NCLEX-RN Immune System
Pharmacology Exam Questions with
Rationales
20 Original NCLEX Practice MCQs
ATI & NGN Nursing Review
Question 1
Clinical Scenario
A 46-year-old woman with severe rheumatoid arthritis has been
receiving methotrexate 15 mg orally once weekly for 3 months.
She reports increasing fatigue, painful mouth sores, and
nausea. Laboratory results reveal: WBC 2,900/mm³, platelet
count 98,000/mm³, ALT 82 U/L, AST 76 U/L. She asks whether
she should take an extra dose because she accidentally missed
her scheduled dose 2 days ago.
Question Stem
Which nursing action is the priority?
,A. Advise the client to take the missed dose immediately and
resume the weekly schedule.
B. Hold the medication and notify the health care provider
immediately.
C. Encourage the client to increase dietary protein intake.
D. Administer folic acid and continue methotrexate as
prescribed.
Correct Answer
B. Hold the medication and notify the health care provider
immediately.
Detailed Rationale
Methotrexate is a disease-modifying antirheumatic drug
(DMARD) that inhibits folate metabolism, suppressing immune
cell proliferation. Although effective in controlling rheumatoid
arthritis, it carries significant risks of bone marrow suppression,
hepatotoxicity, and mucositis. This client's leukopenia,
thrombocytopenia, elevated liver enzymes, and oral ulcers
strongly suggest methotrexate toxicity. The nurse's priority is to
withhold further doses and notify the provider so the
medication can be evaluated, laboratory abnormalities
addressed, and supportive treatment initiated. Continuing
therapy could increase the risk of life-threatening infection or
bleeding.
, • Option A: Incorrect. Clients should never independently
double or "catch up" missed weekly methotrexate doses,
particularly when toxicity is suspected.
• Option C: Incorrect. Nutritional support does not address
severe drug toxicity or cytopenias.
• Option D: Incorrect. Although folic acid commonly reduces
minor adverse effects, it is not appropriate to continue
methotrexate in the presence of significant hematologic
and hepatic toxicity.
Patient teaching should emphasize weekly—not daily—
administration, regular CBC and liver function monitoring,
avoidance of alcohol, prompt reporting of fever or unusual
bleeding, and avoiding live vaccines unless approved by the
provider.
Learning Objectives
After completing this question, the learner should be able to:
• Recognize manifestations of methotrexate toxicity.
• Prioritize nursing actions when severe adverse effects
occur.
• Identify laboratory findings requiring discontinuation of
therapy.
• Educate clients about safe methotrexate administration.
, Medication Safety Focus
Monitoring for bone marrow suppression and hepatotoxicity.
Question 2
Clinical Scenario
A 52-year-old man underwent a kidney transplant 10 days ago
and is prescribed tacrolimus. Morning laboratory results show a
serum creatinine increase from 1.1 mg/dL to 2.0 mg/dL. Blood
pressure is 158/94 mm Hg. He reports hand tremors but denies
pain or fever.
Question Stem
Which assessment finding requires the nurse's immediate
attention?
A. Mild tremors
B. Elevated serum creatinine
C. Slight headache
D. Decreased appetite
Correct Answer
B. Elevated serum creatinine
Detailed Rationale
Pharmacology Exam Questions with
Rationales
20 Original NCLEX Practice MCQs
ATI & NGN Nursing Review
Question 1
Clinical Scenario
A 46-year-old woman with severe rheumatoid arthritis has been
receiving methotrexate 15 mg orally once weekly for 3 months.
She reports increasing fatigue, painful mouth sores, and
nausea. Laboratory results reveal: WBC 2,900/mm³, platelet
count 98,000/mm³, ALT 82 U/L, AST 76 U/L. She asks whether
she should take an extra dose because she accidentally missed
her scheduled dose 2 days ago.
Question Stem
Which nursing action is the priority?
,A. Advise the client to take the missed dose immediately and
resume the weekly schedule.
B. Hold the medication and notify the health care provider
immediately.
C. Encourage the client to increase dietary protein intake.
D. Administer folic acid and continue methotrexate as
prescribed.
Correct Answer
B. Hold the medication and notify the health care provider
immediately.
Detailed Rationale
Methotrexate is a disease-modifying antirheumatic drug
(DMARD) that inhibits folate metabolism, suppressing immune
cell proliferation. Although effective in controlling rheumatoid
arthritis, it carries significant risks of bone marrow suppression,
hepatotoxicity, and mucositis. This client's leukopenia,
thrombocytopenia, elevated liver enzymes, and oral ulcers
strongly suggest methotrexate toxicity. The nurse's priority is to
withhold further doses and notify the provider so the
medication can be evaluated, laboratory abnormalities
addressed, and supportive treatment initiated. Continuing
therapy could increase the risk of life-threatening infection or
bleeding.
, • Option A: Incorrect. Clients should never independently
double or "catch up" missed weekly methotrexate doses,
particularly when toxicity is suspected.
• Option C: Incorrect. Nutritional support does not address
severe drug toxicity or cytopenias.
• Option D: Incorrect. Although folic acid commonly reduces
minor adverse effects, it is not appropriate to continue
methotrexate in the presence of significant hematologic
and hepatic toxicity.
Patient teaching should emphasize weekly—not daily—
administration, regular CBC and liver function monitoring,
avoidance of alcohol, prompt reporting of fever or unusual
bleeding, and avoiding live vaccines unless approved by the
provider.
Learning Objectives
After completing this question, the learner should be able to:
• Recognize manifestations of methotrexate toxicity.
• Prioritize nursing actions when severe adverse effects
occur.
• Identify laboratory findings requiring discontinuation of
therapy.
• Educate clients about safe methotrexate administration.
, Medication Safety Focus
Monitoring for bone marrow suppression and hepatotoxicity.
Question 2
Clinical Scenario
A 52-year-old man underwent a kidney transplant 10 days ago
and is prescribed tacrolimus. Morning laboratory results show a
serum creatinine increase from 1.1 mg/dL to 2.0 mg/dL. Blood
pressure is 158/94 mm Hg. He reports hand tremors but denies
pain or fever.
Question Stem
Which assessment finding requires the nurse's immediate
attention?
A. Mild tremors
B. Elevated serum creatinine
C. Slight headache
D. Decreased appetite
Correct Answer
B. Elevated serum creatinine
Detailed Rationale
