NCLEX-RN Pharmacology Immune
System Exam Questions
20 Original NGN-Style MCQs with
Rationales
Question 1
Clinical Scenario
A 46-year-old woman with severe rheumatoid arthritis is
prescribed methotrexate 15 mg orally once weekly. During a
follow-up visit, she tells the nurse, "I take it every morning
because I thought taking it more often would help my joints
heal faster." Assessment reveals painful mouth ulcers and
fatigue. Laboratory results show WBC 2,800/mm³, platelets
110,000/mm³, AST 92 U/L, and ALT 105 U/L.
Question Stem
Which nursing action is the priority?
A. Instruct the client to continue taking the medication with
meals.
,B. Hold the medication and notify the healthcare provider
immediately.
C. Encourage increased dietary protein intake.
D. Advise the client to take folic acid only when mouth ulcers
develop.
Correct Answer
Correct Answer: B. Hold the medication and notify the
healthcare provider immediately.
Detailed Rationale
Methotrexate is a disease-modifying antirheumatic drug
(DMARD) that suppresses immune activity by inhibiting folate
metabolism and DNA synthesis. It is prescribed once weekly,
not daily. Daily administration can rapidly lead to life-
threatening toxicity, including severe bone marrow suppression,
hepatotoxicity, and mucositis. This client's leukopenia,
thrombocytopenia, elevated liver enzymes, and oral ulcers
strongly suggest methotrexate toxicity. The priority nursing
intervention is to withhold the medication and immediately
notify the healthcare provider so further evaluation, laboratory
monitoring, and treatment can occur.
Option A is incorrect because continuing methotrexate would
worsen toxicity. Taking it with food may reduce gastrointestinal
upset but does not address overdose.
,Option C is incorrect because nutritional support does not treat
medication-induced bone marrow suppression or liver injury.
Option D is incorrect because folic acid is often prescribed
routinely to reduce adverse effects, not only after symptoms
appear. It does not replace proper weekly dosing.
Nurses should reinforce weekly dosing schedules, monitor CBC
and liver function tests regularly, assess for infection or
bleeding, and educate patients to report mouth sores, fever,
bruising, or unusual fatigue promptly.
Learning Objectives
After completing this question, the learner should be able to:
• Identify signs of methotrexate toxicity.
• Recognize the importance of weekly methotrexate dosing.
• Prioritize nursing interventions for medication overdose.
• Monitor laboratory values associated with DMARD
therapy.
Medication Safety Focus
Medication administration
Question 2
Clinical Scenario
, A 58-year-old man received a kidney transplant 3 weeks ago
and is prescribed tacrolimus. During assessment, the nurse
notes a blood pressure of 168/96 mm Hg, serum creatinine of
2.3 mg/dL (baseline 1.2 mg/dL), and reports of hand tremors.
Question Stem
Which assessment finding should the nurse recognize as
requiring the most immediate follow-up?
A. Mild hand tremors
B. Elevated serum creatinine
C. Blood pressure of 168/96 mm Hg
D. Mild headache
Correct Answer
Correct Answer: B. Elevated serum creatinine
Detailed Rationale
Tacrolimus is a calcineurin inhibitor used to prevent organ
transplant rejection by suppressing T-lymphocyte activation.
One of its most clinically significant adverse effects is
nephrotoxicity, often manifested by rising serum creatinine.
Because kidney damage may become irreversible if not
addressed promptly, an increasing creatinine level requires
immediate evaluation. The healthcare provider may adjust the
System Exam Questions
20 Original NGN-Style MCQs with
Rationales
Question 1
Clinical Scenario
A 46-year-old woman with severe rheumatoid arthritis is
prescribed methotrexate 15 mg orally once weekly. During a
follow-up visit, she tells the nurse, "I take it every morning
because I thought taking it more often would help my joints
heal faster." Assessment reveals painful mouth ulcers and
fatigue. Laboratory results show WBC 2,800/mm³, platelets
110,000/mm³, AST 92 U/L, and ALT 105 U/L.
Question Stem
Which nursing action is the priority?
A. Instruct the client to continue taking the medication with
meals.
,B. Hold the medication and notify the healthcare provider
immediately.
C. Encourage increased dietary protein intake.
D. Advise the client to take folic acid only when mouth ulcers
develop.
Correct Answer
Correct Answer: B. Hold the medication and notify the
healthcare provider immediately.
Detailed Rationale
Methotrexate is a disease-modifying antirheumatic drug
(DMARD) that suppresses immune activity by inhibiting folate
metabolism and DNA synthesis. It is prescribed once weekly,
not daily. Daily administration can rapidly lead to life-
threatening toxicity, including severe bone marrow suppression,
hepatotoxicity, and mucositis. This client's leukopenia,
thrombocytopenia, elevated liver enzymes, and oral ulcers
strongly suggest methotrexate toxicity. The priority nursing
intervention is to withhold the medication and immediately
notify the healthcare provider so further evaluation, laboratory
monitoring, and treatment can occur.
Option A is incorrect because continuing methotrexate would
worsen toxicity. Taking it with food may reduce gastrointestinal
upset but does not address overdose.
,Option C is incorrect because nutritional support does not treat
medication-induced bone marrow suppression or liver injury.
Option D is incorrect because folic acid is often prescribed
routinely to reduce adverse effects, not only after symptoms
appear. It does not replace proper weekly dosing.
Nurses should reinforce weekly dosing schedules, monitor CBC
and liver function tests regularly, assess for infection or
bleeding, and educate patients to report mouth sores, fever,
bruising, or unusual fatigue promptly.
Learning Objectives
After completing this question, the learner should be able to:
• Identify signs of methotrexate toxicity.
• Recognize the importance of weekly methotrexate dosing.
• Prioritize nursing interventions for medication overdose.
• Monitor laboratory values associated with DMARD
therapy.
Medication Safety Focus
Medication administration
Question 2
Clinical Scenario
, A 58-year-old man received a kidney transplant 3 weeks ago
and is prescribed tacrolimus. During assessment, the nurse
notes a blood pressure of 168/96 mm Hg, serum creatinine of
2.3 mg/dL (baseline 1.2 mg/dL), and reports of hand tremors.
Question Stem
Which assessment finding should the nurse recognize as
requiring the most immediate follow-up?
A. Mild hand tremors
B. Elevated serum creatinine
C. Blood pressure of 168/96 mm Hg
D. Mild headache
Correct Answer
Correct Answer: B. Elevated serum creatinine
Detailed Rationale
Tacrolimus is a calcineurin inhibitor used to prevent organ
transplant rejection by suppressing T-lymphocyte activation.
One of its most clinically significant adverse effects is
nephrotoxicity, often manifested by rising serum creatinine.
Because kidney damage may become irreversible if not
addressed promptly, an increasing creatinine level requires
immediate evaluation. The healthcare provider may adjust the
