674.

Weight of evidence determined by a review of
interventions for depression by the Oncology
Nursing Society shows that relaxation therapy
is likely to be effective. Effectiveness has not
been established for massage, exercise, and
Reiki. CSM, Page 665.
I. SEXUALITY

The ability to conceive or father a child after
stem cell transplantation is related to age and
treatment with total body irradiation. CNPP,
Pages 1025–1026.

Numerous research studies report that
children born to mothers or fathers who had
previously been treated for cancer indicated no
increase in genetic disease or in congenital
anomalies in the offspring when compared to
the general population. CNPP, Page 1031.

Women older than 40 who develop
amenorrhea have the highest risk of
experiencing an abrupt permanent
menopause. In contrast to standard-dose
chemotherapy, high-dose chemotherapy is
associated with a high rate of ovarian failure
(90%), even in young women. It is the nurse’s
responsibility to inform patients regarding
their risks associated with reproductive and
hormonal sequelae of chemotherapy. CNPP,
Page 1023.

The effect of cancer treatment on sperm
counts may be temporary or permanent. Some
men with azoospermia immediately after
cancer treatment eventually recover sperm
counts sufficient to conceive children. Studies
comparing the offspring of survivors with the
offspring of survivors’ siblings have
demonstrated no increased risk of birth
defects among the children of survivors.
Because of the uncertainty about treatment-
related chromosomal damage, men should
wait at least 6 months after the end of cancer
treatment before attempting to conceive or to
harvest sperm for assisted reproduction.

Edgar et al. (2007) identified several large
international studies providing a pool of
25,000 childhood survivors and noted no
increased risk of genetic abnormality in the
offspring of cancer survivors. Other studies
have found no increased risk of nonhereditary
cancers among offspring, no increased risk of
birth defects, and no increased risk of
malignancies or anomalies in the offspring.
CNPP, Page 1031.

Radiation exposure during the first trimester
represents the greatest risk to the fetus. In the
second or third trimester, fetal death is
unlikely, but growth retardation, sterility, and
cataracts are common. Chemotherapy,
particularly when received during the first
trimester, has been related to congenital
abnormalities, with approximately 10% of
fetuses experiencing some type of anomaly.
CNPP, Page 1032.

Chemotherapy in the second and third
trimester may cause premature birth or low
birth weight, but congenital abnormalities are
not increased over the normal pregnancy
incidence. CNPP, Page 1032.

Women over the age of 30 are less likely to
regain ovarian function because they have
fewer oocytes. CNPP, Page 1020.

Treatment options will be evaluated as though
the patient was not pregnant and therapy
instituted when appropriate. Most cancers do
not adversely affect a pregnancy, however,
cancer treatments can have an effect.
Therapeutic abortion has not been shown to be
beneficial in altering disease progression and
should not be considered unless pregnancy
will compromise treatment and thus
prognosis. CNPP, Page 1038.

During the first two trimesters, surgery or
radiation therapy, without therapeutic
abortion, is usually undertaken. Early-stage
disease may be treated with radical
hysterectomy and pelvic node dissection,
whereas radiation therapy is the most
common treatment in advanced disease.
During the third trimester, fetal viability
usually can be awaited and the infant delivered
by cesarean section, after which appropriate
cancer therapy can be given. CNPP, Page 1040.

Melanoma is known to spread from the
mother to the fetus. If the mother has
melanoma, the placenta should be carefully
evaluated at delivery and the baby monitored
for development of the disease. CNPP, Page
1043.
Chemotherapy during the first trimester has
been associated with fetal wastage,
malformations, and low birth weight, although
the incidence of fetal malformation is low and
may be minimized or avoided with careful
selection of agents. Maternal surgery can be
safely accomplished with minimal risk to the
fetus. Pelvic surgery is more easily
accomplished during the second trimester.
There is little risk to the fetus from short
exposure to anesthetic agents after the first
trimester, provided ventilation is adequate and
hypotension is prevented. Low doses of
radiation associated with diagnostic x-ray
studies are not harmful if adequate fetal
shielding is provided. CNPP, Page 1032.

Only a few cancers spread from the mother to
the fetus; melanoma, non-Hodgkin lymphoma,
and leukemia are the most common. CNPP,
Page 1043.

Appropriate shielding of the testes or ovaries
or oophoropexy to position the ovaries outside
the radiation field are beneficial. Studies
evaluating treatment of men and women with
GnRH analogs have been disappointing and
inconsistent. CNPP, Pages 1020, 1031.

A standard of care is embryo and oocyte
cryopreservation. The others remain
investigational. CNPP, Page 1033.

For all patients, the removal of rectal tissue
appears to be the most common denominator
to organic sexual dysfunction. If the rectum
remains intact, there rarely is an associated
sexual dysfunction without direct tumor
invasion. Choices a, c, and d, although all
associated with sexual dysfunction resulting
from gastrointestinal surgery, primarily are
psychosexual and not organic issues. CNPP,
Pages 1013, 1470.

Evaluation of sexual dysfunction according to
the ALARM model includes:
A – Activity or sexual function
L – Libido or desire
A – Arousal and orgasm
R – Resolution or release
M – Medical data. CNPP, Page 1029.
Chemotherapy-induced reproductive and
sexual dysfunction is related to the type of
drug, dose, length of treatment, age, and sex of
the individual receiving treatment and to the
length of time after treatment, as well as to the
use of single rather than multiple agents and
drugs to combat side effects of chemotherapy.
Combination chemotherapy including
alkylating agents such as mechlorethamine
have been shown to produce sexual
dysfunction and to decrease fertility in both
men and women. Androgen therapy affects
sexual function in women; estrogen therapy
affects sexual function in men. Chemotherapy
may deplete the germinal epithelium that lines
the seminiferous tubules in men. CNPP, Pages
1021–1023.

Decreased libido and ovarian dysfunction are
side effects of gemcitabine and cisplatin.
CNPP, Page 1022.

The traditional radical prostatectomy results in
the loss of antegrade ejaculation with resultant
infertility from retrograde ejaculation. The
ability to experience a normal orgasm is not
impaired. CNPP, Pages 1015, 1861.

According to the Centers for Disease Control
and Prevention (CDC), HPV is the most
common sexually transmitted disease in the
United States and is responsible for causing
nearly all cases of cervical cancer. CNPP, Page
98.

Research is proving there is an increased risk
of premature morbidity and mortality with the
inducement of early menopause. CSM, Page
48.

In breast cancer survivors, 50% to 75% have
one or more symptoms of urogenital
dysfunction that includes dyspareunia, vaginal
dryness, urinary tract infections, decreased
libido, and loss of sexual satisfaction. CSM,
Page 55.

Slow breathing techniques and meditation
reduce the effects of the sympathetic nervous
system, thereby reducing the frequency of
vasomotor symptoms. There is no evidence
that exercise, ginseng, and soy supplements
reduce hot flashes. CSM, Pages 51, 54.

To provide culturally appropriate care, use the
ASK (Awareness, Sensitivity, and Knowledge)
framework when assessing for sexual and
reproductive dysfunction associated with
cancer. CNPP, Page 1037; CSM, Page 516.

Complete loss of sexual interest is Grade 3.
Grade 1 is decreased sexual interest and Grade
2 is severe loss of sexual interest. There is no
Grade 4. CSM, Page 517.

A commonly prescribed intervention to
enhance sexual contact is the sensate focus
touching technique rather than on genital
contact and intercourse. The goal is to take the
pressure off intercourse while understanding
how each partner likes to touch or be touched.
CSM, Page 520.

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A.

HEALTH PROMOTION AND DISEASE

1. A research study focuses on smoking

2. You educate Miss Smith about the

3. Which of the following lifestyle factors is

4. After her father’s death from colon

5. Which of the following best describes

6. Which of the following statements

7. According to research, which of the

8. Which of the following scenarios

9. Physical activity is one of the few known

10. Moderate to heavy alcohol intake has

11. Ms. Jones recently read a report from the

12. The most important factors that appear

13. Which of the following is the most

15. Mr. Smith, a heavy smoker, wants to quit

16. Epidemiology studies have provided

17. Successes in the immunologic

18. Once the elements of a cancer risk

19. Chemoprevention focuses on individuals

20. Most chemopreventive agents are

21. Your patient, Mrs. Smith, who has

22. Which statement is the best reason to

23. The American Cancer Society

24. Colorectal surveillance

25. The most significant reduction in

26. The most important risk-reduction

1. Which of the following statements is

2. The most widely used screening

3. Nurses must communicate to patients

4. Which of the following tests is

5. You are providing a community

6. The single most important factor in

7. Which of the following models has been

8. Which of the following statements is

9. Research has shown that providing

10. A nurse asks you which risk model

11. Which of the following modalities is used

12. One of the early signs of ovarian cancer

13. Physical recognition of cutaneous

14. Which of the following statements about

15. One way that basal cell carcinoma (BCC)

16. Which of the following is the most likely

17. Ms. Allison notices a “funny

19. Mrs. Smith is pregnant and discovers a

20. Mrs. Blase presents with a continuous

21. The most common presenting symptom

22. Early detection of stomach cancer is

1. The primary purpose of patient navigator

2. Dr. Harold Freeman, a pioneer in patient

3. The best description of a lay navigator is:

4. Which of the following statements about

5. As a newly hired breast care navigator,

6. On Jane’s follow-up visit to the breast

7. Measuring the success of breast care

8. A 48-year-old woman had a routine

9. The breast nurse navigator can identify

10. A colleague asks you about what

11. Multiple barriers to breast cancer care