NCLEX-RN Pharmacology Exam Prep: 20 Next-
Gen NGN & ATI Style Immune System MCQs
(Expert Rationales & Safety Focus)
Question 1
Clinical Scenario
A 45-year-old female client who underwent a living-donor
kidney transplantation four weeks ago is admitted to the
transplant unit. She has been taking cyclosporine,
mycophenolate mofetil, and prednisone daily. During the
morning assessment, the nurse notes the client's blood
pressure is 152/94 mmHg, she has 1+ generalized edema, and
she complains of a persistent, fine tremor in both hands. Her
laboratory results reveal a serum creatinine of 1.9 mg/dL
(baseline was 1.1 mg/dL) and a blood urea nitrogen (BUN) of 34
mg/dL.
Question Stem
,Which action should the nurse take first?
A. Administer a PRN dose of hydralazine for the elevated blood
pressure.
B. Document the hand tremor as a common, transient side
effect of prednisone.
C. Notify the healthcare provider and prepare to check a trough
cyclosporine level.
D. Instruct the client to restrict oral fluid intake to 1,000 mL
over the next 24 hours.
Correct Answer
Correct Answer: C. Notify the healthcare provider and prepare
to check a trough cyclosporine level.
Detailed Rationale
Cyclosporine is a calcineurin inhibitor immunosuppressant used
to prevent organ transplant rejection. It has a narrow
therapeutic index and is notoriously nephrotoxic. The client is
exhibiting classic signs of cyclosporine toxicity, which include
elevated serum creatinine and BUN (nephrotoxicity),
hypertension, and neurological symptoms such as tremors.
While a hand tremor is a known adverse effect of cyclosporine
rather than prednisone, the critical finding here is the acute rise
in serum creatinine from the client's baseline, indicating
potential kidney injury or transplant rejection.
,Obtaining a trough cyclosporine level is the priority action
because it allows the healthcare provider to differentiate
between drug toxicity and acute organ rejection, both of which
can cause renal dysfunction. Checking the trough level ensures
the medication dose can be adjusted accurately and safely.
Administering hydralazine (Option A) addresses the symptom of
hypertension but fails to address the underlying cause of the
renal impairment. Attributing the tremor to prednisone (Option
B) is pharmacologically incorrect and delays necessary
intervention. Restricting fluids (Option D) could further reduce
renal perfusion, worsening the acute kidney injury.
Learning Objective
After completing this question, the learner should be able to:
• Recognize the clinical manifestations of cyclosporine
toxicity, including nephrotoxicity, hypertension, and
tremors.
• Prioritize laboratory monitoring parameters, specifically
trough drug levels, for high-alert immunosuppressant
medications.
• Differentiate between expected side effects and critical
adverse drug reactions in a post-transplant patient.
Medication Safety Focus
High-alert medication
, Question 2
Clinical Scenario
A 28-year-old male client with severe Crohn's disease is
scheduled to receive his first intravenous infusion of infliximab.
The nurse is reviewing the client's medical record, pre-infusion
checklist, and laboratory diagnostic results prior to initiating the
medication. The chart contains the following entries: a negative
pregnancy test (not applicable), a complete blood count within
normal limits, a liver function panel showing mild elevations,
and a positive interferon-gamma release assay (IGRA) test.
Question Stem
Which action should the nurse take next?
A. Hold the infusion and immediately notify the provider of the
positive IGRA test result.
B. Administer pre-medications (acetaminophen and
diphenhydramine) and start the infusion.
C. Reassure the client that a positive IGRA test is an expected
therapeutic baseline for autoimmune conditions.
D. Request a prescription for a liver ultrasound before
administering the infliximab.
Correct Answer
Gen NGN & ATI Style Immune System MCQs
(Expert Rationales & Safety Focus)
Question 1
Clinical Scenario
A 45-year-old female client who underwent a living-donor
kidney transplantation four weeks ago is admitted to the
transplant unit. She has been taking cyclosporine,
mycophenolate mofetil, and prednisone daily. During the
morning assessment, the nurse notes the client's blood
pressure is 152/94 mmHg, she has 1+ generalized edema, and
she complains of a persistent, fine tremor in both hands. Her
laboratory results reveal a serum creatinine of 1.9 mg/dL
(baseline was 1.1 mg/dL) and a blood urea nitrogen (BUN) of 34
mg/dL.
Question Stem
,Which action should the nurse take first?
A. Administer a PRN dose of hydralazine for the elevated blood
pressure.
B. Document the hand tremor as a common, transient side
effect of prednisone.
C. Notify the healthcare provider and prepare to check a trough
cyclosporine level.
D. Instruct the client to restrict oral fluid intake to 1,000 mL
over the next 24 hours.
Correct Answer
Correct Answer: C. Notify the healthcare provider and prepare
to check a trough cyclosporine level.
Detailed Rationale
Cyclosporine is a calcineurin inhibitor immunosuppressant used
to prevent organ transplant rejection. It has a narrow
therapeutic index and is notoriously nephrotoxic. The client is
exhibiting classic signs of cyclosporine toxicity, which include
elevated serum creatinine and BUN (nephrotoxicity),
hypertension, and neurological symptoms such as tremors.
While a hand tremor is a known adverse effect of cyclosporine
rather than prednisone, the critical finding here is the acute rise
in serum creatinine from the client's baseline, indicating
potential kidney injury or transplant rejection.
,Obtaining a trough cyclosporine level is the priority action
because it allows the healthcare provider to differentiate
between drug toxicity and acute organ rejection, both of which
can cause renal dysfunction. Checking the trough level ensures
the medication dose can be adjusted accurately and safely.
Administering hydralazine (Option A) addresses the symptom of
hypertension but fails to address the underlying cause of the
renal impairment. Attributing the tremor to prednisone (Option
B) is pharmacologically incorrect and delays necessary
intervention. Restricting fluids (Option D) could further reduce
renal perfusion, worsening the acute kidney injury.
Learning Objective
After completing this question, the learner should be able to:
• Recognize the clinical manifestations of cyclosporine
toxicity, including nephrotoxicity, hypertension, and
tremors.
• Prioritize laboratory monitoring parameters, specifically
trough drug levels, for high-alert immunosuppressant
medications.
• Differentiate between expected side effects and critical
adverse drug reactions in a post-transplant patient.
Medication Safety Focus
High-alert medication
, Question 2
Clinical Scenario
A 28-year-old male client with severe Crohn's disease is
scheduled to receive his first intravenous infusion of infliximab.
The nurse is reviewing the client's medical record, pre-infusion
checklist, and laboratory diagnostic results prior to initiating the
medication. The chart contains the following entries: a negative
pregnancy test (not applicable), a complete blood count within
normal limits, a liver function panel showing mild elevations,
and a positive interferon-gamma release assay (IGRA) test.
Question Stem
Which action should the nurse take next?
A. Hold the infusion and immediately notify the provider of the
positive IGRA test result.
B. Administer pre-medications (acetaminophen and
diphenhydramine) and start the infusion.
C. Reassure the client that a positive IGRA test is an expected
therapeutic baseline for autoimmune conditions.
D. Request a prescription for a liver ultrasound before
administering the infliximab.
Correct Answer
