NCLEX-PN
NCLEX Immune System Questions Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention?
Correct Answer: A
Rationale: Assessing weight and dietary intake provides baseline data for malnutrition management. Isolation is unnecessary, lab orders are secondary, and TPN teaching is premature.
Question 3 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?
Correct Answer: C
Rationale: A pulse oximeter reading of 85% indicates hypoxemia, requiring immediate intervention. Ventilator rate, resuscitation bag, and normal ABGs are appropriate.
Question 4 of 5
Which statement by the client supports the diagnosis of Guillain-Barré syndrome?
Correct Answer: B
Rationale: A recent viral infection (e.g., cold) is a common trigger for Guillain-Barré syndrome. Travel, coworker illness, and herbs are less relevant.
Question 5 of 5
The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse?
Correct Answer: D
Rationale: Allowing the wife to ventilate feelings is therapeutic, addressing immediate emotional distress. Foundation discussion, support groups, and counseling are secondary.