NCLEX-PN
NCLEX Immune System Questions Questions
Extract:
Question 1 of 5
The client diagnosed with Systemic Response Inflammatory Syndrome (SIRS) asks the nurse what the diagnosis means. Which is the nurse's best response?
Correct Answer: D
Rationale: SIRS is a systemic response to insults like infection or trauma. It is not localized, has variable prognosis, and is not solely respiratory.
Question 2 of 5
The client diagnosed with an anaphylactic reaction is admitted to the emergency department. Which assessment data indicate the client is not responding to the treatment?
Correct Answer: B
Rationale: Hypotension (BP 90/60) and tachycardia (AP 110) indicate ongoing anaphylaxis despite treatment. Normal urine output, clear lungs, and bowel sounds suggest improvement.
Question 3 of 5
The primary nurse is administering medications to the assigned clients. Which client situation requires immediate intervention by the charge nurse?
Correct Answer: C
Rationale: A 30-minute delay in anticholinesterase for myasthenia gravis risks muscle weakness exacerbation, requiring intervention. Digoxin, beta blocker, and antibiotic administration are appropriate.
Question 4 of 5
The client recently diagnosed with rheumatoid arthritis is prescribed aspirin, a nonsteroidal anti-inflammatory medication. Which comment by the client warrants immediate intervention by the nurse?
Correct Answer: D
Rationale: Ringing in the ears (tinnitus) indicates aspirin toxicity, requiring immediate intervention. Taking with food, reporting dark stools, and understanding no cure are correct.
Question 5 of 5
Which assessment data should make the nurse suspect the client has chronic allergies?
Correct Answer: B
Rationale: Pale, boggy, edematous nasal mucosa indicates chronic allergic rhinitis. Jaundice, oral plaques, and facial patches suggest other conditions.