NCLEX Immune System Questions

Extract:

Question 1 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 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?

A. The client has a urinary output of 120 mL in two (2) hours. B. The client has an AP of 110 and a BP of 90/60. C. The client has clear breath sounds and an RR of 26. D. The client has hyperactive bowel sounds.

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 nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves?

A. Use only sterile, nonlatex gloves for any procedure requiring gloves. B. Do not use gloves when starting an IV or performing a procedure. C. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform. D. Wear white cotton gloves at all times to protect the hands.

Correct Answer: C

Rationale: Carrying nonsterile, nonlatex gloves ensures safe practice for a latex-allergic nurse. Sterile gloves are unnecessary, avoiding gloves risks infection, and cotton gloves are inadequate.

Question 4 of 5

The client asks the nurse, 'Which time of the year is allergic rhinitis least likely to occur?' Which statement is the nurse's best response?

A. It is least likely to occur during the springtime. B. Allergic rhinitis is not likely to occur during the summer. C. It is least likely to occur in the early fall. D. Allergic rhinitis is least likely to occur in early winter.

Correct Answer: D

Rationale: Early winter has lower pollen levels, reducing allergic rhinitis. Spring, summer, and fall are peak seasons.

Question 5 of 5

The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse?

A. The ventilator rate is set at 14 breaths per minute. B. A manual resuscitation bag is at the client's bedside. C. The client's pulse oximeter reading is 85%. D. The ABG results are pH 7.4, PaO2 88, PaCO2 35, and HCO3 24.

Correct Answer: C

Rationale: A pulse oximeter reading of 85% indicates hypoxemia, requiring immediate intervention. Ventilator rate, resuscitation bag, and normal ABGs are appropriate.

NCLEX Immune System Questions | Nurselytic

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