Oncology Nurse Practitioner (Oncology
NP) Certification Exam Review 2025/2026 |
Cancer Pathophysiology, Chemotherapy
Management, Symptom Control &
Evidence-Based Oncology Practice |
Board-Style Practice Questions with
Rationales
QUESTION 1 — A 58-year-old woman with metastatic ER+/PR+/HER2- breast cancer
is started on fulvestrant after progression on an aromatase inhibitor. Which of the
following best describes fulvestrant's primary mechanism of action?
a) Selective estrogen receptor modulator (SERM) that acts as estrogen antagonist in breast and
agonist in bone
b) Aromatase inhibitor that blocks peripheral conversion of androgens to estrogens
c) Estrogen receptor antagonist that accelerates receptor degradation (selective estrogen
receptor degrader, SERD) — Correct
d) GnRH agonist causing ovarian suppression
RATIONALE: Fulvestrant is a selective estrogen receptor degrader (SERD) that binds the
estrogen receptor, blocks its activity, and promotes receptor degradation, reducing ER signaling.
It is distinct from SERMs (tamoxifen) and aromatase inhibitors.
2.
QUESTION 2 — A 65-year-old man with small-cell lung cancer (SCLC) develops
SIADH with hyponatremia (Na+ 120 mEq/L) and mild confusion. Which initial
management is most appropriate if the patient is hemodynamically stable and symptoms
are moderate?
a) Rapid infusion of 3% hypertonic saline to correct sodium to >130 mEq/L within 6 hours
b) Fluid restriction and hypertonic saline reserved for severe or progressive neurologic
symptoms; consider demeclocycline or tolvaptan if persistent — Correct
c) Immediate administration of high-dose loop diuretics alone
d) Immediate free water infusion to dilute sodium correction
RATIONALE: SIADH management depends on severity. For moderate hyponatremia with
mild to moderate symptoms, start with fluid restriction and address underlying cause. Hypertonic
saline is used for severe or life-threatening neurologic symptoms. Demeclocycline or vasopressin
receptor antagonists (tolvaptan) may be used when fluid restriction fails.
, 3.
QUESTION 3 — A patient receiving cisplatin experiences significant nephrotoxicity
despite hydration. Which of the following interventions has the best evidence for reducing
cisplatin-induced nephrotoxicity?
a) Concurrent administration of aminoglycoside antibiotics to reduce infection risk
b) Aggressive IV hydration with isotonic saline plus mannitol diuresis and magnesium
supplementation — Correct
c) Pre-treatment with allopurinol
d) Avoiding hydration and instead using low-dose furosemide only
RATIONALE: Cisplatin nephrotoxicity is mitigated by vigorous IV hydration (isotonic
saline), use of diuretics such as mannitol in some protocols to promote diuresis, and
correction/supplementation of magnesium. Aminoglycosides increase nephrotoxicity; allopurinol
is for TLS prevention; furosemide alone without proper hydration is inadequate.
4.
QUESTION 4 — A 42-year-old woman with BRCA1-associated ovarian cancer is
considering maintenance therapy after platinum-sensitive relapse. Which targeted
maintenance option has the strongest evidence for improving progression-free survival in
BRCA-mutated disease?
a) Bevacizumab (anti-VEGF) alone
b) PARP inhibitor (e.g., olaparib) maintenance therapy — Correct
c) Immune checkpoint inhibitor monotherapy (PD-1/PD-L1 inhibitor)
d) High-dose IV vitamin C
RATIONALE: PARP inhibitors have demonstrated improved progression-free survival as
maintenance therapy in patients with BRCA-mutated ovarian cancer after response to platinum
therapy. Bevacizumab has benefit in certain settings but PARP inhibitors are specifically
effective in BRCA-mutant disease.
5.
QUESTION 5 — A 70-year-old patient with metastatic colorectal cancer and KRAS
wild-type status is being considered for first-line biologic therapy. Which statement is most
evidence-based regarding EGFR inhibitors (cetuximab, panitumumab)?
a) EGFR inhibitors are beneficial regardless of RAS mutation status
b) EGFR inhibitors are contraindicated in left-sided tumors only
c) EGFR inhibitors improve outcomes in RAS wild-type tumors and are more effective in
,left-sided primary tumors compared with right-sided — Correct
d) EGFR inhibitors can be combined safely with bevacizumab for additive benefit
RATIONALE: Anti-EGFR antibodies improve outcomes in RAS (KRAS/NRAS) wild-type
metastatic colorectal cancer and show greater benefit in left-sided primaries. They are ineffective
in RAS-mutant tumors. Combining EGFR antibodies with bevacizumab is not recommended due
to lack of benefit and increased toxicity.
6.
QUESTION 6 — A patient undergoing high-dose methotrexate for osteosarcoma has
delayed methotrexate clearance. Which is the best immediate intervention?
a) Give intravenous leucovorin rescue and continue monitoring levels; consider glucarpidase if
life-threatening delayed clearance or renal failure
b) Initiate hemodialysis immediately in all cases of delayed clearance
c) Administer additional methotrexate to outcompete toxicity
d) Administer oral folic acid and discontinue leucovorin — Correct (Note: this is a trap: oral
folic acid is NOT appropriate; the correct management is actually option a)
RATIONALE: (Correction and teaching point) The evidence-based management of
delayed methotrexate clearance is aggressive IV leucovorin rescue and monitoring methotrexate
serum levels. If there is life-threatening toxicity and renal failure causing inability to clear
methotrexate, glucarpidase (carboxypeptidase) is indicated. Hemodialysis is generally ineffective
for methotrexate removal compared with glucarpidase.
Corrected display:
Correct answer: a) Give intravenous leucovorin rescue and continue monitoring levels;
consider glucarpidase if life-threatening delayed clearance or renal failure.
7.
QUESTION 7 — In a randomized trial comparing two chemotherapy regimens, the
reported hazard ratio (HR) for overall survival is 0.85 with a 95% confidence interval (CI)
0.70–1.03 and p = 0.09. Which interpretation is most accurate?
a) The experimental regimen significantly improves survival
b) There is a statistically significant increased risk of death with the experimental regimen
c) There is a trend toward improved survival with the experimental regimen, but the result
is not statistically significant at the conventional 0.05 level — Correct
d) The trial proves equivalence between regimens
, RATIONALE: HR <1 favors the experimental arm, but the CI includes 1 and p>0.05, so
the finding is not statistically significant. It suggests a trend but not definitive proof. Equivalence
requires pre-specified equivalence testing.
8.
QUESTION 8 — A 55-year-old woman receiving doxorubicin for breast cancer asks
about long-term cardiac risk. Which statement is most accurate regarding anthracycline
cardiotoxicity?
a) Cardiotoxicity is dose-independent and unpredictable
b) Risk increases with cumulative dose; lifetime limits (e.g., ~450–550 mg/m2 for
doxorubicin) and cardiac monitoring are recommended — Correct
c) Dexrazoxane should never be used because it reduces chemotherapy efficacy
d) Cardiotoxicity only occurs immediately during infusion and never late
RATIONALE: Anthracycline cardiotoxicity is dose-dependent, with increasing risk at
higher cumulative doses. Lifelong risk exists; monitoring (echocardiography/MUGA) and risk
mitigation like dexrazoxane (in select high-risk/high-dose settings) may be used. Dexrazoxane
can reduce cardiotoxicity and is allowed in certain situations.
9.
QUESTION 9 — A patient with newly diagnosed acute leukemia has a white blood cell
count of 120,000/mm3 and hyperuricemia. Which prophylactic intervention is most
appropriate to prevent tumor lysis syndrome (TLS)?
a) Routine administration of allopurinol alone after TLS develops
b) Aggressive IV hydration, allopurinol, and consider rasburicase if high-risk or with established
hyperuricemia; monitor electrolytes closely — Correct
c) Immediate initiation of high-dose corticosteroids only
d) No prophylaxis is necessary; treat TLS if it occurs
Correct: b) Aggressive IV hydration, allopurinol, and consider rasburicase if high-risk or
with established hyperuricemia; monitor electrolytes closely.
RATIONALE: High-risk patients require aggressive preventive measures: IV fluids, uric
acid management (allopurinol for prevention; rasburicase for rapid uric acid reduction or when
hyperuricemia already present), and close electrolyte/renal monitoring.
10.
NP) Certification Exam Review 2025/2026 |
Cancer Pathophysiology, Chemotherapy
Management, Symptom Control &
Evidence-Based Oncology Practice |
Board-Style Practice Questions with
Rationales
QUESTION 1 — A 58-year-old woman with metastatic ER+/PR+/HER2- breast cancer
is started on fulvestrant after progression on an aromatase inhibitor. Which of the
following best describes fulvestrant's primary mechanism of action?
a) Selective estrogen receptor modulator (SERM) that acts as estrogen antagonist in breast and
agonist in bone
b) Aromatase inhibitor that blocks peripheral conversion of androgens to estrogens
c) Estrogen receptor antagonist that accelerates receptor degradation (selective estrogen
receptor degrader, SERD) — Correct
d) GnRH agonist causing ovarian suppression
RATIONALE: Fulvestrant is a selective estrogen receptor degrader (SERD) that binds the
estrogen receptor, blocks its activity, and promotes receptor degradation, reducing ER signaling.
It is distinct from SERMs (tamoxifen) and aromatase inhibitors.
2.
QUESTION 2 — A 65-year-old man with small-cell lung cancer (SCLC) develops
SIADH with hyponatremia (Na+ 120 mEq/L) and mild confusion. Which initial
management is most appropriate if the patient is hemodynamically stable and symptoms
are moderate?
a) Rapid infusion of 3% hypertonic saline to correct sodium to >130 mEq/L within 6 hours
b) Fluid restriction and hypertonic saline reserved for severe or progressive neurologic
symptoms; consider demeclocycline or tolvaptan if persistent — Correct
c) Immediate administration of high-dose loop diuretics alone
d) Immediate free water infusion to dilute sodium correction
RATIONALE: SIADH management depends on severity. For moderate hyponatremia with
mild to moderate symptoms, start with fluid restriction and address underlying cause. Hypertonic
saline is used for severe or life-threatening neurologic symptoms. Demeclocycline or vasopressin
receptor antagonists (tolvaptan) may be used when fluid restriction fails.
, 3.
QUESTION 3 — A patient receiving cisplatin experiences significant nephrotoxicity
despite hydration. Which of the following interventions has the best evidence for reducing
cisplatin-induced nephrotoxicity?
a) Concurrent administration of aminoglycoside antibiotics to reduce infection risk
b) Aggressive IV hydration with isotonic saline plus mannitol diuresis and magnesium
supplementation — Correct
c) Pre-treatment with allopurinol
d) Avoiding hydration and instead using low-dose furosemide only
RATIONALE: Cisplatin nephrotoxicity is mitigated by vigorous IV hydration (isotonic
saline), use of diuretics such as mannitol in some protocols to promote diuresis, and
correction/supplementation of magnesium. Aminoglycosides increase nephrotoxicity; allopurinol
is for TLS prevention; furosemide alone without proper hydration is inadequate.
4.
QUESTION 4 — A 42-year-old woman with BRCA1-associated ovarian cancer is
considering maintenance therapy after platinum-sensitive relapse. Which targeted
maintenance option has the strongest evidence for improving progression-free survival in
BRCA-mutated disease?
a) Bevacizumab (anti-VEGF) alone
b) PARP inhibitor (e.g., olaparib) maintenance therapy — Correct
c) Immune checkpoint inhibitor monotherapy (PD-1/PD-L1 inhibitor)
d) High-dose IV vitamin C
RATIONALE: PARP inhibitors have demonstrated improved progression-free survival as
maintenance therapy in patients with BRCA-mutated ovarian cancer after response to platinum
therapy. Bevacizumab has benefit in certain settings but PARP inhibitors are specifically
effective in BRCA-mutant disease.
5.
QUESTION 5 — A 70-year-old patient with metastatic colorectal cancer and KRAS
wild-type status is being considered for first-line biologic therapy. Which statement is most
evidence-based regarding EGFR inhibitors (cetuximab, panitumumab)?
a) EGFR inhibitors are beneficial regardless of RAS mutation status
b) EGFR inhibitors are contraindicated in left-sided tumors only
c) EGFR inhibitors improve outcomes in RAS wild-type tumors and are more effective in
,left-sided primary tumors compared with right-sided — Correct
d) EGFR inhibitors can be combined safely with bevacizumab for additive benefit
RATIONALE: Anti-EGFR antibodies improve outcomes in RAS (KRAS/NRAS) wild-type
metastatic colorectal cancer and show greater benefit in left-sided primaries. They are ineffective
in RAS-mutant tumors. Combining EGFR antibodies with bevacizumab is not recommended due
to lack of benefit and increased toxicity.
6.
QUESTION 6 — A patient undergoing high-dose methotrexate for osteosarcoma has
delayed methotrexate clearance. Which is the best immediate intervention?
a) Give intravenous leucovorin rescue and continue monitoring levels; consider glucarpidase if
life-threatening delayed clearance or renal failure
b) Initiate hemodialysis immediately in all cases of delayed clearance
c) Administer additional methotrexate to outcompete toxicity
d) Administer oral folic acid and discontinue leucovorin — Correct (Note: this is a trap: oral
folic acid is NOT appropriate; the correct management is actually option a)
RATIONALE: (Correction and teaching point) The evidence-based management of
delayed methotrexate clearance is aggressive IV leucovorin rescue and monitoring methotrexate
serum levels. If there is life-threatening toxicity and renal failure causing inability to clear
methotrexate, glucarpidase (carboxypeptidase) is indicated. Hemodialysis is generally ineffective
for methotrexate removal compared with glucarpidase.
Corrected display:
Correct answer: a) Give intravenous leucovorin rescue and continue monitoring levels;
consider glucarpidase if life-threatening delayed clearance or renal failure.
7.
QUESTION 7 — In a randomized trial comparing two chemotherapy regimens, the
reported hazard ratio (HR) for overall survival is 0.85 with a 95% confidence interval (CI)
0.70–1.03 and p = 0.09. Which interpretation is most accurate?
a) The experimental regimen significantly improves survival
b) There is a statistically significant increased risk of death with the experimental regimen
c) There is a trend toward improved survival with the experimental regimen, but the result
is not statistically significant at the conventional 0.05 level — Correct
d) The trial proves equivalence between regimens
, RATIONALE: HR <1 favors the experimental arm, but the CI includes 1 and p>0.05, so
the finding is not statistically significant. It suggests a trend but not definitive proof. Equivalence
requires pre-specified equivalence testing.
8.
QUESTION 8 — A 55-year-old woman receiving doxorubicin for breast cancer asks
about long-term cardiac risk. Which statement is most accurate regarding anthracycline
cardiotoxicity?
a) Cardiotoxicity is dose-independent and unpredictable
b) Risk increases with cumulative dose; lifetime limits (e.g., ~450–550 mg/m2 for
doxorubicin) and cardiac monitoring are recommended — Correct
c) Dexrazoxane should never be used because it reduces chemotherapy efficacy
d) Cardiotoxicity only occurs immediately during infusion and never late
RATIONALE: Anthracycline cardiotoxicity is dose-dependent, with increasing risk at
higher cumulative doses. Lifelong risk exists; monitoring (echocardiography/MUGA) and risk
mitigation like dexrazoxane (in select high-risk/high-dose settings) may be used. Dexrazoxane
can reduce cardiotoxicity and is allowed in certain situations.
9.
QUESTION 9 — A patient with newly diagnosed acute leukemia has a white blood cell
count of 120,000/mm3 and hyperuricemia. Which prophylactic intervention is most
appropriate to prevent tumor lysis syndrome (TLS)?
a) Routine administration of allopurinol alone after TLS develops
b) Aggressive IV hydration, allopurinol, and consider rasburicase if high-risk or with established
hyperuricemia; monitor electrolytes closely — Correct
c) Immediate initiation of high-dose corticosteroids only
d) No prophylaxis is necessary; treat TLS if it occurs
Correct: b) Aggressive IV hydration, allopurinol, and consider rasburicase if high-risk or
with established hyperuricemia; monitor electrolytes closely.
RATIONALE: High-risk patients require aggressive preventive measures: IV fluids, uric
acid management (allopurinol for prevention; rasburicase for rapid uric acid reduction or when
hyperuricemia already present), and close electrolyte/renal monitoring.
10.
