NCLEX-PN
Immune System NCLEX Questions
Extract:
Question 1 of 5
The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply.
Correct Answer: A,C,E
Rationale: Solu-Medrol, rapid response team, and vital sign assessment address anaphylaxis. Chest x-ray is unnecessary, and epinephrine is an agonist, not a blocker.
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
Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections?
Correct Answer: D
Rationale: Standard Precautions reduce transmission of all infections by assuming all patients are infectious. Contact, airborne, and droplet precautions are for specific transmission modes.