BMTCN Practice Questions (Review Manual and Cert Review)

What is the normal range for magnesium?

1.7 - 2.1 (in SCT)

What is the normal sodium range?

136 - 146 (or 135-145 depending where you read)

What is a normal albumin level?

2.2 and above

What is the normal range for potassium?

3.5 - 5.0

How much lymphodepleting chemo do patients receive prior to CAR-T?

4 days fludarabine, 2 days cyclophosphamide

What is the normal range for calcium?

8.7 - 10.2

What is considered HYPOkalemia?

<3.5

13. Identify an example of myeloid cell from the following? A. T cells B. Megakaryocytes C. Neuroglial cells D. Monocytes

? --> D

2. Which of the following is the leading cause of death after a cord blood transplant? A. Infection B. Bleeding C. Malnutrition D. Renal failure

A. Infection

1. When a patient senses a leaking in IV site during a chemotherapy infusion, what does the nurse do first? A. Please warning signs across the area to alert others to the spill B. Restart chemotherapy with a new order C. Put on the right safety gear D. Environmental programs should be contacted

A. Place warning signs across the area to alert others to the spill

18. Acute GVHD is a reaction of donor immune cells against host tissues that occur after ALLO transplant. Which graft source is more likely to develop ACUTE GVHG? A. Umbilical cord blood B. Peripheral blood stem cells C. Bone marrow D. None of the above

A? --> B

12. A cyclosporine (CSA)-treated patient was given a prescription for voriconazole, which he could self-administer. The nurse recognizes the following: A. When voriconazole and cyclosporine (CSA) are taken together, liver toxicity can occur B. After starting vori, CSA levels should be closely monitored C. Vori is not recommended for people who are taking CSA D. When CSA is combined with vori, hyperglycermia can occur

A? --> B (you knew this)

17. TMA is a condition that causes thrombosis in capillaries and arterioles as a result of endothelial damage. What is the first line of defense against thrombotic microangiopathy? A. Administering defibrotide B. Ketoconazole is being discontinued C. Cyclosporine (CSA) D. Tacrolimus withdrawal

A? --> D (that makes sense), its drug induced so you want to scale back on immunosuppressant

21. The factor that increases the likelihood of infertility following a SCT is? A. Alkylating agents used as part of conditioning process B. During transplant, monoclonal antibodies were given C. Less intensified preparative regimen D. None of the above

A? YAY

What can cause HYPERkalemia in SCT patients?

Acute renal failure (leukemic infiltration), sepsis, TLS, TMP-SMX, contrast

What are examples of anti-VIRAL antibiotics?

Acyclovir, valacyclovir, gancyclovir/valgancyclovir

What treatment is provided for Grade 4 CRS?

All of the grades before + CPAP/BIPAP or intubation and several pressors

What are examples of anti-BACTERIAL antibiotics?

Amoxicillin, azithromycin, cephalosporins

What are the signs and symptoms of HYPERcalcemia in SCT patients?

Anorexia, constipation N/V, polyuria, severe dehydration, BRADYcardia, CNS (confusion, seizures)

What treatment is provided with Grade 1 CRS?

Assess for infection (labs/etc), treat if neutropenic, and monitor fluid status

15. Based on the research process, which of the following is an example of delivering effective, high-quality care? A. Evaluation of abilities B. Evidence based practice (EBP) C. Statutory requirements D. Certification requirements

B YAY

8. Non-squamous cell carcinoma has been diagnosed in a patient who obtained an allogenic HSCT twelve years ago. Which of the following factors does the nurse believe contributed to the development of this secondary malignancy? A. Effect of alkylating agents as part of the chemotherapy treatment previously B. Record of previous condition regimen with radiation therapy C. Attack of EBV D. Gender and age of the patient

B. Record of previous condition regimen with radiation therapy

23. Delayed immune reconstitution is a major challenge in SCT. Infectious complications account for most of the morbidity and mortality after SCT. What is the recommended regimen to prevent infection for a patient who underwent a SCT? A. Avoiding frosty items in the diet B. Using alcohol-based hand sanitizer C. Eliminating raw vegetables from diet D. Using washcloths impregnated with chlorohexidine (CHG)

B? --> yeeee

14. Which of the below is a good reason to use high dose TBI while conditioning? A. Reduce long-term toxicity B. Locate and reach tumor-bearing zone in the body C. Toxic chemotherapy is no longer needed D. Prevent pancytopenia from developing

B? YAY

20. Which of the following clinical signs or symptoms is associated to polymyositis? A. Lesion on the spinal cord B. Proximal muscle weakness C. Facial weakness D. Blepharoptosis

B? YAY

What are examples of anti-PCP antibiotics?

Bactrim, pentamidine, atovaquone/dapsone

How is CRS severity measured?

By grade (1-4)

How do you score/measure ICANS?

By grade (1-4), similar to CRS

19. Linda has to undergo a SCT. Doctor asked you to take Linda to evaluate certain factors about the patient before HSCT which is a standard policy of the hospital. What is not a consideration for you during the eval? A. Response to prior treatment B. Patient's age and performance status C. Caretaker's age D. Cytogenetic abnormalities

C

4. Daisy has leukemia. She will require HSCT treatment. In this situation, which of the following is the most important thing for the nurse to consider while teaching her caregiver? A. Request that the teaching be done by a nurse who is not caring for the patient B. Discuss the probability of transferring the details to someone other than the caregiver C. Concentrate on details about the present stage of treatment D. Keep track of the caregiver's emotional reaction

C. Concentrate on details about the present stage of treatment

7. A medical treatment that removes blood via machine and isolates white blood cells has shown to reduce the severity of oral chronic GVHD. Identify the treatment from below? A. Methotrexate B. Mercaptopurine (6MP) C. ECP D. IBD

C. ECP

22. If a patient has an increased amount of mucus, shiny, swollen or red gums, soft white patches or pus on the tongue, or blood in the mouth, which are symptoms of oral mucositis, how will he be instructed to manage it? A. Request an acyclovir rinse prescription B. If there are no open lesions, use hydrogen peroxide rinses C. Obtain a prescription for "magic mouthwash" from doctor D. Rinsing the mouth frequently with saline

C? --> D (interesting since most of our SCT patients use magic mouthwash instead, but i guess this is more general mucositis with onc as well)

16. During the stem cell infusion, a patient experiences facial swelling. What drug does the nurse expect an order for when the infusion is decided to stop? A. Furosemide B. Methotrexate C. Antihistamines D. Phenytoin

C? YAY

What is tisagenlecleucel?

CAR-T cell therapy

What are 2 examples of CAR-T therapy?

CD19 & CD22 CAR cell therapy

What is used to treat HYPOcalcemia in SCT patients?

Calcium gluconate, calcium chloride, PO calcium carbonate (tums, if asymptomatic)

What drugs/medications can also cause HYPOkalemia?

Chemo: carbo, cisplat, ifos Other meds: ampho, foscarnet, loop diuretics (potassium wasting), cidofovir, penicillin, aminoglycoside

What drugs/medications can also cause HYPOnatremia?

Chemo: carboplatin, cisplat, ARA-C, ifos, melphalan, vincristine Others: diuretics, opioids, TMP-SMX

What are the signs and symptoms of HYPOcalcemia?

Chills, headache, cramps, numbness of extremities or lips, cardiac/muscle abnormalities, N/V

What treatment do you do for patent with ICANS Grade 3?

Corticosteroids, toci, ICU, evaluate for increased ICP

What are signs and symptoms of HYPOnatremia?

Cramps, N/V, CNS abormalities, HYPOvolemia (dry, HYPOtension, TACHYcardia)

What drugs can cause HYPERcalcemia?

Cyclosporine, ganciclovir, utrium, thiazides, vitamin D

What is CRS?

Cytokine release syndrome

9. Alex underwent as HSCT a couple of weeks back. His wife Emma is the caregiver for him. She noticed some behavior changes in Alex like agitation, severe anxiety, insomnia, depression, and hypervigilance recently and reported to the staff nurse. What will be the primary suspect of the nurse? A. Emma is under stress and exaggerating B. Alex is trying to be self-pity C. Emma is having PTSD D. Alex is having PTSD

D. Alex is having PTSD

3. Which of the following drugs will most likely lead to heart failure as being used in the conditioning regimen? A. Busulfan B. Cytarabine C. Fludarabine D. Cyclophosphamide

D. Cyclophosphamide (Cytoxan)

6. Identify which among the following electrolyte abnormalities, is not characterized as an acute tumor lysis syndrome (TLS)? A. HYPOcalcemia B. HYPERkalemia C. HYPERuricemia D. HYPOphosphatemia

D. HYPOphosphatemia

5. Under utilization for certain diseases occurs due to transplant-related toxicity. For which of the following disease is transplant-related toxicity a barrier? A. Neuroblastoma B. Arrhythmia C. Acute myeloid leukemia D. Sickle cell disease

D. Sickle cell disease

10. What immunosuppressive medication can result in serum sickness? A. Calcineurin inhibitors B. ATG C. Steroids D. All of the above

D? --> B!

11. Although xerostomia is not a disease, it may be a symptom of a variety of illnesses or a side effect of radiation therapy. As a result, which of the following will occur? A. Hyperemesis gravidarum B. Cerebral palsy C. Dental caries D. Acid Reflux

D? --> C!

What does tociluzimab do in the setting of CRS treatment?

Dampens (lessens) CRS symptoms/side effects without compromising the CAR-T cells function (rescue drug that doesn't reverse effect/infusion)

What can cause HYPOkalemia in SCT patients?

Decreased PO intake, GI losses, renal dysfunction, cellular reuptake

What labs indicate malnutrition?

Decreased albumin, transferrin and pre-albumin

What does malnutrition in SCT patients cause/increase risk of?

Decreased survival rate and increased infection risk

What is used to treat HYPERkalemia?

Diuretics (K > 5.1-6) K > 6.1: glucose + insulin, albuterol, sodium bicarb, sodium polystyrene sulfonate K > or = 7: calcium gluconate, dialysis +/- above

What lab changes would you monitor for/anticipate with CRS?

Elevated urea, d-dimer, and bilirubin Decreased fibrinogen +/- bleeding Transaminitis

What are the signs and symptoms of HYPERkalemia?

Fatigue, weakness, abd distension, arrythmias, N/V

What does Grade 1 CRS entail (criteria)?

Fever

What does Grade 2 CRS entail (criteria)?

Fever + HYPOtension + hypoxia (requiring < or = 6L/min NC or blowby oxygen

What does Grade 4 CRS entail (criteria)?

Fever + HYPOtension requiring MULTIPLE vasopressors + hypoxia requiring POSITIVE PRESSURE

What does Grade 3 CRS entail (criteria)?

Fever + HYPOtension requiring vasopressor + hypoxia requiring HFNC/face mask/non-rebreather

What are signs and symptoms of CRS?

Fever +/- rigors, malaise, fatigue, anorexia, headache, N/V/D, myalgias, TACHYpnea, HYPOxemia, TACHYcardia, HYPOtension

What are examples of anti-FUNGAL antibiotics?

Fluconazole, posaconazole, voriconazole (hint hint "-conazole")

What drugs can cause HYPOcalcemia?

Foscarnet, aminoglycosides, aphosphonates, PEG, pentamidine, loop diuretics

What are the signs and symptoms of HYPOkalemia?

General weakness, CRAMPS, constipation, arrythmias, ascending paralysis, decreased resp function

What do you do if your patient's ICANS is Grade 2?

HOB above 30 degrees, monitor VS (low HR, high BP, irregular breathing), place on monitors, MRI, increase keppra, consider dex (steroids)

What are the adverse effects possible with administering tociluzumab?

HYPERtension, increased/elevated serum cholesterol, diarrhea, upper abd pain, dizziness, headaches, infusion reaction

What signs and symptoms can indicate ICANS?

Headache, change in mental status, confusion, delirium, word finding difficulty/aphasia, hallucinations, tremors, dysmetria, altered gait, seizures

What treatment do you offer for patient with ICANS Grade 4?

High dose steroids

What does Grade 3 ICANS entail (criteria)?

ICE 0-2 or CAP-D > or = 9, awake to tactile stimulation, seizure, edema on imaging

What does Grade 2 ICANS entail (criteria)?

ICE 3-6 or CAP-D <9, awake to voice

What does Grade 1 ICANS entail (criteria)?

ICE score 7-9 or CAP-D score <9

How do you screen a patient for ICANS?

ICE scores for children > or = 12 yrs, CAP-D scores for < 12 yrs (at least q8-10 hours)

What does Grade 4 ICANS entail (criteria)?

ICE/CAP-D 0, unarousable, prolonged/repeat seizures, weak, decerebrate

What is tociluzimab?

IL6 receptor inhibitor

What is ICANS?

Immune effector cell-associated neurotoxicity syndrome

Where is CAR-T infused?

Inpatient AND outpatient (pending patient)

What rule exists for bedside RN when tociluzumab is ordered?

It MUST be started within 2 hours of MD order

What are common markers for ICANS?

LOC, seizures, motor weakness, increased ICP

What is HYPOnatremia?

Low serum Na <25

What preparation do patients receive prior to CAR-T infusions?

Lymphodepleting chemotherapy

What treatment is provided in Grade 2 CRS?

No extensive comorbidities: tx same as Grade 1 Comorbidities: closely monitor organ function and consider starting TOCIluzimab +/- corticosteroids (repeat in 24 hours if no improvement)

What do you do if your patient's ICANS is Grade 1?

Notify MD, place neuro consult, EEG/MRI, increase keppra dosing, and consider beginning toci

What can cause HYPERcalcemia in SCT patients?

PTH secretion by tumors, HHM, bone reabsorption (MM/lymphoma), vitamin D secretion

What can cause HYPOcalcemia in SCT patients?

Poor PO intake, renal dysfunction, apheresis, precipitation of calcium-phosphate complex

What is used to treat HYPOkalemia in SCT patients?

Potassium chloride repletion (3-3.4 = PO, < or = 2.9 IV)

What puts a patient at higher risk for developing SOS?

Prior hepatic (liver) injury, TBI (radiation), after these chemos: cyclophos, busulfan, thiotepa (longterm)

How are CAR-T cells prepared?

Product is cryopreserved and thawed at bedside prior to infusion

What are the signs/symptoms of SOS?

Refractory thrombocytopenia, hepatomegaly, ascites, jaundice

What treatment is used for HYPERcalcemia in SCT patients?

Rehydration, biphosphonates, calcitonin, dialysis

What can cause HYPOnatremia in SCT patients?

SOS (aka VOD), decreased albumin, diarrhea/emesis, SIADH, renal injury

What treatment is provided for Grade 3 CRS?

Same as Grades 1 & 2 with the addition of a vasopressor to hold pressures and higher oxygen requirement/support

What does SOS stand for?

Sinusoidal obstruction syndrome

What is the relationship between steroids and CAR-T?

Steroids are stopped >5 days prior to CAR-T infusion

When would this relationship change between steroids and CAR-T?

Steroids given if life threatening emergency occurs for CRS toxicities (no premeds)

What is used to treat HYPOnatremia?

Treat the cause, water restriction, tolvaptan/conivaptan (med)

When does SOS occur in regards to timeline with SCT?

Typically days or weeks AFTER SCT

What does SOS replace?

VOD (former name)

What was VOD?

Veno-occlusive disorder

What is the other term for Kymriah?

tisagenlecleucel