COMPREHENSIVE PEDIATRIC ONCOLOGY & NCLEX
EXAM REVIEW
Focus: Acute Lymphocytic Leukemia (ALL), Febrile Neutropenia,
Oncology Emergencies, and Advanced Pediatric Nursing
200 Clinical Questions with Detailed Rationales
Question 1: A nurse is assessing a toddler who has acute
lymphocytic leukemia (ALL) and a temperature of 38.5°C (101.3°F).
Which of the following actions is the nurse's priority?
A. Obtain blood cultures from two sites and a central line if present.
B. Initiate broad-spectrum intravenous antibiotics immediately as
prescribed.
C. Administer prescribed antipyretics such as acetaminophen.
D. Place the child in strict reverse isolation.
Correct Answer: B. Initiate broad-spectrum intravenous
antibiotics immediately as prescribed.
Rationale: In a child with acute lymphocytic leukemia (ALL) who is
immunocompromised, a fever (≥38.0°C / 100.4°F) is a medical
emergency indicating potential neutropenic sepsis. The priority
nursing action is the immediate administration of prescribed broad-
spectrum IV antibiotics (typically within 60 minutes of presentation)
after blood cultures are drawn. While obtaining cultures (Option A)
is critical, antibiotic administration takes precedence to prevent rapid
septic shock and death. Antipyretics (Option C) mask fever but do not
treat the underlying life-threatening infection. Reverse isolation
(Option D) should already be in place and is a continuous measure,
not an acute resuscitation priority.
,Question 2: A nurse is caring for a 4-year-old child with ALL
receiving induction chemotherapy. The child develops petechiae,
purpura, and oozing from the gums. Which laboratory result
correlates best with these clinical findings?
A. White blood cell (WBC) count of 1,200/mm³
B. Hemoglobin of 7.2 g/dL
C. Platelet count of 18,000/mm³
D. Absolute neutrophil count (ANC) of 300/mm³
Correct Answer: C. Platelet count of 18,000/mm³
Rationale: Petechiae, purpura, and mucosal bleeding are classic
signs of thrombocytopenia (low platelets). Normal platelet count
ranges from 150,000 to 450,000/mm³. A count of 18,000/mm³ places
the child at severe risk for spontaneous bleeding and hemorrhage. A
low WBC or ANC (Options A and D) increases infection risk. A low
hemoglobin of 7.2 g/dL (Option B) indicates anemia, causing pallor,
fatigue, and tachycardia, but not spontaneous mucosal bleeding.
Question 3: A child with ALL is admitted for chemotherapy. The
nurse notes bone pain in the lower extremities. Which
pathophysiological mechanism explains this symptom?
A. Rapid proliferation of malignant lymphoblasts expanding the bone
marrow cavity
B. Calcium depletion resulting from hypocalcemia secondary to
tumor lysis
C. Peripheral neuropathy caused by vincristine toxicity
D. Direct bacterial invasion of the periosteum
Correct Answer: A. Rapid proliferation of malignant
lymphoblasts expanding the bone marrow cavity
Rationale: In ALL, malignant, immature lymphocytes (lymphoblasts)
, proliferate uncontrollably within the bone marrow. This massive
expansion increases intramedullary pressure, stretching the
periosteum and resulting in characteristic bone and joint pain,
particularly in the long bones of the legs. Calcium depletion (Option
B) causes tetany or muscle spasms. Vincristine neurotoxicity (Option
C) causes foot drop, numbness, and constipation, not initial bone
pain. Bacterial osteomyelitis (Option D) is possible in neutropenic
patients but is not the primary cause of generalized leukemia bone
pain.
Question 4: A nurse is educating the parents of a child newly
diagnosed with ALL regarding home care precautions during
maintenance chemotherapy. Which statement by the parents
indicates an understanding of infection prevention?
A. 'We will ensure our child receives all live viral vaccines on
schedule.'
B. 'We should encourage our child to play outside in the soil and
garden.'
C. 'We will wash our hands frequently and avoid crowds and sick
individuals.'
D. 'We can keep our pet parrot and clean its cage daily.'
Correct Answer: C. 'We will wash our hands frequently and
avoid crowds and sick individuals.'
Rationale: Immunocompromised children undergoing chemotherapy
must avoid crowds, sick contacts, and practice meticulous hand
hygiene to prevent severe infections. Live viral vaccines (Option A,
such as MMR, varicella, rotavirus) are strictly contraindicated
because they can cause disseminated disease in immunosuppressed
hosts. Gardening and soil exposure (Option B) carry high risks of
fungal infections like Aspergillus. Exotic pets and bird cages (Option
, D) harbor opportunistic pathogens such as Cryptococcus, Psittacosis,
and Salmonella.
Question 5: During the infusion of IV vincristine for ALL, the nurse
notes swelling, coolness, and lack of blood return at the peripheral
IV site. What is the nurse's immediate action?
A. Flush the IV line aggressively with normal saline to clear the
vessel.
B. Stop the infusion immediately and disconnect the tubing.
C. Apply warm compresses to the insertion site to promote
absorption.
D. Slow the infusion rate and notify the primary healthcare provider.
Correct Answer: B. Stop the infusion immediately and disconnect
the tubing.
Rationale: Vincristine is a potent vesicant drug. Extravasation causes
severe local tissue necrosis, sloughing, and potential nerve damage.
The immediate priority is to stop the infusion and disconnect the
tubing while leaving the cannula in place in order to attempt
aspiration of residual drug before administering the specific antidote
(hyaluronidase). Flushing (Option A) pushes more vesicant into
tissues. Warm compresses (Option C) are contraindicated for
vincristine extravasation (cold compresses are used for vincristine;
warm for DNA-binding vesicants like anthracyclines).
Question 6: Question 6: A child with newly diagnosed ALL with a
high tumor burden starts chemotherapy. Which laboratory
abnormality is characteristic of Tumor Lysis Syndrome (TLS)?
A. Hypokalemia, hypophosphatemia, hypuricemia, hypercalcemia
B. Hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia
C. Hyponatremia, hypokalemia, hypercalcemia, hypophosphatemia
EXAM REVIEW
Focus: Acute Lymphocytic Leukemia (ALL), Febrile Neutropenia,
Oncology Emergencies, and Advanced Pediatric Nursing
200 Clinical Questions with Detailed Rationales
Question 1: A nurse is assessing a toddler who has acute
lymphocytic leukemia (ALL) and a temperature of 38.5°C (101.3°F).
Which of the following actions is the nurse's priority?
A. Obtain blood cultures from two sites and a central line if present.
B. Initiate broad-spectrum intravenous antibiotics immediately as
prescribed.
C. Administer prescribed antipyretics such as acetaminophen.
D. Place the child in strict reverse isolation.
Correct Answer: B. Initiate broad-spectrum intravenous
antibiotics immediately as prescribed.
Rationale: In a child with acute lymphocytic leukemia (ALL) who is
immunocompromised, a fever (≥38.0°C / 100.4°F) is a medical
emergency indicating potential neutropenic sepsis. The priority
nursing action is the immediate administration of prescribed broad-
spectrum IV antibiotics (typically within 60 minutes of presentation)
after blood cultures are drawn. While obtaining cultures (Option A)
is critical, antibiotic administration takes precedence to prevent rapid
septic shock and death. Antipyretics (Option C) mask fever but do not
treat the underlying life-threatening infection. Reverse isolation
(Option D) should already be in place and is a continuous measure,
not an acute resuscitation priority.
,Question 2: A nurse is caring for a 4-year-old child with ALL
receiving induction chemotherapy. The child develops petechiae,
purpura, and oozing from the gums. Which laboratory result
correlates best with these clinical findings?
A. White blood cell (WBC) count of 1,200/mm³
B. Hemoglobin of 7.2 g/dL
C. Platelet count of 18,000/mm³
D. Absolute neutrophil count (ANC) of 300/mm³
Correct Answer: C. Platelet count of 18,000/mm³
Rationale: Petechiae, purpura, and mucosal bleeding are classic
signs of thrombocytopenia (low platelets). Normal platelet count
ranges from 150,000 to 450,000/mm³. A count of 18,000/mm³ places
the child at severe risk for spontaneous bleeding and hemorrhage. A
low WBC or ANC (Options A and D) increases infection risk. A low
hemoglobin of 7.2 g/dL (Option B) indicates anemia, causing pallor,
fatigue, and tachycardia, but not spontaneous mucosal bleeding.
Question 3: A child with ALL is admitted for chemotherapy. The
nurse notes bone pain in the lower extremities. Which
pathophysiological mechanism explains this symptom?
A. Rapid proliferation of malignant lymphoblasts expanding the bone
marrow cavity
B. Calcium depletion resulting from hypocalcemia secondary to
tumor lysis
C. Peripheral neuropathy caused by vincristine toxicity
D. Direct bacterial invasion of the periosteum
Correct Answer: A. Rapid proliferation of malignant
lymphoblasts expanding the bone marrow cavity
Rationale: In ALL, malignant, immature lymphocytes (lymphoblasts)
, proliferate uncontrollably within the bone marrow. This massive
expansion increases intramedullary pressure, stretching the
periosteum and resulting in characteristic bone and joint pain,
particularly in the long bones of the legs. Calcium depletion (Option
B) causes tetany or muscle spasms. Vincristine neurotoxicity (Option
C) causes foot drop, numbness, and constipation, not initial bone
pain. Bacterial osteomyelitis (Option D) is possible in neutropenic
patients but is not the primary cause of generalized leukemia bone
pain.
Question 4: A nurse is educating the parents of a child newly
diagnosed with ALL regarding home care precautions during
maintenance chemotherapy. Which statement by the parents
indicates an understanding of infection prevention?
A. 'We will ensure our child receives all live viral vaccines on
schedule.'
B. 'We should encourage our child to play outside in the soil and
garden.'
C. 'We will wash our hands frequently and avoid crowds and sick
individuals.'
D. 'We can keep our pet parrot and clean its cage daily.'
Correct Answer: C. 'We will wash our hands frequently and
avoid crowds and sick individuals.'
Rationale: Immunocompromised children undergoing chemotherapy
must avoid crowds, sick contacts, and practice meticulous hand
hygiene to prevent severe infections. Live viral vaccines (Option A,
such as MMR, varicella, rotavirus) are strictly contraindicated
because they can cause disseminated disease in immunosuppressed
hosts. Gardening and soil exposure (Option B) carry high risks of
fungal infections like Aspergillus. Exotic pets and bird cages (Option
, D) harbor opportunistic pathogens such as Cryptococcus, Psittacosis,
and Salmonella.
Question 5: During the infusion of IV vincristine for ALL, the nurse
notes swelling, coolness, and lack of blood return at the peripheral
IV site. What is the nurse's immediate action?
A. Flush the IV line aggressively with normal saline to clear the
vessel.
B. Stop the infusion immediately and disconnect the tubing.
C. Apply warm compresses to the insertion site to promote
absorption.
D. Slow the infusion rate and notify the primary healthcare provider.
Correct Answer: B. Stop the infusion immediately and disconnect
the tubing.
Rationale: Vincristine is a potent vesicant drug. Extravasation causes
severe local tissue necrosis, sloughing, and potential nerve damage.
The immediate priority is to stop the infusion and disconnect the
tubing while leaving the cannula in place in order to attempt
aspiration of residual drug before administering the specific antidote
(hyaluronidase). Flushing (Option A) pushes more vesicant into
tissues. Warm compresses (Option C) are contraindicated for
vincristine extravasation (cold compresses are used for vincristine;
warm for DNA-binding vesicants like anthracyclines).
Question 6: Question 6: A child with newly diagnosed ALL with a
high tumor burden starts chemotherapy. Which laboratory
abnormality is characteristic of Tumor Lysis Syndrome (TLS)?
A. Hypokalemia, hypophosphatemia, hypuricemia, hypercalcemia
B. Hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia
C. Hyponatremia, hypokalemia, hypercalcemia, hypophosphatemia
