NCLEX-RN Pharmacology Immune
System Exam Questions with Rationales
| 20 NGN NCLEX-Style MCQs |
Immunosuppressants, Biologics,
Corticosteroids, Transplant Medications
Study Guide
Question 1
Clinical Scenario
A 42-year-old woman with rheumatoid arthritis is prescribed
methotrexate 15 mg orally once weekly. She tells the nurse
that she has been taking the medication every morning because
she thought it would work faster. She reports mouth sores,
nausea, and increasing fatigue. Laboratory results reveal:
• WBC: 2,900/mm³
• Platelets: 95,000/mm³
• ALT: 78 U/L
• AST: 72 U/L
,Question Stem
Which action should the nurse take first?
Options
A. Instruct the client to increase oral fluid intake.
B. Hold the medication and notify the healthcare provider
immediately.
C. Administer folic acid and continue the prescribed
methotrexate.
D. Advise the client to divide the weekly dose into daily doses.
Correct Answer
B. Hold the medication and notify the healthcare provider
immediately.
Detailed Rationale
Methotrexate is a disease-modifying antirheumatic drug
(DMARD) that inhibits folate metabolism, reducing immune cell
proliferation. It is intended to be taken once weekly, not daily.
Daily administration significantly increases the risk of severe
toxicity, including bone marrow suppression, hepatotoxicity,
mucositis, and gastrointestinal injury. This client demonstrates
classic signs of overdose: oral ulcers, leukopenia,
thrombocytopenia, and elevated liver enzymes. The priority
nursing action is to withhold additional doses and immediately
,notify the healthcare provider. Further evaluation, including
repeat laboratory testing and possible administration of
leucovorin (folinic acid) rescue, may be required depending on
the severity of toxicity.
Option A is inappropriate because hydration does not address
life-threatening myelosuppression or liver injury. Option C is
incorrect because folic acid supplementation may reduce minor
adverse effects but should not be used as a substitute for
withholding methotrexate when toxicity is suspected. Option D
is dangerous because dividing the weekly dose into daily doses
further increases toxicity. Nurses should emphasize the
importance of weekly dosing, monitor CBC and liver function
tests regularly, and reinforce that methotrexate is
contraindicated during pregnancy due to teratogenicity.
Learning Objectives
After completing this question, the learner should be able to:
• Identify signs of methotrexate toxicity.
• Prioritize nursing interventions for medication overdose.
• Interpret laboratory findings associated with bone marrow
suppression.
• Educate clients on correct methotrexate dosing schedules.
Medication Safety Focus
, Medication administration
Question 2
Clinical Scenario
A 56-year-old man underwent a kidney transplant 3 months ago
and is taking tacrolimus. During a follow-up visit, he reports
hand tremors and mild headaches. Laboratory findings include:
• Serum creatinine: 2.1 mg/dL
• Potassium: 5.8 mEq/L
• Tacrolimus trough level: Above therapeutic range
Question Stem
Which finding requires the nurse's highest priority
intervention?
Options
A. Mild headache
B. Elevated serum creatinine
C. Fine hand tremors
D. Occasional nausea
Correct Answer
B. Elevated serum creatinine
System Exam Questions with Rationales
| 20 NGN NCLEX-Style MCQs |
Immunosuppressants, Biologics,
Corticosteroids, Transplant Medications
Study Guide
Question 1
Clinical Scenario
A 42-year-old woman with rheumatoid arthritis is prescribed
methotrexate 15 mg orally once weekly. She tells the nurse
that she has been taking the medication every morning because
she thought it would work faster. She reports mouth sores,
nausea, and increasing fatigue. Laboratory results reveal:
• WBC: 2,900/mm³
• Platelets: 95,000/mm³
• ALT: 78 U/L
• AST: 72 U/L
,Question Stem
Which action should the nurse take first?
Options
A. Instruct the client to increase oral fluid intake.
B. Hold the medication and notify the healthcare provider
immediately.
C. Administer folic acid and continue the prescribed
methotrexate.
D. Advise the client to divide the weekly dose into daily doses.
Correct Answer
B. Hold the medication and notify the healthcare provider
immediately.
Detailed Rationale
Methotrexate is a disease-modifying antirheumatic drug
(DMARD) that inhibits folate metabolism, reducing immune cell
proliferation. It is intended to be taken once weekly, not daily.
Daily administration significantly increases the risk of severe
toxicity, including bone marrow suppression, hepatotoxicity,
mucositis, and gastrointestinal injury. This client demonstrates
classic signs of overdose: oral ulcers, leukopenia,
thrombocytopenia, and elevated liver enzymes. The priority
nursing action is to withhold additional doses and immediately
,notify the healthcare provider. Further evaluation, including
repeat laboratory testing and possible administration of
leucovorin (folinic acid) rescue, may be required depending on
the severity of toxicity.
Option A is inappropriate because hydration does not address
life-threatening myelosuppression or liver injury. Option C is
incorrect because folic acid supplementation may reduce minor
adverse effects but should not be used as a substitute for
withholding methotrexate when toxicity is suspected. Option D
is dangerous because dividing the weekly dose into daily doses
further increases toxicity. Nurses should emphasize the
importance of weekly dosing, monitor CBC and liver function
tests regularly, and reinforce that methotrexate is
contraindicated during pregnancy due to teratogenicity.
Learning Objectives
After completing this question, the learner should be able to:
• Identify signs of methotrexate toxicity.
• Prioritize nursing interventions for medication overdose.
• Interpret laboratory findings associated with bone marrow
suppression.
• Educate clients on correct methotrexate dosing schedules.
Medication Safety Focus
, Medication administration
Question 2
Clinical Scenario
A 56-year-old man underwent a kidney transplant 3 months ago
and is taking tacrolimus. During a follow-up visit, he reports
hand tremors and mild headaches. Laboratory findings include:
• Serum creatinine: 2.1 mg/dL
• Potassium: 5.8 mEq/L
• Tacrolimus trough level: Above therapeutic range
Question Stem
Which finding requires the nurse's highest priority
intervention?
Options
A. Mild headache
B. Elevated serum creatinine
C. Fine hand tremors
D. Occasional nausea
Correct Answer
B. Elevated serum creatinine
