BMTCN Practice Test B: HSCT Nursing Care, GVHD &
Survivorship Essentials|2025-2026|Updated!!
SECTION I: HSCT NURSING CARE (Questions 1-40)
1. A 45-year-old patient undergoes allogeneic hematopoietic stem cell transplantation
(HSCT) for acute myeloid leukemia. On day +7, the patient develops fever, erythematous
maculopapular rash on the palms and soles, and watery diarrhea. Which condition is most
likely?
• A) Engraftment syndrome
• B) Acute GVHD
• C) Conditioning regimen toxicity
• D) Viral gastroenteritis
Answer: B
Rationale: Acute GVHD typically occurs between days +10 and +100 post-allogeneic HSCT.
Classic triad: rash (maculopapular, often palms/soles), diarrhea (>500 mL/day), and elevated
bilirubin. Engraftment syndrome occurs earlier (around engraftment, day +7–14) but fever
and rash are common; however, diarrhea points more to GVHD.
2. Which cell count is the earliest indicator of hematopoietic engraftment after autologous
HSCT?
• A) Hemoglobin >8 g/dL
• B) Platelet count >50,000/mcL
• C) Absolute neutrophil count (ANC) >500/mcL for 3 consecutive days
• D) Reticulocyte count >1%
Answer: C
Rationale: Neutrophil engraftment is defined as ANC >500/mcL for 3 days. Platelets lag
behind neutrophils. Autologous transplants engraft faster than allogeneic (usually day +10–
14).
3. A patient receiving high-dose melphalan before autologous HSCT for multiple myeloma
reports severe mucositis. Which intervention is most effective?
, • A) Oral nystatin swish and swallow
• B) IV patient-controlled analgesia (PCA) morphine
• C) Cryotherapy (oral ice chips) during melphalan infusion
• D) Sucralfate slurry
Answer: C
Rationale: Cryotherapy causes vasoconstriction of oral mucosa, reducing melphalan
exposure and mucositis severity. Evidence supports its use specifically with melphalan. PCA
is for pain after mucositis develops, not prevention.
4. On day +3 after allogeneic HSCT, a patient’s serum potassium is 2.8 mEq/L despite oral
and IV supplementation. What is the priority action?
• A) Increase IV potassium rate to 20 mEq/hour
• B) Check serum magnesium level
• C) Administer sodium polystyrene sulfonate
• D) Restrict oral intake
Answer: B
Rationale: Refractory hypokalemia is often due to concurrent hypomagnesemia, because
magnesium is required for Na+/K+-ATPase pump function. Correct Mg before K will correct.
5. Which finding is most suggestive of hepatic sinusoidal obstruction syndrome (SOS/VOD)
post-HSCT?
• A) Elevated direct bilirubin and hepatomegaly with ascites
• B) Elevated AST/ALT without weight gain
• C) Right upper quadrant pain and fever
• D) Thrombocytopenia and elevated alkaline phosphatase
Answer: A
Rationale: SOS/VOD (now called sinusoidal obstruction syndrome) presents with painful
hepatomegaly, jaundice (bilirubin >2 mg/dL), ascites, and weight gain (>5% baseline). It
typically occurs within first 21 days post-HSCT.
6. Which medication is used for prophylaxis of cytomegalovirus (CMV) reactivation in
seropositive allogeneic HSCT recipients?
, • A) Acyclovir
• B) Valganciclovir
• C) Letermovir
• D) Foscarnet
Answer: C
Rationale: Letermovir is approved for CMV prophylaxis in high-risk CMV-seropositive
allogeneic HSCT recipients (days 0–100). Valganciclovir is used for treatment or preemptive
therapy, not prophylaxis due to myelosuppression.
7. A patient after allogeneic HSCT develops crackles, hypoxemia, and a diffuse ground-glass
opacities on CT chest. Bronchoalveolar lavage is negative for bacteria, viruses, and fungi.
What is the most likely diagnosis?
• A) Idiopathic pneumonia syndrome (IPS)
• B) CMV pneumonitis
• C) Pulmonary GVHD
• D) Bronchiolitis obliterans organizing pneumonia (BOOP)
Answer: A
Rationale: IPS is a non-infectious diffuse lung injury post-HSCT with hypoxia and bilateral
infiltrates, no infection. It occurs in 5-15% of allogeneic recipients, typically before day +100.
8. What is the recommended central line care to reduce bloodstream infections in HSCT
patients?
• A) Change central line dressing every 72 hours and prn
• B) Flush all lumens daily with 10 mL normal saline
• C) Use chlorhexidine-impregnated dressings and scrub hub with 70% alcohol for 15
seconds before access
• D) Rotate central line to new site every 14 days
Answer: C
Rationale: Chlorhexidine dressings reduce catheter-related infections. Alcohol scrub of hubs
(15 sec friction) is critical. Routine site rotation is not indicated.
, 9. A patient receiving total body irradiation (TBI) as conditioning reports nausea 30
minutes after starting treatment. What is the best immediate nursing action?
• A) Stop the TBI and administer ondansetron
• B) Reassure that nausea is mild and continue
• C) Administer prescribed as-needed lorazepam and continue TBI
• D) Reschedule TBI for next day
Answer: C
Rationale: Nausea during TBI is common due to vagal stimulation. Lorazepam (antiemetic +
anxiolytic) and ondansetron are given before and during. Stopping TBI is not needed;
interruption can be brief.
10. Which vaccination is contraindicated after allogeneic HSCT?
• A) Inactivated influenza vaccine
• B) Pneumococcal conjugate vaccine (PCV13)
• C) Measles-mumps-rubella (MMR)
• D) Tetanus-diphtheria-pertussis (Tdap)
Answer: C
Rationale: Live vaccines (MMR, varicella, live zoster) are contraindicated until at least 24
months post-transplant and only if immune reconstitution is confirmed (CD4 >200, off
immunosuppression). Inactivated vaccines are safe starting 6 months post-HSCT.
11. A patient post-autologous HSCT has platelet count 12,000/mcL. Which action is a
priority?
• A) Administer platelet transfusion
• B) Apply firm pressure to venipuncture site for 10 minutes
• C) Remove all sharp objects from room
• D) Measure for intracranial bleeding every 4 hours
Answer: B
Rationale: Prolonged pressure after any invasive procedure prevents bleeding. Platelet
transfusion threshold is typically 10,000/mcL if asymptomatic, but pressure is an immediate
nursing action for safety.
Survivorship Essentials|2025-2026|Updated!!
SECTION I: HSCT NURSING CARE (Questions 1-40)
1. A 45-year-old patient undergoes allogeneic hematopoietic stem cell transplantation
(HSCT) for acute myeloid leukemia. On day +7, the patient develops fever, erythematous
maculopapular rash on the palms and soles, and watery diarrhea. Which condition is most
likely?
• A) Engraftment syndrome
• B) Acute GVHD
• C) Conditioning regimen toxicity
• D) Viral gastroenteritis
Answer: B
Rationale: Acute GVHD typically occurs between days +10 and +100 post-allogeneic HSCT.
Classic triad: rash (maculopapular, often palms/soles), diarrhea (>500 mL/day), and elevated
bilirubin. Engraftment syndrome occurs earlier (around engraftment, day +7–14) but fever
and rash are common; however, diarrhea points more to GVHD.
2. Which cell count is the earliest indicator of hematopoietic engraftment after autologous
HSCT?
• A) Hemoglobin >8 g/dL
• B) Platelet count >50,000/mcL
• C) Absolute neutrophil count (ANC) >500/mcL for 3 consecutive days
• D) Reticulocyte count >1%
Answer: C
Rationale: Neutrophil engraftment is defined as ANC >500/mcL for 3 days. Platelets lag
behind neutrophils. Autologous transplants engraft faster than allogeneic (usually day +10–
14).
3. A patient receiving high-dose melphalan before autologous HSCT for multiple myeloma
reports severe mucositis. Which intervention is most effective?
, • A) Oral nystatin swish and swallow
• B) IV patient-controlled analgesia (PCA) morphine
• C) Cryotherapy (oral ice chips) during melphalan infusion
• D) Sucralfate slurry
Answer: C
Rationale: Cryotherapy causes vasoconstriction of oral mucosa, reducing melphalan
exposure and mucositis severity. Evidence supports its use specifically with melphalan. PCA
is for pain after mucositis develops, not prevention.
4. On day +3 after allogeneic HSCT, a patient’s serum potassium is 2.8 mEq/L despite oral
and IV supplementation. What is the priority action?
• A) Increase IV potassium rate to 20 mEq/hour
• B) Check serum magnesium level
• C) Administer sodium polystyrene sulfonate
• D) Restrict oral intake
Answer: B
Rationale: Refractory hypokalemia is often due to concurrent hypomagnesemia, because
magnesium is required for Na+/K+-ATPase pump function. Correct Mg before K will correct.
5. Which finding is most suggestive of hepatic sinusoidal obstruction syndrome (SOS/VOD)
post-HSCT?
• A) Elevated direct bilirubin and hepatomegaly with ascites
• B) Elevated AST/ALT without weight gain
• C) Right upper quadrant pain and fever
• D) Thrombocytopenia and elevated alkaline phosphatase
Answer: A
Rationale: SOS/VOD (now called sinusoidal obstruction syndrome) presents with painful
hepatomegaly, jaundice (bilirubin >2 mg/dL), ascites, and weight gain (>5% baseline). It
typically occurs within first 21 days post-HSCT.
6. Which medication is used for prophylaxis of cytomegalovirus (CMV) reactivation in
seropositive allogeneic HSCT recipients?
, • A) Acyclovir
• B) Valganciclovir
• C) Letermovir
• D) Foscarnet
Answer: C
Rationale: Letermovir is approved for CMV prophylaxis in high-risk CMV-seropositive
allogeneic HSCT recipients (days 0–100). Valganciclovir is used for treatment or preemptive
therapy, not prophylaxis due to myelosuppression.
7. A patient after allogeneic HSCT develops crackles, hypoxemia, and a diffuse ground-glass
opacities on CT chest. Bronchoalveolar lavage is negative for bacteria, viruses, and fungi.
What is the most likely diagnosis?
• A) Idiopathic pneumonia syndrome (IPS)
• B) CMV pneumonitis
• C) Pulmonary GVHD
• D) Bronchiolitis obliterans organizing pneumonia (BOOP)
Answer: A
Rationale: IPS is a non-infectious diffuse lung injury post-HSCT with hypoxia and bilateral
infiltrates, no infection. It occurs in 5-15% of allogeneic recipients, typically before day +100.
8. What is the recommended central line care to reduce bloodstream infections in HSCT
patients?
• A) Change central line dressing every 72 hours and prn
• B) Flush all lumens daily with 10 mL normal saline
• C) Use chlorhexidine-impregnated dressings and scrub hub with 70% alcohol for 15
seconds before access
• D) Rotate central line to new site every 14 days
Answer: C
Rationale: Chlorhexidine dressings reduce catheter-related infections. Alcohol scrub of hubs
(15 sec friction) is critical. Routine site rotation is not indicated.
, 9. A patient receiving total body irradiation (TBI) as conditioning reports nausea 30
minutes after starting treatment. What is the best immediate nursing action?
• A) Stop the TBI and administer ondansetron
• B) Reassure that nausea is mild and continue
• C) Administer prescribed as-needed lorazepam and continue TBI
• D) Reschedule TBI for next day
Answer: C
Rationale: Nausea during TBI is common due to vagal stimulation. Lorazepam (antiemetic +
anxiolytic) and ondansetron are given before and during. Stopping TBI is not needed;
interruption can be brief.
10. Which vaccination is contraindicated after allogeneic HSCT?
• A) Inactivated influenza vaccine
• B) Pneumococcal conjugate vaccine (PCV13)
• C) Measles-mumps-rubella (MMR)
• D) Tetanus-diphtheria-pertussis (Tdap)
Answer: C
Rationale: Live vaccines (MMR, varicella, live zoster) are contraindicated until at least 24
months post-transplant and only if immune reconstitution is confirmed (CD4 >200, off
immunosuppression). Inactivated vaccines are safe starting 6 months post-HSCT.
11. A patient post-autologous HSCT has platelet count 12,000/mcL. Which action is a
priority?
• A) Administer platelet transfusion
• B) Apply firm pressure to venipuncture site for 10 minutes
• C) Remove all sharp objects from room
• D) Measure for intracranial bleeding every 4 hours
Answer: B
Rationale: Prolonged pressure after any invasive procedure prevents bleeding. Platelet
transfusion threshold is typically 10,000/mcL if asymptomatic, but pressure is an immediate
nursing action for safety.
