NCLEX-PN
Immune System NCLEX Questions
Question 1 of 5
Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction?
Correct Answer: D
Rationale: Establishing a patent airway is the highest priority in anaphylaxis, per ABCs. Epinephrine, intubation, and reassurance follow.
Question 2 of 5
Which intervention should the nurse implement for the client diagnosed with systemic sclerosis (scleroderma)?
Correct Answer: B
Rationale: Frequent moisturizers combat skin fibrosis in scleroderma. Artificial tears are for Sjögren’s, braces are unrelated, and smoking cessation is secondary.
Question 3 of 5
The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE?
Correct Answer: A
Rationale: Pericardial friction rub and lung crackles indicate serositis, common in SLE. Spasticity, hirsutism, and somnolence suggest other conditions.
Question 4 of 5
The client is diagnosed with Multi Organ Dysfunction Syndrome (MODS). Which is the most appropriate goal for the nurse to write when planning the client's care?
Correct Answer: A
Rationale: Maintaining normal vital signs is a broad, achievable goal in MODS. Urine output is specific, elevated enzymes are undesirable, and high glucose is not a goal.
Question 5 of 5
The client diagnosed with multiple sclerosis is having trouble maintaining balance. Which intervention should the nurse discuss with the client?
Correct Answer: B
Rationale: Standing with feet apart widens the base of support, improving balance in MS. Wheelchairs are premature, narrowing support worsens balance, and rest is secondary.