NCLEX-RN Pharmacology Immune
System Exam
20 Original ATI-Style Practice Questions
with Detailed Rationales
Nursing Test Bank
NGN Clinical Judgment
Question 1
Clinical Scenario
A 28-year-old woman with rheumatoid arthritis is prescribed
methotrexate 15 mg orally once weekly. During a follow-up
clinic visit, she tells the nurse that she has been taking the
medication every morning because she thought it would
control her symptoms more effectively. She reports mouth
sores, nausea, and increasing fatigue over the past several days.
Her laboratory results reveal:
• WBC: 2,900/mm³
• Platelets: 105,000/mm³
, • ALT: 88 U/L
• AST: 76 U/L
Question Stem
Which nursing action is the priority?
A. Instruct the client to increase fluid intake and continue the
medication.
B. Hold the medication and notify the health care provider
immediately.
C. Administer the next scheduled dose with food to decrease
nausea.
D. Recommend an over-the-counter mouthwash for oral
discomfort.
Correct Answer
Correct Answer: B. Hold the medication and notify the health
care provider immediately.
Detailed Rationale
Methotrexate is a folate antagonist classified as a disease-
modifying antirheumatic drug (DMARD). For inflammatory
diseases such as rheumatoid arthritis, it is administered once
weekly, not daily. Daily administration greatly increases the risk
of severe toxicity, including bone marrow suppression,
mucositis, hepatotoxicity, and potentially fatal complications.
,This client's oral ulcers, leukopenia, thrombocytopenia,
elevated liver enzymes, and fatigue strongly suggest
methotrexate toxicity. The priority nursing intervention is to
withhold further doses and notify the provider immediately for
evaluation, additional laboratory monitoring, and possible
treatment such as folinic acid (leucovorin) rescue depending on
the clinical situation.
Option A is incorrect because continuing the medication could
worsen life-threatening toxicity. Hydration alone is insufficient.
Option C is incorrect because administering another dose
would increase toxicity despite reducing gastrointestinal
irritation.
Option D addresses a symptom but fails to address the
underlying medication error and potentially serious adverse
effects.
Patient education is essential. Nurses should emphasize that
methotrexate for autoimmune disorders is taken only once
weekly, avoid alcohol because of hepatotoxicity risk, monitor
CBC and liver function tests regularly, and report fever,
bleeding, bruising, persistent sore throat, or mouth ulcers
promptly.
Learning Objectives
After completing this question, the learner should be able to:
, • Recognize signs of methotrexate toxicity.
• Identify the correct weekly dosing schedule for
methotrexate in autoimmune disorders.
• Prioritize nursing interventions for medication
administration errors.
• Monitor laboratory findings associated with bone marrow
suppression.
Medication Safety Focus
Medication administration error (weekly versus daily dosing).
Question 2
Clinical Scenario
A 56-year-old man with severe psoriasis is receiving
adalimumab by subcutaneous injection every other week.
Before today's scheduled injection, he reports a productive
cough, night sweats, and an unintentional 8-lb weight loss over
the past month. His temperature is 38.3°C (100.9°F). A
tuberculosis screening completed before therapy was negative
two years ago.
Question Stem
What is the nurse's priority action?
System Exam
20 Original ATI-Style Practice Questions
with Detailed Rationales
Nursing Test Bank
NGN Clinical Judgment
Question 1
Clinical Scenario
A 28-year-old woman with rheumatoid arthritis is prescribed
methotrexate 15 mg orally once weekly. During a follow-up
clinic visit, she tells the nurse that she has been taking the
medication every morning because she thought it would
control her symptoms more effectively. She reports mouth
sores, nausea, and increasing fatigue over the past several days.
Her laboratory results reveal:
• WBC: 2,900/mm³
• Platelets: 105,000/mm³
, • ALT: 88 U/L
• AST: 76 U/L
Question Stem
Which nursing action is the priority?
A. Instruct the client to increase fluid intake and continue the
medication.
B. Hold the medication and notify the health care provider
immediately.
C. Administer the next scheduled dose with food to decrease
nausea.
D. Recommend an over-the-counter mouthwash for oral
discomfort.
Correct Answer
Correct Answer: B. Hold the medication and notify the health
care provider immediately.
Detailed Rationale
Methotrexate is a folate antagonist classified as a disease-
modifying antirheumatic drug (DMARD). For inflammatory
diseases such as rheumatoid arthritis, it is administered once
weekly, not daily. Daily administration greatly increases the risk
of severe toxicity, including bone marrow suppression,
mucositis, hepatotoxicity, and potentially fatal complications.
,This client's oral ulcers, leukopenia, thrombocytopenia,
elevated liver enzymes, and fatigue strongly suggest
methotrexate toxicity. The priority nursing intervention is to
withhold further doses and notify the provider immediately for
evaluation, additional laboratory monitoring, and possible
treatment such as folinic acid (leucovorin) rescue depending on
the clinical situation.
Option A is incorrect because continuing the medication could
worsen life-threatening toxicity. Hydration alone is insufficient.
Option C is incorrect because administering another dose
would increase toxicity despite reducing gastrointestinal
irritation.
Option D addresses a symptom but fails to address the
underlying medication error and potentially serious adverse
effects.
Patient education is essential. Nurses should emphasize that
methotrexate for autoimmune disorders is taken only once
weekly, avoid alcohol because of hepatotoxicity risk, monitor
CBC and liver function tests regularly, and report fever,
bleeding, bruising, persistent sore throat, or mouth ulcers
promptly.
Learning Objectives
After completing this question, the learner should be able to:
, • Recognize signs of methotrexate toxicity.
• Identify the correct weekly dosing schedule for
methotrexate in autoimmune disorders.
• Prioritize nursing interventions for medication
administration errors.
• Monitor laboratory findings associated with bone marrow
suppression.
Medication Safety Focus
Medication administration error (weekly versus daily dosing).
Question 2
Clinical Scenario
A 56-year-old man with severe psoriasis is receiving
adalimumab by subcutaneous injection every other week.
Before today's scheduled injection, he reports a productive
cough, night sweats, and an unintentional 8-lb weight loss over
the past month. His temperature is 38.3°C (100.9°F). A
tuberculosis screening completed before therapy was negative
two years ago.
Question Stem
What is the nurse's priority action?
