NCLEX-PN
Immune System NCLEX Questions
Extract:
Question 1 of 5
The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which preprocedure intervention has priority?
Correct Answer: B
Rationale: Voiding before a lumbar puncture prevents discomfort and reduces complications. NPO is unnecessary, lithotomy is incorrect, and pedal pulse is irrelevant.
Question 2 of 5
The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make?
Correct Answer: B
Rationale: Acknowledging the client’s distress and offering to talk is therapeutic, fostering emotional support. 'Why' questions are confrontational, disease facts dismiss feelings, and chaplain referral is premature.
Question 3 of 5
The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach?
Correct Answer: C
Rationale: A steroid dose pack reduces inflammation and itching in poison ivy reactions. Never scratching is unrealistic, IM Benadryl is HCP-administered, and clothing is preventive.
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 health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which preprocedure intervention has priority?
Correct Answer: B
Rationale: Voiding before a lumbar puncture prevents discomfort and reduces complications. NPO is unnecessary, lithotomy is incorrect, and pedal pulse is irrelevant.