BMTCN Exam, GVHD & Medication
Study Test Bank
1. A transplant recipient develops a maculopapular rash on the palms and soles, along
with nausea and elevated bilirubin on day 28 post-allogeneic transplant. Which GVHD
classification and staging system is most appropriate for this presentation?
A. Acute GVHD, Glucksberg staging
B. Chronic GVHD, NIH consensus criteria
C. Acute GVHD, Mount Sinai Acute GVHD International Consortium (MAGIC)
algorithm
D. Late-onset acute GVHD, IBMTR severity index
Answer: A. Acute GVHD, Glucksberg staging
Rationale: This presentation is classic acute GVHD occurring within the first 100 days,
and the Glucksberg staging system is the traditional standard for acute GVHD. Chronic
GVHD typically presents after day 100 with distinct features. MAGIC is used for
biomarker-based risk stratification, not initial staging. Late-onset acute GVHD occurs
after day 100 and is not the primary classification here.
2. Which medication is a first-line agent for GVHD prophylaxis in reduced-intensity
conditioning allogeneic transplant, and requires monitoring of trough levels due to
narrow therapeutic index?
A. Mycophenolate mofetil
B. Tacrolimus
C. Methotrexate
D. Antithymocyte globulin
Answer: B. Tacrolimus
Rationale: Tacrolimus is a calcineurin inhibitor commonly used for GVHD prophylaxis and
requires therapeutic drug monitoring due to its narrow therapeutic index and risk of
nephrotoxicity. Mycophenolate mofetil is often used in combination but does not require
routine trough monitoring. Methotrexate is used but is not typically monitored by trough
levels. Antithymocyte globulin is used for prophylaxis in some regimens but is not the
primary agent requiring trough monitoring.
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,3. A patient on tacrolimus for GVHD prophylaxis has a trough level of 18 ng/mL and
reports new-onset tremors and hypertension. What is the most appropriate nursing
action?
A. Administer the next dose as scheduled and document findings.
B. Hold the next dose and notify the provider immediately.
C. Encourage increased fluid intake to enhance excretion.
D. Recheck the level after the next dose.
Answer: B. Hold the next dose and notify the provider immediately.
Rationale: Tacrolimus levels above the therapeutic range (typically 5-15 ng/mL) increase
risk of nephrotoxicity and neurotoxicity; tremors and hypertension are signs of toxicity. The
nurse should hold the dose and notify the provider. Administering the dose could worsen
toxicity. Fluid intake does not significantly enhance tacrolimus excretion. Rechecking after
another dose delays intervention and could cause harm.
4. Which statement accurately reflects the mechanism of action of ruxolitinib in the
treatment of steroid-refractory acute GVHD?
A. It inhibits calcineurin, reducing T-cell activation.
B. It blocks IL-6 receptors, decreasing cytokine release.
C. It selectively inhibits JAK1/2, dampening inflammatory cytokine signaling.
D. It depletes B cells via anti-CD20 activity.
Answer: C. It selectively inhibits JAK1/2, dampening inflammatory cytokine
signaling.
Rationale: Ruxolitinib is a JAK1/2 inhibitor that reduces signaling of multiple
inflammatory cytokines involved in GVHD. Calcineurin inhibition is the mechanism of
tacrolimus and cyclosporine. IL-6 receptor blockade is characteristic of tocilizumab. B-cell
depletion is the mechanism of rituximab, not ruxolitinib.
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, 5. A patient with chronic GVHD is started on ibrutinib. Which adverse effect requires
priority monitoring?
A. Hyperglycemia
B. Atrial fibrillation
C. Hypothyroidism
D. Peripheral neuropathy
Answer: B. Atrial fibrillation
Rationale: Ibrutinib is associated with an increased risk of atrial fibrillation and bleeding.
Hyperglycemia is more common with corticosteroids. Hypothyroidism and peripheral
neuropathy are not typical adverse effects of ibrutinib.
6. Which vaccine is contraindicated in an allogeneic transplant recipient during the
first year post-transplant due to risk of disseminated infection?
A. Inactivated influenza vaccine
B. Live attenuated varicella-zoster vaccine
C. Pneumococcal conjugate vaccine
D. Hepatitis B vaccine
Answer: B. Live attenuated varicella-zoster vaccine
Rationale: Live attenuated vaccines are generally contraindicated in immunocompromised
transplant recipients due to the risk of disseminated disease. Inactivated influenza,
pneumococcal, and hepatitis B vaccines are safe and recommended. Live vaccines may be
considered later in select patients but are avoided in the first year.
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Study Test Bank
1. A transplant recipient develops a maculopapular rash on the palms and soles, along
with nausea and elevated bilirubin on day 28 post-allogeneic transplant. Which GVHD
classification and staging system is most appropriate for this presentation?
A. Acute GVHD, Glucksberg staging
B. Chronic GVHD, NIH consensus criteria
C. Acute GVHD, Mount Sinai Acute GVHD International Consortium (MAGIC)
algorithm
D. Late-onset acute GVHD, IBMTR severity index
Answer: A. Acute GVHD, Glucksberg staging
Rationale: This presentation is classic acute GVHD occurring within the first 100 days,
and the Glucksberg staging system is the traditional standard for acute GVHD. Chronic
GVHD typically presents after day 100 with distinct features. MAGIC is used for
biomarker-based risk stratification, not initial staging. Late-onset acute GVHD occurs
after day 100 and is not the primary classification here.
2. Which medication is a first-line agent for GVHD prophylaxis in reduced-intensity
conditioning allogeneic transplant, and requires monitoring of trough levels due to
narrow therapeutic index?
A. Mycophenolate mofetil
B. Tacrolimus
C. Methotrexate
D. Antithymocyte globulin
Answer: B. Tacrolimus
Rationale: Tacrolimus is a calcineurin inhibitor commonly used for GVHD prophylaxis and
requires therapeutic drug monitoring due to its narrow therapeutic index and risk of
nephrotoxicity. Mycophenolate mofetil is often used in combination but does not require
routine trough monitoring. Methotrexate is used but is not typically monitored by trough
levels. Antithymocyte globulin is used for prophylaxis in some regimens but is not the
primary agent requiring trough monitoring.
Page 1 of 76
,Page 2 of 76
,3. A patient on tacrolimus for GVHD prophylaxis has a trough level of 18 ng/mL and
reports new-onset tremors and hypertension. What is the most appropriate nursing
action?
A. Administer the next dose as scheduled and document findings.
B. Hold the next dose and notify the provider immediately.
C. Encourage increased fluid intake to enhance excretion.
D. Recheck the level after the next dose.
Answer: B. Hold the next dose and notify the provider immediately.
Rationale: Tacrolimus levels above the therapeutic range (typically 5-15 ng/mL) increase
risk of nephrotoxicity and neurotoxicity; tremors and hypertension are signs of toxicity. The
nurse should hold the dose and notify the provider. Administering the dose could worsen
toxicity. Fluid intake does not significantly enhance tacrolimus excretion. Rechecking after
another dose delays intervention and could cause harm.
4. Which statement accurately reflects the mechanism of action of ruxolitinib in the
treatment of steroid-refractory acute GVHD?
A. It inhibits calcineurin, reducing T-cell activation.
B. It blocks IL-6 receptors, decreasing cytokine release.
C. It selectively inhibits JAK1/2, dampening inflammatory cytokine signaling.
D. It depletes B cells via anti-CD20 activity.
Answer: C. It selectively inhibits JAK1/2, dampening inflammatory cytokine
signaling.
Rationale: Ruxolitinib is a JAK1/2 inhibitor that reduces signaling of multiple
inflammatory cytokines involved in GVHD. Calcineurin inhibition is the mechanism of
tacrolimus and cyclosporine. IL-6 receptor blockade is characteristic of tocilizumab. B-cell
depletion is the mechanism of rituximab, not ruxolitinib.
Page 3 of 76
, 5. A patient with chronic GVHD is started on ibrutinib. Which adverse effect requires
priority monitoring?
A. Hyperglycemia
B. Atrial fibrillation
C. Hypothyroidism
D. Peripheral neuropathy
Answer: B. Atrial fibrillation
Rationale: Ibrutinib is associated with an increased risk of atrial fibrillation and bleeding.
Hyperglycemia is more common with corticosteroids. Hypothyroidism and peripheral
neuropathy are not typical adverse effects of ibrutinib.
6. Which vaccine is contraindicated in an allogeneic transplant recipient during the
first year post-transplant due to risk of disseminated infection?
A. Inactivated influenza vaccine
B. Live attenuated varicella-zoster vaccine
C. Pneumococcal conjugate vaccine
D. Hepatitis B vaccine
Answer: B. Live attenuated varicella-zoster vaccine
Rationale: Live attenuated vaccines are generally contraindicated in immunocompromised
transplant recipients due to the risk of disseminated disease. Inactivated influenza,
pneumococcal, and hepatitis B vaccines are safe and recommended. Live vaccines may be
considered later in select patients but are avoided in the first year.
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