ONS/ONCC Chemotherapy &
Immunotherapy Certificate – Practice Exam
Total Questions: 50 QUESTIONS AND
ANSWERS
Format: Multiple choice (4 options), each with correct answer + rationale
1. A patient receiving IV paclitaxel reports shortness of breath, chest tightness, and back pain
within 2 minutes of starting the infusion. What is the most appropriate first action?
A) Stop the infusion and call a rapid response
B) Slow the infusion to 50% and monitor
C) Administer premedications now
D) Reassure the patient and continue
Correct Answer: A
Rationale: This is a severe infusion reaction (likely grade 3-4) to paclitaxel, not a minor
hypersensitivity. Stopping the infusion immediately and activating emergency response is
critical. Slowing (B) is unsafe. Premedications (C) should have been given before infusion.
Continuing (D) risks anaphylaxis.
2. Which lab value would prompt holding fluorouracil (5-FU) before the next cycle?
A) ANC 1,200/mm³
B) Platelets 80,000/mm³
C) DPD enzyme deficiency
D) Hemoglobin 9.5 g/dL
Correct Answer: C
Rationale: Dihydropyrimidine dehydrogenase (DPD) deficiency leads to severe, life-threatening
5-FU toxicity (mucositis, diarrhea, myelosuppression). Testing is now recommended before first
dose. Mild neutropenia (A) or thrombocytopenia (B) may allow dose reduction but not always
hold. Anemia (D) is not a hold criterion alone.
,3. A patient on ipilimumab (Yervoy) plus nivolumab develops grade 3 transaminitis (AST/ALT >
5-8x ULN). The nurse anticipates:
A) Continue both drugs and add ursodiol
B) Hold both drugs and start high-dose corticosteroids (1-2 mg/kg/day)
C) Discontinue nivolumab permanently but continue ipilimumab
D) Administer mycophenolate mofetil without holding immunotherapy
Correct Answer: B
Rationale: Grade 3 immune-mediated hepatitis requires holding ICIs and starting prednisone 1–
2 mg/kg/day. If no improvement in 3–5 days, consider mycophenolate (not D). Continuing
either drug (A, C) is unsafe. Ursodiol (A) is for cholestatic patterns, not hepatitis.
4. A nurse is preparing to administer bendamustine. Which type of administration set is
required?
A) Polyvinyl chloride (PVC)-free administration set
B) Polyethylene-lined tubing
C) Standard IV tubing with 0.22 micron filter
D) Non-PVC, non-DEHP, in-line filter
Correct Answer: D
Rationale: Bendamustine is incompatible with PVC and DEHP (leaching). The manufacturer
recommends a non-PVC, non-DEHP administration set with an in-line 0.22 micron filter. Option
A is incomplete (no filter). Option C is standard PVC tubing – incorrect.
5. A patient receiving high-dose methotrexate has a methotrexate level of 8 µmol/L at 48
hours. What intervention is indicated?
A) Increase IV fluids to 3 L/day
B) Administer folinic acid (leucovorin) rescue
C) Measure serum creatinine only
D) Discharge home with oral leucovorin
Correct Answer: B
Rationale: Delayed methotrexate clearance (level > 0.1 µmol/L at 48 hours requires leucovorin
rescue). Increasing fluids (A) alone is insufficient. Creatinine (C) is already monitored. Discharge
(D) is unsafe; patient needs inpatient hydration and monitoring.
, 6. Which adverse effect is unique to chimeric antigen receptor (CAR)-T therapy compared to
immune checkpoint inhibitors?
A) Cytokine release syndrome (CRS)
B) Immune-related pneumonitis
C) Hypophysitis
D) Severe arthralgias
Correct Answer: A
Rationale: CRS (fever, hypotension, hypoxia) is a hallmark of CAR-T due to massive cytokine
release from activated T cells. CRS is rare with ICIs. Pneumonitis (B) and hypophysitis (C) are
more common with ICIs. Arthralgias (D) occur with both but not unique.
7. A patient accidentally spills a vial of powdered cyclophosphamide on a counter. What is the
first step in spill management?
A) Wipe with wet absorbent pads
B) Evacuate the area and restrict access
C) Notify pharmacy for disposal
D) Cover the spill with a dry cloth
Correct Answer: B
Rationale: Spill management protocol: first, evacuate and restrict access to prevent exposure.
Then use a hazardous drug spill kit (wet pads, PPE). Wiping (A) without PPE is unsafe. Notifying
pharmacy (C) occurs after containment. Dry cloth (D) can aerosolize powder.
8. A patient on trastuzumab (Herceptin) has a baseline LVEF of 55%. After 6 months, LVEF
drops to 40% with symptoms of heart failure. The nurse expects:
A) Continue trastuzumab and add a beta-blocker
B) Permanently discontinue trastuzumab
C) Hold trastuzumab and repeat LVEF in 3 weeks
D) Reduce trastuzumab dose by 50%
Correct Answer: B
Rationale: Trastuzumab cardiotoxicity is usually reversible, but a symptomatic drop to LVEF <
40% requires permanent discontinuation per guidelines. Holding and repeating (C) is for
asymptomatic drops. Dose reduction (D) not standard.
Immunotherapy Certificate – Practice Exam
Total Questions: 50 QUESTIONS AND
ANSWERS
Format: Multiple choice (4 options), each with correct answer + rationale
1. A patient receiving IV paclitaxel reports shortness of breath, chest tightness, and back pain
within 2 minutes of starting the infusion. What is the most appropriate first action?
A) Stop the infusion and call a rapid response
B) Slow the infusion to 50% and monitor
C) Administer premedications now
D) Reassure the patient and continue
Correct Answer: A
Rationale: This is a severe infusion reaction (likely grade 3-4) to paclitaxel, not a minor
hypersensitivity. Stopping the infusion immediately and activating emergency response is
critical. Slowing (B) is unsafe. Premedications (C) should have been given before infusion.
Continuing (D) risks anaphylaxis.
2. Which lab value would prompt holding fluorouracil (5-FU) before the next cycle?
A) ANC 1,200/mm³
B) Platelets 80,000/mm³
C) DPD enzyme deficiency
D) Hemoglobin 9.5 g/dL
Correct Answer: C
Rationale: Dihydropyrimidine dehydrogenase (DPD) deficiency leads to severe, life-threatening
5-FU toxicity (mucositis, diarrhea, myelosuppression). Testing is now recommended before first
dose. Mild neutropenia (A) or thrombocytopenia (B) may allow dose reduction but not always
hold. Anemia (D) is not a hold criterion alone.
,3. A patient on ipilimumab (Yervoy) plus nivolumab develops grade 3 transaminitis (AST/ALT >
5-8x ULN). The nurse anticipates:
A) Continue both drugs and add ursodiol
B) Hold both drugs and start high-dose corticosteroids (1-2 mg/kg/day)
C) Discontinue nivolumab permanently but continue ipilimumab
D) Administer mycophenolate mofetil without holding immunotherapy
Correct Answer: B
Rationale: Grade 3 immune-mediated hepatitis requires holding ICIs and starting prednisone 1–
2 mg/kg/day. If no improvement in 3–5 days, consider mycophenolate (not D). Continuing
either drug (A, C) is unsafe. Ursodiol (A) is for cholestatic patterns, not hepatitis.
4. A nurse is preparing to administer bendamustine. Which type of administration set is
required?
A) Polyvinyl chloride (PVC)-free administration set
B) Polyethylene-lined tubing
C) Standard IV tubing with 0.22 micron filter
D) Non-PVC, non-DEHP, in-line filter
Correct Answer: D
Rationale: Bendamustine is incompatible with PVC and DEHP (leaching). The manufacturer
recommends a non-PVC, non-DEHP administration set with an in-line 0.22 micron filter. Option
A is incomplete (no filter). Option C is standard PVC tubing – incorrect.
5. A patient receiving high-dose methotrexate has a methotrexate level of 8 µmol/L at 48
hours. What intervention is indicated?
A) Increase IV fluids to 3 L/day
B) Administer folinic acid (leucovorin) rescue
C) Measure serum creatinine only
D) Discharge home with oral leucovorin
Correct Answer: B
Rationale: Delayed methotrexate clearance (level > 0.1 µmol/L at 48 hours requires leucovorin
rescue). Increasing fluids (A) alone is insufficient. Creatinine (C) is already monitored. Discharge
(D) is unsafe; patient needs inpatient hydration and monitoring.
, 6. Which adverse effect is unique to chimeric antigen receptor (CAR)-T therapy compared to
immune checkpoint inhibitors?
A) Cytokine release syndrome (CRS)
B) Immune-related pneumonitis
C) Hypophysitis
D) Severe arthralgias
Correct Answer: A
Rationale: CRS (fever, hypotension, hypoxia) is a hallmark of CAR-T due to massive cytokine
release from activated T cells. CRS is rare with ICIs. Pneumonitis (B) and hypophysitis (C) are
more common with ICIs. Arthralgias (D) occur with both but not unique.
7. A patient accidentally spills a vial of powdered cyclophosphamide on a counter. What is the
first step in spill management?
A) Wipe with wet absorbent pads
B) Evacuate the area and restrict access
C) Notify pharmacy for disposal
D) Cover the spill with a dry cloth
Correct Answer: B
Rationale: Spill management protocol: first, evacuate and restrict access to prevent exposure.
Then use a hazardous drug spill kit (wet pads, PPE). Wiping (A) without PPE is unsafe. Notifying
pharmacy (C) occurs after containment. Dry cloth (D) can aerosolize powder.
8. A patient on trastuzumab (Herceptin) has a baseline LVEF of 55%. After 6 months, LVEF
drops to 40% with symptoms of heart failure. The nurse expects:
A) Continue trastuzumab and add a beta-blocker
B) Permanently discontinue trastuzumab
C) Hold trastuzumab and repeat LVEF in 3 weeks
D) Reduce trastuzumab dose by 50%
Correct Answer: B
Rationale: Trastuzumab cardiotoxicity is usually reversible, but a symptomatic drop to LVEF <
40% requires permanent discontinuation per guidelines. Holding and repeating (C) is for
asymptomatic drops. Dose reduction (D) not standard.
