NCLEX Immune System Questions

Extract:

Question 1 of 5

The nurse and a licensed practical nurse are caring for clients in a rheumatologist's office. Which task can the nurse assign to the licensed practical nurse?

Correct Answer: C

Rationale: Demonstrating Velcro clothing is within LPN scope. Methotrexate administration, lung assessment, and birth control discussion require RN judgment.

Question 2 of 5

Which intervention has the highest priority when caring for a client diagnosed with rheumatoid arthritis?

A. Encourage the client to ventilate feelings about the disease process. B. Discuss the effects of disease on the client's career and other life roles. C. Instruct the client to perform most important activities in the morning. D. Teach the client the proper use of hot and cold therapy to provide pain relief.

Correct Answer: D

Rationale: Hot and cold therapy directly relieves RA pain, a priority. Emotional ventilation, career impact, and morning activity are secondary.

Question 3 of 5

The client recently diagnosed with SLE asks the nurse, 'What is SLE and how did I get it?' Which statement best explains the scientific rationale for the nurse's response?

A. SLE occurs because the kidneys do not filter antibodies from the blood. B. SLE occurs after a viral illness as a result of damage to the endocrine system. C. There is no known identifiable reason for a client to develop SLE. D. This is an autoimmune disease that may have a genetic or hormonal component.

Correct Answer: D

Rationale: SLE is an autoimmune disease with genetic and hormonal influences. Kidney issues are a complication, viral triggers are secondary, and the cause is partially understood.

Question 4 of 5

The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis?

A. The client has no apparent change in the assessment data. B. There is increased amplitude of electrical stimulation in the muscle. C. The circulating acetylcholine receptor antibodies are decreased. D. The client shows a marked improvement of muscle strength.

Correct Answer: D

Rationale: The Tensilon test improves muscle strength in myasthenia gravis by inhibiting acetylcholinesterase. No change, electrical stimulation, or antibody levels are not diagnostic.

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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