CHAPTER 5

Oncologic Emergencies

1. The most common cancer associated with disseminated intravascular coagulation (DIC) is:

1. Pancreatic cancer
   
2. Small cell lung cancer
   
3. Acute promyelocytic leukemia (APL)
   
4. Chronic myelogenous leukemia

2. The symptoms of disseminated intravascular coagulation (DIC) seem paradoxical because:

1. DIC may be both the cause and effect of malignancy.
   
2. Thrombosis and hemorrhage may occur simultaneously.
   
3. Both platelet function and platelet numbers are implicated in DIC.
   
4. Patients may experience fever at the same time their bodies are hypothermic.

3. The most common cause of acute disseminated intravascular coagulation (DIC) associated with cancer is:

1. Infection
   
2. Anaphylaxis
   
3. Tumor products
   
4. Thrombopoiesis

4. Which of the following statements best describes the physiologic characteristics of disseminated intravascular coagulation (DIC)?

1. All clotting factors are prolonged.
   
2. The international normalized ratio, prothrombin time, and partial thromboplastin time (PTT) are elevated.
   
3. The platelet count is decreased, the plasma fibrinogen is low, and the prothrombin time is prolonged.
   
4. There is an absence of coagulation, and therefore, there is widespread hemorrhage.

5. Signs and symptoms of bleeding related to disseminated intravascular coagulation (DIC) include:

1. Epistaxis, purpura, petechiae, ecchymoses
   
2. Focal ischemia, acrocyanosis, superficial gangrene
   
3. Anorexia, nausea, vomiting, constipation, weight loss
   
4. Elevated temperature, hypotension, elevated respirations

6. Which of the following tests are specific and sensitive for the presence of disseminated intravascular coagulation (DIC)?

1. Fibrinogen level and platelet count
   
2. International normalized ratio (INR)
   
3. Plasminogen level and plasmin α-2-antiplasmin level
   
4. D-dimer assay and Fibrin Degradation Product (FDP) titer

7. The only definitive treatment for disseminated intravascular coagulation (DIC) is:

1. Aggressive antibiotic therapy
   
2. Treatment of the underlying cancer
   
3. Administration of platelets and fresh frozen plasma
   
4. Reversing the clotting cascade by the administration of heparin

8. Mary is being treated for acute promyelocytic leukemia (APL). On the second day of her chemotherapy, she complains of shortness of breath, and you note that she has new bleeding from her peripherally inserted central catheter (PICC), as well as hematuria. Her white blood cell count is 80,000/mm³, hemoglobin is 9 g/dL, and platelets are 20,000/mm³. What oncologic emergency is she most likely to be experiencing?

1. Anaphylaxis
   
2. Hypercalcemia
   
3. Tumor lysis syndrome (TLS)
   
4. Disseminated intravascular coagulation (DIC)

9. The primary treatment for thrombotic thrombocytopenic purpura is:

1. Vitamin K
   
2. Plasma therapy
   
3. Platelet therapy
   
4. Epsilon-amino caproic acid

10. Mr. Jones, a patient with small cell lung cancer, develops anorexia, weakness, and fatigue. At first, these are attributed to the cancer itself. As his condition worsens Mr. Jones’s wife calls you in tears, reporting that he has suddenly become combative. You tell her that he must have a serum chemistry as soon as possible because you suspect:

1. Hyponatremia
   
2. Hypercalcemia
   
3. End-stage cancer
   
4. Paraneoplastic adrenotropic hormone (pACTH) syndrome

11. Which of the following is indicative of the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

1. Increased plasma sodium and decreased urine output
   
2. Hyponatremia with high serum osmolality and high urine osmolality
   
3. Hypernatremia with high serum osmolality and high urine osmolality
   
4. Hyponatremia with low serum osmolality, high urine sodium, and high urine osmolality

12. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a paraneoplastic endocrine disorder most often associated with the ectopic production of what peptide?

1. Cyclic adenosine 3’,5’-cyclic monophosphate (cAMP)
   
2. G protein
   
3. Adenylate cyclase
   
4. Arginine vasopressin (AVP)

13. Which of the following is diagnostic for syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

1. Absence of edema, euvolemia, decreased serum osmolality, decreased serum sodium
   
2. Absence of edema, hypervolemia, decreased serum osmolality, decreased serum sodium
   
3. Presence of edema, hypervolemia, increased serum osmolality, decreased serum sodium
   
4. Presence of edema, euvolemia, decreased serum osmolality, decreased serum sodium

14. Jason is being treated with chemotherapy for small cell lung cancer. His recent lab values demonstrate a serum sodium of 132 mEq/L. What is the likely initial treatment for his low sodium?

1. Administer chemotherapy
   
2. Hypertonic (3%) saline infusions
   
3. Administration of intravenous furosemide
   
4. Free-water restriction to 500 to 1000 mL/day

15. What is the most common adverse event reported with the use of conivaptan, a nonselective nonpeptide arginine vasopressin-receptor antagonist, used to treat euvolemia and hypervolemic hyponatremia?

1. Thirst
   
2. Headache
   
3. Orthostatic hypotension
   
4. Mild infusion-site phlebitis

16. Appropriate teaching for the patient receiving demeclocycline includes:

1. Treatment with demeclocycline allows the patient to maintain a normal daily intake of free water and other fluids.
   
2. Treatment with demeclocycline requires a strict free water and other fluid intake of <500 cc/day.
   
3. Treatment with demeclocycline requires a strict free water and other fluid intake of <1000 cc/day.
   
4. Treatment with demeclocycline requires intravenous (IV) fluid boluses of 2 liters/day while on treatment.

17. Systemic inflammatory response syndrome (SIRS) is recognized when two of the following criteria are met:

1. Temperature >100.4°F or <96.8°F; heart rate >90 beats per minute; respiratory rate >20 breaths per minute; white blood cell count >12,000/mm³, <4000/mm³, or >10% bands
   
2. Temperature >100.4°F or <96.8°F; heart rate >120 beats per minute; respiratory rate >20 breaths per minute; white blood cell count >12,000/mm³, <4000/mm³, or >10% bands
   
3. Temperature >102°F or <96.8°; heart rate >90 beats per minute; respiratory rate >20 breaths per minute; white blood cell count >12,000/mm³, <4000/mm³, or >10% bands
   
4. Temperature >102°F or <96.8°F; heart rate >120 beats per minute; respiratory rate >20 breaths per minute; white blood cell count >12,000/mm³, <4000/mm³, or >10% bands

18. Sepsis is a common cause of disseminated intravascular coagulation (DIC). Which of the following conditions most accurately describes how sepsis causes DIC?

1. Sepsis causes viruses to thrive, and viruses cause DIC.
   
2. Endotoxins released from bacteria activate the coagulation cascade.
   
3. Sepsis and bleeding occur simultaneously in patients who are immunosuppressed.
   
4. Antiangiogenesis factors are released during periods of sepsis, which leads to DIC.

19. Which of the following is considered the most important prognostic indicator for septic shock?

1. Prolonged neutropenia
   
2. Polymicrobial infections
   
3. Sepsis-induced hypotension
   
4. The presence of multiple organ dysfunction syndrome

20. Major fluid volume depletion occurs in patients with septic shock. Which of the following pathophysiological mechanisms of fluid volume depletion is characteristic of shock?

1. Arterial vasodilation
   
2. Arterial vasoconstriction
   
3. Decreased cardiac output
   
4. Decreased vascular permeability

21. What is the single most important risk factor for sepsis in individuals with cancer?

1. Age less than 1
   
2. Age less than 65
   
3. Chronic illness
   
4. Granulocytopenia

22. Septic shock ultimately causes death due to which of the following?

1. Fever
   
2. Coagulopathy
   
3. Tissue ischemia
   
4. Hypotension

23. The purpose of the Modified Early Warning Score (MEWS) related to sepsis is:

1. To act as an algorithm of care
   
2. To alert physicians when patients are at risk of sepsis
   
3. To identify the presence of sepsis in patients with cancer
   
4. To facilitate prompt communication between healthcare providers about early deterioration in a patient’s condition

24. Jason was just admitted to the hospital via the emergency department with suspected sepsis. He has a history of Hodgkin disease. What is the most important intervention to initiate immediately?

1. Steroid therapy
   
2. Oxygen therapy
   
3. Antibiotic therapy
   
4. Intravenous (IV) therapy

25. Jason is started on dopamine when his blood pressure fails to respond to the antibiotics and fluid resuscitation. What is the mean arterial pressure (MAP) that is targeted to achieve minimal perfusion pressure and to maintain adequate blood flow?

1. MAP of 60 mm Hg or less
   
2. MAP of 60 mm Hg or greater
   
3. MAP of 65 mm Hg or greater
   
4. MAP of 70 mm Hg or greater

26. Acute tumor lysis syndrome (ATLS) is most likely to be seen in which of the following cases?

1. Colon cancer
   
2. Burkitt’s lymphoma
   
3. Small cell lung cancer
   
4. Chronic lymphocytic leukemia

27. The metabolic abnormalities that are characteristic in tumor lysis syndrome (TLS) include:

1. Hypocalcemia, hypouricemia, hypophosphatemia, and hypokalemia
   
2. Hypocalcemia, hyperuricemia, hyperphosphatemia, and hyperkalemia
   
3. Hypercalcemia, hyperuricemia, hypophosphatemia, and hyperkalemia
   
4. Hypercalcemia, hyperuricemia, hyperphosphatemia, and hyperkalemia

28. Patients with non-Hodgkin lymphoma with big, bulky, high-grade disease are at high risk for acute tumor lysis syndrome (ATLS). One important aspect of the nursing care for such patients is:

1. Monitoring urine output for signs of renal failure
   
2. Looking for signs of motor incoordination and cognitive deficits
   
3. Providing oral or intravenous (IV) agents that keep blood and urine acidic
   
4. Discontinuing vinca alkaloid treatment if signs of severe jaw pain occur

29. Mr. Kramer has chronic myelogenous leukemia in blastic transformation. He is considered to have a high tumor burden and has evidence of lymphadenopathy and splenomegaly. Which of the following electrolyte abnormalities indicate that he is experiencing acute tumor lysis syndrome (ATLS) ?

1. Hypokalemia
   
2. Hypercalcemia
   
3. Hypophosphatemia
   
4. Acute hyperuricemia

30. A primary physiologic complication of acute tumor lysis syndrome (ATLS) is:

1. Liver failure caused by a veno-occlusive disease
   
2. Tumor lysis, causing release of tissue, which produces pulmonary emboli
   
3. Uric acid crystallization in the renal tubules, causing obstruction and acute renal failure
   
4. Tumor cell obstruction of microvasculature, causing disseminated intravascular coagulation

31. Tumor lysis syndrome (TLS) results in a release of a large amount of phosphorus into the blood and a proportional decrease in what other serum electrolyte?

1. Sodium
   
2. Calcium
   
3. Potassium
   
4. Magnesium

32. Which of the following is a key strategy in the prevention of tumor lysis syndrome (TLS)?

1. Dialysis
   
2. Weight bearing
   
3. Fluid restriction
   
4. Aggressive hydration

33. Mr. Clay has lymphoma and received chemotherapy 4 days ago. He has been doing well but comes in complaining of fatigue, dizziness, and a “fluttering” feeling in his chest. Chemistries reveal potassium, 6 mEq/L; creatinine, 2.7 mg/dL; and calcium, 6 mg/dL. Your assessment is which of the following?

1. He is dehydrated and needs fluids.
   
2. He could have a life-threatening arrhythmia and should be admitted.
   
3. He is losing calcium and needs magnesium.
   
4. He is probably anemic and needs a blood transfusion.

34. Allopurinol is a xanthine oxidase inhibitor that acts to:

1. Reduce serum uric acid levels
   
2. Convert uric acid to a more soluble form
   
3. Decrease deposits of uric acid in the kidneys
   
4. Eliminate already formed uric acid deposits in the kidneys

35. M.T. is admitted to the hospital for treatment of Burkitt’s lymphoma. Her lab values on admission to the hospital demonstrate a potassium level of 4 mEq/L, phosphorus of 3.5 mg/dL, calcium of 9 mg/dL, and a uric acid of 9.5 mg/dL. Which of the following medications would you anticipate being ordered initially to help manage M.T.?

1. Kayexalate
   
2. Allopurinol
   
3. Rasburicase
   
4. Doxycycline

36. Pretreatment risk factors in the development of tumor lysis syndrome (TLS) include which of the following?

1. Hypocalcemia
   
2. Hypophosphatemia
   
3. Dehydration or renal impairment
   
4. Decreased lactate dehydrogenase level

37. During his hospitalization, Mr. Clay develops hyperphosphatemia and is treated with a phosphate binding, aluminum-containing agent. Based on the actions of these agents, what other medication should be administered concomitantly?

1. Laxatives
   
2. Catecholamines
   
3. Antiarrhythmics
   
4. Calcium gluconate

38. Mr. Stevens has just begun his first treatment with rituximab. One hour into the infusion he complains of fever, chills, and rigors. Appropriate nursing action is based on which of the following?

1. The symptoms are expected and are expected to lessen with each subsequent treatment.
   
2. This is an anaphylactic reaction, and the medication should be permanently discontinued.
   
3. The infusion should be maintained; these symptoms are expected and signal a good response to therapy.
   
4. Monitor the blood pressure because rituximab can significantly raise the blood pressure, requiring the drug to be discontinued.

39. Measures to prevent a hypersensitivity reaction to a monoclonal antibody include which of the following?

1. Administer pretreatment hydration.
   
2. Administer an opioid before the infusion.
   
3. Administer acetaminophen and an antihistamine before the infusion.
   
4. Speed up the infusion to decrease the amount of time the infusion takes.

40. Mrs. Howe has just arrived for her first treatment with trastuzumab, a monoclonal antibody. As you plan her teaching about her medication, you are careful to include which of the following?

1. If she has fever, chills, or rigors, the infusion will be turned off, and she will not receive this medication in the future.
   
2. If she has fever, chills, or rigors, the medication will be stopped temporarily and restarted after her symptoms subside.
   
3. Fever, chills, or rigors are expected reactions to trastuzumab and demonstrate a good response to her treatment.
   
4. Diphenhydramine and acetaminophen are often given before the first infusion to minimize risk of an infusion-related reaction.

41. Jack is receiving his first infusion of paclitaxel. Ten minutes into the infusion, he complains of tightness in his chest and shortness of breath and begins to experience wheezing. What are the most important nursing actions to take?

1. Slow the infusion and monitor the patient closely.
   
2. Decrease the infusion by half the initial rate and treat his symptoms.
   
3. Stop the infusion, maintain a patent intravenous (IV) line, and prepare for CPR as necessary.
   
4. Stop the infusion, maintain a patent IV line, and restart the drug when the patient stabilizes.

42. Alex has an infection of his vascular access device and is beginning vancomycin therapy. Twenty minutes into a 60-minute infusion, you notice his face and upper torso are flushed and warm to touch. Appropriate nursing action includes which of the following?

1. Slow the infusion and administer morphine.
   
2. Stop the infusion; he is having an allergic reaction.
   
3. Administer Decadron and diphenhydramine immediately.
   
4. This is not an antigen antibody reaction; slow the infusion to 90 minutes.

43. Which of the following drugs is commonly associated with a hypersensitivity reaction?

1. Paclitaxel
   
2. Bleomycin
   
3. 5-Fluorouracil
   
4. Cyclophosphamide

44. Which of the following malignancies is most likely to be associated with hypercalcemia?

1. Lung cancer
   
2. Acute leukemia
   
3. Chronic leukemia
   
4. Osteogenic sarcoma

45. The most important initial treatment for hypercalcemia is:

1. Inhibiting bone resorption
   
2. Treating the primary tumor
   
3. Inhibiting osteoclast function
   
4. Improving renal calcium excretion

46. Early symptoms of hypercalcemia in patients with cancer include:

1. Obstipation
   
2. Atonic ileus
   
3. Renal failure
   
4. Nausea and vomiting

47. The pathophysiology of hypercalcemia involves a combination of two factors: bone resorption and:

1. Increased osteoclast activity
   
2. Increased glomerular function
   
3. Decreased renal calcium clearance
   
4. Decreased availability of ionized calcium

48. Factors produced by tumors have been implicated in malignancy-associated hypercalcemia. Probably the most important of these humoral circulating factors is:

1. Prostaglandin
   
2. Bisphosphonate
   
3. Osteoclast-activating factor
   
4. Parathyroid hormone-related factor

49. A patient is found to have a large tumor mass associated with high levels of parathyroid hormone-related protein but normal levels of 1,25-dihydroxyvitamin D and normal intestinal absorption rates. Bone absorption is found to exceed bone formation. The most likely diagnosis is:

1. Hodgkin disease
   
2. Multiple myeloma
   
3. Primary hyperparathyroidism
   
4. Humoral hypercalcemia of malignancy (HHM)

50. The symptoms of hypercalcemia in patients with cancer are best described as:

1. Numerous, vague, and nonspecific
   
2. Easily identified but difficult to treat
   
3. Similar to those of acute renal failure
   
4. Distinct from those of end-stage disease

51. Patients with severe hypercalcemia are invariably symptomatic and urgent intervention is required. What corrected calcium level is indicative of severe hypercalcemia?

1. 8.5–10 mg/dL
   
2. 10.5–11.9 mg/dL
   
3. 12–14 mg/dL
   
4. >14 mg/dL

52. Which of the following is used in the treatment of hypercalcemia?

1. Diuretics
   
2. Allopurinol
   
3. Bisphosphonates
   
4. Fluid intake restriction

53. Which of the following is the most common side effect of bisphosphonate therapy?

1. Extravasation
   
2. Nephrotoxicity
   
3. Hypersensitivity
   
4. Atypical femoral fractures

54. A patient with metastatic squamous cell lung cancer develops confusion, disorientation, and hallucinations and has an elevated serum calcium. Part of your patient teaching will include the importance of:

1. Decreasing fluid intake
   
2. Weight-bearing exercise
   
3. Taking thiazide diuretics
   
4. Restriction of salt intake

55. Zoledronic acid is the most potent bisphosphonate in use in the United States for the treatment of hypercalcemia of malignancy. It is recommended that the dose not exceed 4 mg delivered over no less than 15 minutes every 3–4 weeks. The rationale behind this recommendation is which of the following:

1. Doses higher than 4 mg given in less than 15 minutes increase liver toxicity.
   
2. Doses higher than 4 mg given in less than 15 minutes increase renal toxicity.
   
3. Doses higher than 4 mg given in less than 15 minutes increase nausea and diarrhea.
   
4. Does higher than 4 mg given in less than 15 minutes increase bone marrow suppression.

56. Malignant pericardial effusions:

1. Are extremely rare
   
2. Are not easily detected because many patients are asymptomatic
   
3. Are easily detected by tachycardia, low blood pressure, and shortness of breath
   
4. Occur in 50% of all patients with cancer, especially the hematologic malignancies

57. Possible early signs of cardiac tamponade include:

1. Hypotension, bradycardia, and fatigue
   
2. Tachycardia, fatigue, and shortness of breath
   
3. Hypotension, cough, and narrowing pulse pressure
   
4. Hypertension, bradycardia, and widening pulse pressure

58. Which of the following tumor types is commonly associated with pericardial effusion and tamponade?

1. Lung cancer
   
2. Colon cancer
   
3. Pancreatic cancer
   
4. Gastrointestinal cancer

59. Which of the following is a significant risk factor for the development of cardiac tamponade?

1. Hyperkalemia
   
2. Hyperuricemia
   
3. Radiation to the pericardium
   
4. Pericardial fluid accumulation of 100 cc

60. Your patient is suspected to have a cardiac tamponade. What test is considered to be the most sensitive method for diagnosing this oncologic emergency?

1. Chest radiograph
   
2. Electrocardiogram (EKG)
   
3. Magnetic resonance imaging (MRI)
   
4. Two-dimensional echocardiogram

61. J.T. has metastatic lung cancer and has been diagnosed with hemodynamically unstable cardiac tamponade. What treatment do you anticipate that J.T. will imminently need to undergo to treat his cardiac tamponade?

1. Radiotherapy
   
2. Chemotherapy
   
3. Pericardiectomy
   
4. Pericardiocentesis

62. J.T. has been readmitted to the hospital with a recurrent malignant pericardial effusion and is scheduled to undergo a pericardiocentesis with sclerosis with cisplatin. You explain to J.T. that the sclerosing agent acts to:

1. Treat the cancer cells in the pericardium that are causing the effusions
   
2. Relieve pain in the pericardial space caused by the malignant pericardial effusion
   
3. Create inflammation and cause additional space between the pericardial layers to allow more space for the fluid to drain
   
4. Create inflammation and cause adhesions between the pericardial layers to obliterate the space and prevent reaccumulation of fluid

63. Which of the following is used as a sclerosing agent for the management of recurrent cardiac tamponade?

1. Rituximab
   
2. Bleomycin
   
3. Gemcitabine
   
4. Doxorubicin

64. A side effect of most sclerosing agents that should be treated proactively includes:

1. Pain
   
2. Hypotension
   
3. Vasovagal response
   
4. Nausea and vomiting

65. You will soon begin work in a clinic that specializes in the detection and treatment of spinal cord tumors. You are aware that the most common presenting symptom of a spinal cord tumor is:

1. Pain
   
2. Weakness
   
3. Numbness and tingling
   
4. Uncoordinated ataxic gait

66. The most common cause of spinal cord compression is:

1. Chronic steroid use
   
2. Carcinomatosis meningitis
   
3. Metastasis to the vertebral column
   
4. Primary disease of the vertebral column

67. The most common cancer associated with spinal cord compression is:

1. Breast cancer
   
2. Gastric cancer
   
3. Multiple myeloma
   
4. Hepatocellular cancer

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