Chemotherapy administration, from order to spill kit
Chemotherapy administration on the OCN is mostly about process: checking the order, confirming the dose, protecting yourself and the room from a hazardous drug, and acting quickly when the patient reacts or the drug leaks. It draws on three domains of the outline at once, which is why it gets a separate page.
During a doxorubicin infusion through an implanted port, the patient reports burning at the port and the nurse sees swelling around it. After the initial extravasation steps are completed, which step is specific to an extravasation from a central device?
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No further drug goes through a device that has leaked until its integrity and position are confirmed.
Anthracycline extravasation is managed with cold, and a compress of either kind is not a step specific to a port.
A central device leak can track into the chest wall or mediastinum, so the source is imaged and a surgeon evaluates the site and the device for debridement or removal.
Flushing pushes more vesicant into the tissue around the port.
Safe administration
Which is the most common cause of vesicant extravasation from an implanted port?
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A heparin lock is placed after the drug is in and does not cause leakage.
A 10-mL or larger syringe is the safe choice because it generates lower pressure than small syringes.
Noncoring (Huber) needles are the correct device for accessing a port.
A noncoring needle that backs out of the septum, often from patient movement or poor securement, sends drug into the subcutaneous pocket.
Safe administration
Topical dimethyl sulfoxide (DMSO) is used as an antidote for extravasation of which drug?
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DMSO is a free-radical scavenger applied to the skin after extravasation of mitomycin, and of anthracyclines when dexrazoxane is not given.
Oxaliplatin has no specific antidote; cold is avoided because it can trigger the drug's acute neuropathy.
Carboplatin is an irritant rather than a vesicant and has no antidote.
Paclitaxel extravasation is managed without DMSO; some protocols use hyaluronidase.
Safe administration
During a peripheral minibag infusion of vinorelbine, the patient reports burning and the nurse sees swelling at the site. What is the nurse's first action?
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Restarting through an infiltrated site keeps delivering vesicant into the tissue, whatever the rate.
Pulling the catheter first loses the chance to aspirate, and pressure spreads drug through the tissue.
Stopping limits the dose to the tissue, and the catheter stays in so the nurse can try to aspirate residual drug before removing it.
Flushing pushes more drug into the tissue and widens the injury.
Safe administration
After a vesicant extravasation has been managed, ongoing assessment of the site should include:
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Dated photographs with measurements document how the injury evolves, since vesicant damage can deepen over days to weeks.
Repeated aspiration through injured skin adds trauma and infection risk.
Duplex ultrasound looks for clots, not for vesicant tissue injury.
Cultures are taken only if infection is suspected, not as routine follow-up.
Safe administration
Carboplatin is ordered at a target AUC of 5. The patient's creatinine clearance has fallen since the last cycle. The nurse anticipates that the carboplatin dose in milligrams will:
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The target stays the same, but the milligrams needed to reach it fall when clearance falls.
Slower clearance means the drug stays longer, so the same dose would overshoot the target.
Carboplatin is dosed to AUC because its clearance follows kidney function rather than body size.
In the Calvert formula, dose (mg) = target AUC × (GFR + 25), so lower kidney function means a smaller dose for the same exposure.
Safe administration
A patient with a body surface area of 2.0 m² is prescribed irinotecan 180 mg/m². UGT1A1 testing shows a *28/*28 genotype. The protocol says: *1/*1, give 100% of the dose; *1/*28, reduce by 20%; *28/*28, reduce by 30%. Pharmacy prepares the modified dose at 2.0 mg/mL to run over 90 minutes. What is the correct pump rate?
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This is the full 360 mg dose, which skips the 30% reduction required for a poor metabolizer.
This makes both errors: pounds left unconverted and the square root skipped.
Safe administration
During the independent double check before vincristine is given, the nurse finds that the signed order and the MAR both read 2 mg, but the pharmacy label on the minibag reads 1.5 mg. What should the nurse do?
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Nurses do not compound or alter hazardous drug doses at the bedside; that bypasses pharmacy checks and adds exposure.
Telling pharmacy after the dose does not prevent the error; the mismatch is resolved before anything is given.
Giving a dose that differs from the order is a medication error, even if it is documented.
The product does not match a clear order, so nothing is given until pharmacy explains or corrects the preparation; safety standards require that match before administration.
Safe administration
A patient goes home with a 46-hour fluorouracil infusion running through an ambulatory pump connected to a port. Which instruction is most important?
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A leak means hazardous drug exposure and lost dose; clamping stops the flow and the clinic arranges safe cleanup and line care.
Spills are cleaned with the spill kit and gloves, and the waste is handled as hazardous, not with household linens.
Changing the rate gives an unplanned dose and can cause severe toxicity.
Pulling the needle at home risks exposure and bleeding and does not fix the alarm; the clinic directs troubleshooting.
Safe administration
Which pattern most suggests a thrombotic central catheter occlusion?
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A positional block points to a mechanical problem such as pinch-off between clavicle and first rib.
Thrombotic occlusions build as fibrin and clot accumulate, so sluggish flushing and lost blood return develop over time.
An abrupt block right after incompatible solutions suggests a drug precipitate.
A closed clamp is a mechanical cause; it resolves the moment the clamp is opened.
Safe administration
A patient is receiving blinatumomab by continuous infusion. Which administration practice is correct?
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Blinatumomab runs continuously for 28 days per cycle, because its half-life is very short.
A flush at bag change delivers a bolus of the drug in the tubing, which the label warns against.
The blinatumomab label says not to flush the line, because flushing would push the drug left in the tubing as a bolus.
It runs through a dedicated lumen; other infusions in the same lumen would flush it through as a bolus.
Safe administration
Shortly after a right subclavian central venous catheter is inserted, the patient becomes short of breath and breath sounds are diminished on the right. Which complication should the nurse suspect?
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PE causes dyspnea and tachycardia, but breath sounds usually stay present, and the timing points to the procedure.
The subclavian approach passes close to the lung apex; new dyspnea with absent breath sounds on that side after insertion suggests the pleura was punctured.
A displaced tip changes infusion and causes arm or neck symptoms, not loss of breath sounds.
Air embolism causes sudden hypoxia, chest pain, and hypotension, not breath sounds lost on one side.
Safe administration
Before giving a vesicant through an implanted port, the nurse finds the port flushes easily but has no blood return. What should the nurse do next?
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Blood return confirms the needle and catheter are in the vein; without it the cause, such as a fibrin sheath or a malpositioned catheter, is found before any vesicant is given.
Easy flushing can occur when fluid is going into tissue or along a fibrin sheath; it does not prove placement.
Small hand veins over tendons are the worst sites for a vesicant.
Small syringes create high pressure that can rupture the catheter.
Safe administration
After cleaning up emesis from a patient who received ifosfamide within the past 48 hours, the nurse removes a gown and two pairs of chemotherapy gloves. Which removal order is correct?
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Taking off both pairs first leaves bare hands to handle a contaminated gown.
The outer gloves carry the most drug and come off first; the gown is rolled away from the body; the inner gloves come off last, followed by hand hygiene.
Removing the gown while wearing contaminated outer gloves spreads drug onto the inner layer and clothing, and pulling both pairs together loses the clean inner barrier.
Removing the gown with contaminated outer gloves spreads drug onto the inner gloves and clothing.
Safe administration
An infusion center's hazardous drug policy requires a biological safety cabinet for compounding, two pairs of chemotherapy gloves, and gowns for administration. Under USP <800>, which control is missing for administering IV antineoplastic drugs?
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Smart pumps prevent rate and dose errors but do nothing to contain hazardous drug exposure.
Respirators are for spills or aerosol risk; routine IV administration relies on gloves, gown, and closed systems.
Hazardous drugs are stored under negative pressure so contamination does not spread outward.
USP <800> requires closed-system transfer devices for administering antineoplastic hazardous drugs when the dosage form allows, which limits leaks and vapors at the bedside.
Safe administration
A patient with multiple myeloma is about to receive a first infusion of daratumumab. Which premedication regimen does the nurse expect to give before the infusion?
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Epinephrine and oxygen treat anaphylaxis once it occurs; they are not routine premedication.
This is an antiemetic regimen; daratumumab is not emetogenic enough to need it.
Infusion reactions are common with the first daratumumab dose, so the label calls for a corticosteroid, acetaminophen, and an antihistamine beforehand.
This is tumor lysis prevention, not premedication for an antibody infusion reaction.
Safe administration
A patient who had a moderate hypersensitivity reaction to carboplatin still needs the drug. The nurse anticipates:
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A faster full dose risks a worse reaction than the first one.
Platinum drugs cross-react, so cisplatin can cause the same reaction.
Removing premedication after a reaction makes a repeat reaction more likely.
Rapid drug desensitization, a stepwise escalation of diluted doses under close watch, lets most patients complete platinum therapy after a reaction.
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Giving systemic therapy is item III.D of Treatment Modalities, a domain worth 20% of the exam. Safe handling and protective equipment are a scope-and-standards line, II.C.4, of Oncology Nursing Practice (15%). Hypersensitivity, anaphylaxis and extravasation are items E, F and N of Oncologic Emergencies (16%). The practice standards this topic rests on are the ASCO–ONS antineoplastic therapy administration safety standards (2024).
What the safety lines cover
Before the first dose: consent and teaching, a baseline assessment, and labs and organ function checked against the protocol's limits.
Order verification: what a complete order contains, the independent double check, dose units and when a dose is recalculated.
Hazardous drug handling: the NIOSH list, USP <800>, protective equipment, spills, waste and body fluids.
Reactions: infusion-related reactions, hypersensitivity and anaphylaxis.
Extravasation: vesicants and irritants, flare reactions, antidotes and follow-up.
Orders, double checks and dose units
The 2024 standards set out what a complete order holds and how it is checked:
A complete order: two patient identifiers, the regimen name and cycle number, each drug's dose and the method used to calculate it, the height and weight used, the route, rate and schedule.
Verification: independent checks happen along the path from order to chair, of the order, of the prepared drug, and with the patient before the first drop runs; the 2024 update added a fourth verification to that sequence.
Dose units differ by drug: mg/m² from body surface area for most cytotoxic drugs, mg/kg for many antibodies, a target AUC for carboplatin, and flat doses for others. The dose is recalculated when the weight changes beyond the threshold the practice has set.
Gloves and gown: two pairs of chemotherapy gloves tested to ASTM D6978, and a disposable gown shown to resist permeation by hazardous drugs, to give injectable antineoplastic drugs. Eye and face protection when splashing is possible; a respirator for large spills or aerosol risk.
Spills: a spill kit wherever the drugs are given or stored, and trained staff to contain, clean and report the spill.
Waste and body fluids: trace and bulk waste go to the containers the facility designates. Precautions extend to the patient's body fluids for a period after each dose, longer for some drugs than for others.
Oral drugs count too: crushing, splitting or opening capsules releases drug, so it is done only with precautions, preferably in pharmacy.
Reproductive risk: USP <800> asks staff of reproductive capability to confirm in writing that they understand the risks of handling hazardous drugs.
Certificate is not certification
Some employers ask for the ONS/ONCC Chemotherapy Immunotherapy Certificate before a nurse gives these drugs. It is earned through a course and post-test from ONS, the Oncology Nursing Society, and the ONS/ONCC Chemotherapy Immunotherapy Certificate course page (2026) calls it neither a professional certification nor a license. The OCN is a board certification from ONCC, earned by examination. Neither replaces the other.
Infusion reactions, hypersensitivity and anaphylaxis
The outline lists hypersensitivity and anaphylaxis as separate items, and three things are worth keeping apart:
Infusion-related reactions are mostly cytokine release rather than allergy. They are typical of the first doses of many monoclonal antibodies, rituximab being the classic example, and once symptoms settle the infusion can often restart at a slower rate.
Hypersensitivity reactions are immune-mediated, and taxanes and platinum drugs are the classic cytotoxic causes.
Anaphylaxis is the severe, multisystem form: low blood pressure, bronchospasm or airway swelling, often with skin signs, within minutes of exposure.
The first steps do not depend on the cause: stop the infusion, keep the line open with saline, stay with the patient, check airway, breathing, circulation and vital signs, and call for help as the protocol directs. In the anaphylaxis practice parameter update (2023), epinephrine injected into the outer thigh muscle is the first drug for anaphylaxis; antihistamines and corticosteroids do not replace it. CTCAE v6.0 (2025) grades infusion-related reactions from 1 (mild, no interruption needed) to 4 (life-threatening), and the grade guides whether and how the drug is given again.
Vesicants, irritants and flare reactions
A vesicant can blister and destroy tissue if it leaks out of the vein; anthracyclines, vinca alkaloids, mechlorethamine, dactinomycin and mitomycin are long-standing examples. An irritant causes pain, burning or inflammation along the vein without lasting tissue damage, and some drugs, oxaliplatin and docetaxel among them, sit between the two groups. Early signs of a leak are pain, burning or stinging, swelling, redness and loss of blood return.
A flare reaction, seen with doxorubicin, is not an extravasation: red, often itchy streaks or blotches along the vein, without pain or swelling, that fade within about an hour while blood return stays brisk.
The antidote and the compress after a leak depend on the drug class; the full drug-by-drug table is planned for a later page.
Look-alikes at the infusion chair
Vesicant versus irritant. An irritant hurts; a vesicant destroys tissue. Pain alone does not make a drug a vesicant, and a painless site does not clear one.
Infusion reaction versus anaphylaxis. Flushing and chills during a first rituximab dose are not anaphylaxis by themselves; low blood pressure, wheeze or throat tightness are. The first steps are shared, and the drugs that follow are not.
Flare versus extravasation. Itchy red streaks along the vein are a flare; pain or swelling at the site point to a leak until shown otherwise.
What does USP <800> ask of nurses who give chemotherapy?
Two pairs of chemotherapy-tested gloves and a hazardous-drug gown to give injectable antineoplastic drugs, eye and face protection when splashing is possible, spill kits where the drugs are used, and training before handling. Each state and accreditor decides how it is enforced.
How many times is a chemotherapy order checked?
Several. Under the ASCO–ONS standards, independent checks cover the order, the prepared drug and the patient at the chair, and the 2024 update added a fourth verification to that sequence.
Is the ONS chemo certificate the same as OCN certification?
No. The ONS/ONCC Chemotherapy Immunotherapy Certificate comes from an ONS course for nurses who give these drugs. The OCN is a board certification awarded by ONCC after an exam.
Domain IV · Symptom Management and Supportive Care25%
06Neutropenia and myelosuppressionAbsolute neutrophil count, neutropenic precautions, febrile neutropenia and the first hour of sepsis, growth factors, bleeding precautions, anemia and transfusion.
07Symptom management and supportive careNausea and vomiting, bowel changes, mucositis, neuropathy, fatigue, skin and hair changes, lymphedema and ostomies, nutrition and weight loss, pain, and complementary therapies.
Domain III · Treatment Modalities20%
03Chemotherapy, targeted therapy and immunotherapyDrug classes and how they work, checkpoint inhibitors, CAR T cells and bispecific antibodies, hormonal agents, oral therapy and adherence teaching, intrathecal and intravesical therapy, and recognizing immune-related toxicity.
05Radiation, surgery and transplantSurgical and procedural care, radiation principles and safety (time, distance, shielding; sealed and unsealed sources), common site effects, and an overview of autologous and allogeneic transplant.
Domain V · Oncologic Emergencies16%
08Oncologic emergencies: structural and treatment-relatedSuperior vena cava syndrome, spinal cord compression, cardiac tamponade, raised intracranial pressure, obstructions and pneumonitis, with a map of all sixteen Domain V emergencies.
09Tumor lysis syndrome and metabolic emergenciesTumor lysis syndrome, SIADH, hypercalcemia of malignancy, DIC and venous thromboembolism: who is at risk, the labs, and what the nurse does first.
Domain II · Oncology Nursing Practice15%
02Cancer biology, staging and practice standardsCarcinogenesis and immunology, genetic versus genomic testing, TNM staging and grading, performance status scales, clinical trial basics, ethics, advocacy and compassion fatigue.
Domain I · Care Continuum14%
01Care continuum: prevention, screening and survivorshipRisk factors, screening and prevention, navigation, survivorship care plans and late effects, advance care planning, and end-of-life and hospice care at the level the OCN exam tests.
Domain VI · Psychosocial Dimensions of Care10%
10Psychosocial care in oncologyDistress screening, coping, body image, sexuality and fertility, learning needs, cultural and spiritual care, caregiver strain, crises, and the cost of cancer care.