ONS/ONCC CHEMOTHERAPY IMMUNOTHERAPY
CERTIFICATION EXAM 300 ACTUAL QUESTIONS
AND CORRECT ANWERS WITH RATIONALE LATEST
UPDATE 2026 ALREADY GRADED A+
This comprehensive 300-question practice exam is designed for nurses
preparing for the ONS/ONCC Chemotherapy and Immunotherapy
Certification. It covers all major content areas including pharmacology, cell
cycle kinetics, safe handling and administration, extravasation management,
vesicant precautions, immunotherapy mechanisms, immune-related adverse
events, cytokine release syndrome, targeted therapies, toxicity monitoring,
symptom management, and calculations such as ANC and body surface area.
Each question includes a multiple-choice format with a single correct answer
and a detailed rationale explaining the underlying clinical reasoning,
pathophysiology, and evidence-based nursing interventions, ensuring
thorough preparation for the advanced certification examination.
1. A patient receiving etoposide reports itching around the peripheral IV site. The
nurse observes red streaks along the vein to the IV site and is able to obtain a blood
return. What is the most likely cause?
A) Infiltration
B) Extravasation
C) Vein irritation
D) Flare reaction
Answer: C) Vein irritation
Rationale: The presence of a blood return rules out infiltration and extravasation,
which involve the drug leaking into the surrounding tissue. Red streaking along the
vein with a blood return, coupled with itching, is a classic presentation of vein
irritation (chemical phlebitis). A flare reaction is a localized allergic response at the
site, often characterized by a wheal and erythema, but it would not typically
present with red streaking along the vein path.
2. What is the mechanism of action of Filgrastim (G-CSF)?
A) Regulating the production of cells in the bone marrow
,B) Preventing metastasis of cancer cells
C) Enhancing the immune system to attack cancer cells
D) Changing cancer cells into healthy cells
Answer: A) Regulating the production of cells in the bone marrow
Rationale: Filgrastim is a myeloid growth factor that stimulates the bone marrow to
produce more neutrophils. It does not have direct antitumor effects, nor does it
prevent metastasis or change cancer cell biology. Its primary role is to shorten the
duration of neutropenia following myelosuppressive chemotherapy.
3. A patient is receiving cisplatin. Which assessment finding requires the most
immediate nursing intervention?
A) Serum creatinine of 1.8 mg/dL
B) Nausea rated 4 out of 10
C) Mild tinnitus in both ears
D) Platelet count of 110,000/mcL
Answer: A) Serum creatinine of 1.8 mg/dL
Rationale: Cisplatin is profoundly nephrotoxic, and a serum creatinine of 1.8
mg/dL indicates acute kidney injury. This requires immediate intervention,
including holding the drug and increasing hydration. While nausea, tinnitus, and
thrombocytopenia are all important side effects, renal failure poses a more
immediate and potentially irreversible threat to patient safety.
4. The p53 tumor suppressor gene is often referred to as the "guardian of the
genome." What is its primary function?
A) Promoting angiogenesis in tumors
B) Activating DNA repair mechanisms or initiating apoptosis in damaged cells
C) Stimulating the production of hematopoietic stem cells
D) Enhancing the immune response to foreign antigens
Answer: B) Activating DNA repair mechanisms or initiating apoptosis in damaged
cells
Rationale: The p53 gene plays a critical role in maintaining genomic stability.
When DNA damage is detected, p53 halts the cell cycle to allow for repair. If the
damage is irreparable, p53 initiates apoptosis to prevent the propagation of
mutations that could lead to cancer. It does not promote angiogenesis, stimulate
stem cells, or directly enhance immunity.
,5. A nurse is preparing to administer a vesicant chemotherapy agent. Which action
is the most appropriate to prevent extravasation?
A) Administer the drug via a push over 1 to 2 minutes
B) Use a small gauge butterfly needle in the antecubital fossa
C) Use a central venous access device whenever possible
D) Apply a warm compress to the site prior to infusion
Answer: C) Use a central venous access device whenever possible
Rationale: Central venous access devices (CVADs) deliver drugs into large, high-
flow vessels, which significantly reduces the risk of extravasation. Peripheral
veins, especially those in the antecubital fossa, are higher risk. While a blood
return should be checked, the safest practice is to use a CVAD for vesicant
administration.
6. A patient on a monoclonal antibody therapy develops chills, fever, and
hypotension during the first infusion. What is the priority nursing action?
A) Slow the infusion rate immediately
B) Administer diphenhydramine as prescribed
C) Stop the infusion and notify the provider
D) Increase the infusion rate to complete the treatment
Answer: C) Stop the infusion and notify the provider
Rationale: These symptoms are indicative of a severe infusion-related reaction,
which can progress to anaphylaxis. The immediate priority is to stop the infusion
to prevent further drug administration. While slowing the rate and giving
antihistamines may be subsequent steps, the first action is to discontinue the
infusion and alert the provider.
7. Which of the following cell cycle phases is the primary target for antimetabolite
chemotherapy agents?
A) G0 (resting phase)
B) G1 phase
C) S phase
D) M phase
Answer: C) S phase
Rationale: Antimetabolites such as methotrexate, 5-fluorouracil, and cytarabine are
S-phase specific. They interfere with DNA synthesis by mimicking essential
metabolites or inhibiting key enzymes required for nucleotide production. They are
most effective against rapidly dividing cells that are actively synthesizing DNA.
, 8. A patient is receiving high-dose methotrexate. To prevent renal toxicity, the
nurse should anticipate administering which rescue agent?
A) Mesna
B) Leucovorin
C) Amifostine
D) Dexrazoxane
Answer: B) Leucovorin
Rationale: Leucovorin (folinic acid) is a reduced folate that "rescues" normal cells
by bypassing the metabolic block caused by methotrexate. It is administered to
prevent myelosuppression and mucositis. Mesna is used to prevent hemorrhagic
cystitis with ifosfamide and cyclophosphamide. Amifostine is a cytoprotectant for
cisplatin-related nephrotoxicity, and dexrazoxane is a cardioprotectant for
anthracyclines.
9. What is the primary mechanism of action for alkylating agents such as
cyclophosphamide?
A) Inhibiting microtubule formation
B) Interfering with DNA replication by cross-linking DNA strands
C) Inhibiting topoisomerase enzymes
D) Blocking hormone receptors on cancer cells
Answer: B) Interfering with DNA replication by cross-linking DNA strands
Rationale: Alkylating agents work by adding alkyl groups to the DNA molecule,
specifically at the guanine base. This causes cross-linking between DNA strands,
which prevents DNA replication and leads to cell death. They are cell cycle non-
specific.
10. A patient on trastuzumab develops dyspnea, crackles in the lung bases, and a
weight gain of 3 kg in 48 hours. What is the most likely cause of these symptoms?
A) Anaphylaxis
B) Tumor lysis syndrome
C) Cardiotoxicity leading to heart failure
D) Pulmonary fibrosis
Answer: C) Cardiotoxicity leading to heart failure
Rationale: Trastuzumab is associated with a significant risk of cardiotoxicity,
which can manifest as left ventricular dysfunction and heart failure. Symptoms
include dyspnea, peripheral edema, pulmonary crackles, and rapid weight gain due
CERTIFICATION EXAM 300 ACTUAL QUESTIONS
AND CORRECT ANWERS WITH RATIONALE LATEST
UPDATE 2026 ALREADY GRADED A+
This comprehensive 300-question practice exam is designed for nurses
preparing for the ONS/ONCC Chemotherapy and Immunotherapy
Certification. It covers all major content areas including pharmacology, cell
cycle kinetics, safe handling and administration, extravasation management,
vesicant precautions, immunotherapy mechanisms, immune-related adverse
events, cytokine release syndrome, targeted therapies, toxicity monitoring,
symptom management, and calculations such as ANC and body surface area.
Each question includes a multiple-choice format with a single correct answer
and a detailed rationale explaining the underlying clinical reasoning,
pathophysiology, and evidence-based nursing interventions, ensuring
thorough preparation for the advanced certification examination.
1. A patient receiving etoposide reports itching around the peripheral IV site. The
nurse observes red streaks along the vein to the IV site and is able to obtain a blood
return. What is the most likely cause?
A) Infiltration
B) Extravasation
C) Vein irritation
D) Flare reaction
Answer: C) Vein irritation
Rationale: The presence of a blood return rules out infiltration and extravasation,
which involve the drug leaking into the surrounding tissue. Red streaking along the
vein with a blood return, coupled with itching, is a classic presentation of vein
irritation (chemical phlebitis). A flare reaction is a localized allergic response at the
site, often characterized by a wheal and erythema, but it would not typically
present with red streaking along the vein path.
2. What is the mechanism of action of Filgrastim (G-CSF)?
A) Regulating the production of cells in the bone marrow
,B) Preventing metastasis of cancer cells
C) Enhancing the immune system to attack cancer cells
D) Changing cancer cells into healthy cells
Answer: A) Regulating the production of cells in the bone marrow
Rationale: Filgrastim is a myeloid growth factor that stimulates the bone marrow to
produce more neutrophils. It does not have direct antitumor effects, nor does it
prevent metastasis or change cancer cell biology. Its primary role is to shorten the
duration of neutropenia following myelosuppressive chemotherapy.
3. A patient is receiving cisplatin. Which assessment finding requires the most
immediate nursing intervention?
A) Serum creatinine of 1.8 mg/dL
B) Nausea rated 4 out of 10
C) Mild tinnitus in both ears
D) Platelet count of 110,000/mcL
Answer: A) Serum creatinine of 1.8 mg/dL
Rationale: Cisplatin is profoundly nephrotoxic, and a serum creatinine of 1.8
mg/dL indicates acute kidney injury. This requires immediate intervention,
including holding the drug and increasing hydration. While nausea, tinnitus, and
thrombocytopenia are all important side effects, renal failure poses a more
immediate and potentially irreversible threat to patient safety.
4. The p53 tumor suppressor gene is often referred to as the "guardian of the
genome." What is its primary function?
A) Promoting angiogenesis in tumors
B) Activating DNA repair mechanisms or initiating apoptosis in damaged cells
C) Stimulating the production of hematopoietic stem cells
D) Enhancing the immune response to foreign antigens
Answer: B) Activating DNA repair mechanisms or initiating apoptosis in damaged
cells
Rationale: The p53 gene plays a critical role in maintaining genomic stability.
When DNA damage is detected, p53 halts the cell cycle to allow for repair. If the
damage is irreparable, p53 initiates apoptosis to prevent the propagation of
mutations that could lead to cancer. It does not promote angiogenesis, stimulate
stem cells, or directly enhance immunity.
,5. A nurse is preparing to administer a vesicant chemotherapy agent. Which action
is the most appropriate to prevent extravasation?
A) Administer the drug via a push over 1 to 2 minutes
B) Use a small gauge butterfly needle in the antecubital fossa
C) Use a central venous access device whenever possible
D) Apply a warm compress to the site prior to infusion
Answer: C) Use a central venous access device whenever possible
Rationale: Central venous access devices (CVADs) deliver drugs into large, high-
flow vessels, which significantly reduces the risk of extravasation. Peripheral
veins, especially those in the antecubital fossa, are higher risk. While a blood
return should be checked, the safest practice is to use a CVAD for vesicant
administration.
6. A patient on a monoclonal antibody therapy develops chills, fever, and
hypotension during the first infusion. What is the priority nursing action?
A) Slow the infusion rate immediately
B) Administer diphenhydramine as prescribed
C) Stop the infusion and notify the provider
D) Increase the infusion rate to complete the treatment
Answer: C) Stop the infusion and notify the provider
Rationale: These symptoms are indicative of a severe infusion-related reaction,
which can progress to anaphylaxis. The immediate priority is to stop the infusion
to prevent further drug administration. While slowing the rate and giving
antihistamines may be subsequent steps, the first action is to discontinue the
infusion and alert the provider.
7. Which of the following cell cycle phases is the primary target for antimetabolite
chemotherapy agents?
A) G0 (resting phase)
B) G1 phase
C) S phase
D) M phase
Answer: C) S phase
Rationale: Antimetabolites such as methotrexate, 5-fluorouracil, and cytarabine are
S-phase specific. They interfere with DNA synthesis by mimicking essential
metabolites or inhibiting key enzymes required for nucleotide production. They are
most effective against rapidly dividing cells that are actively synthesizing DNA.
, 8. A patient is receiving high-dose methotrexate. To prevent renal toxicity, the
nurse should anticipate administering which rescue agent?
A) Mesna
B) Leucovorin
C) Amifostine
D) Dexrazoxane
Answer: B) Leucovorin
Rationale: Leucovorin (folinic acid) is a reduced folate that "rescues" normal cells
by bypassing the metabolic block caused by methotrexate. It is administered to
prevent myelosuppression and mucositis. Mesna is used to prevent hemorrhagic
cystitis with ifosfamide and cyclophosphamide. Amifostine is a cytoprotectant for
cisplatin-related nephrotoxicity, and dexrazoxane is a cardioprotectant for
anthracyclines.
9. What is the primary mechanism of action for alkylating agents such as
cyclophosphamide?
A) Inhibiting microtubule formation
B) Interfering with DNA replication by cross-linking DNA strands
C) Inhibiting topoisomerase enzymes
D) Blocking hormone receptors on cancer cells
Answer: B) Interfering with DNA replication by cross-linking DNA strands
Rationale: Alkylating agents work by adding alkyl groups to the DNA molecule,
specifically at the guanine base. This causes cross-linking between DNA strands,
which prevents DNA replication and leads to cell death. They are cell cycle non-
specific.
10. A patient on trastuzumab develops dyspnea, crackles in the lung bases, and a
weight gain of 3 kg in 48 hours. What is the most likely cause of these symptoms?
A) Anaphylaxis
B) Tumor lysis syndrome
C) Cardiotoxicity leading to heart failure
D) Pulmonary fibrosis
Answer: C) Cardiotoxicity leading to heart failure
Rationale: Trastuzumab is associated with a significant risk of cardiotoxicity,
which can manifest as left ventricular dysfunction and heart failure. Symptoms
include dyspnea, peripheral edema, pulmonary crackles, and rapid weight gain due
