NCLEX-RN Pharmacology Exam Prep:
20 NGN Immune System MCQs with Detailed
Rationales
Question 1
Clinical Scenario
A 43-year-old female client with a history of severe rheumatoid
arthritis is admitted to the medical-surgical unit for a scheduled
orthopedic procedure. During the medication reconciliation, the
nurse notes she takes adalimumab subcutaneously every other
week. The client's last dose was 4 days ago. She has no active
signs of infection, and her pre-operative chest X-ray is clear.
Question Stem
Which action is the priority for the nurse regarding the client’s
adalimumab therapy prior to surgery?
A. Administer a scheduled dose immediately to prevent a
rheumatoid arthritis flare-up during recovery.
,B. Hold the medication and collaborate with the surgical team
and rheumatologist regarding the timing of perioperative
discontinuation.
C. Inform the client that she must discontinue adalimumab
permanently due to the high risk of post-operative sepsis.
D. Request a prescription for prophylactic intravenous broad-
spectrum antibiotics to be administered for 7 days post-
operatively.
Correct Answer
Correct Answer: B. Hold the medication and collaborate with
the surgical team and rheumatologist regarding the timing of
perioperative discontinuation.
Detailed Rationale
Adalimumab is a tumor necrosis factor (TNF) alpha inhibitor, a
biological disease-modifying antirheumatic drug (DMARD) that
suppresses the immune system to reduce inflammation in
autoimmune diseases like rheumatoid arthritis. Because TNF-
alpha plays a critical role in the body's defense against
infections and in wound healing, biologic DMARDs significantly
increase the risk of serious post-operative infections and
delayed surgical wound healing. Current clinical guidelines
generally recommend withholding biological therapies prior to
major elective surgeries, typically scheduling the surgery at the
,end of the dosing interval (e.g., 2 weeks after the last dose of
adalimumab) to ensure drug levels have declined.
Option A is incorrect because administering an extra or
premature dose would further elevate immunosuppression
right before a surgical insult, drastically raising infection risks.
Option C is incorrect because permanent discontinuation is
unwarranted; biologic DMARDs are crucial for managing
debilitating autoimmune diseases and are typically resumed
post-operatively once the wound shows advanced healing and
no signs of infection are present. Option D is incorrect because
an extended 7-day course of prophylactic broad-spectrum
antibiotics is not a standard substitute for appropriate
perioperative management of immunosuppressive agents; it
increases the risk of antibiotic resistance, Clostridioides difficile
infection, and drug toxicity without mitigating the impaired
wound healing caused by the TNF inhibitor.
Learning Objective
After completing this question, the learner should be able to:
• Prioritize perioperative nursing actions for clients receiving
biological disease-modifying antirheumatic drugs
(DMARDs).
• Explain the impact of tumor necrosis factor (TNF) inhibitors
on infection risks and wound healing during the surgical
period.
, • Demonstrate appropriate collaborative practice in
medication reconciliation for immunosuppressed surgical
clients.
Medication Safety Focus
High-alert medication / Medication administration
Question 2
Clinical Scenario
A 29-year-old male client is receiving an intravenous infusion of
infliximab for the treatment of moderate-to-severe Crohn's
disease. Forty-five minutes into the scheduled 2-hour infusion,
the client calls the nurse and reports sudden shortness of
breath, chest tightness, and a warm, itchy feeling across his face
and neck. The nurse notes diffuse erythema on the chest and
an oxygen saturation dropping from 98% to 91% on room air.
Question Stem
Which action should the nurse take first?
A. Slow the infusion rate by half and reassess the client's vital
signs in 15 minutes.
B. Administer the prescribed PRN dose of oral acetaminophen
and diphenhydramine.
C. Stop the infusion immediately and disconnect the infusion
tubing from the IV access site.
20 NGN Immune System MCQs with Detailed
Rationales
Question 1
Clinical Scenario
A 43-year-old female client with a history of severe rheumatoid
arthritis is admitted to the medical-surgical unit for a scheduled
orthopedic procedure. During the medication reconciliation, the
nurse notes she takes adalimumab subcutaneously every other
week. The client's last dose was 4 days ago. She has no active
signs of infection, and her pre-operative chest X-ray is clear.
Question Stem
Which action is the priority for the nurse regarding the client’s
adalimumab therapy prior to surgery?
A. Administer a scheduled dose immediately to prevent a
rheumatoid arthritis flare-up during recovery.
,B. Hold the medication and collaborate with the surgical team
and rheumatologist regarding the timing of perioperative
discontinuation.
C. Inform the client that she must discontinue adalimumab
permanently due to the high risk of post-operative sepsis.
D. Request a prescription for prophylactic intravenous broad-
spectrum antibiotics to be administered for 7 days post-
operatively.
Correct Answer
Correct Answer: B. Hold the medication and collaborate with
the surgical team and rheumatologist regarding the timing of
perioperative discontinuation.
Detailed Rationale
Adalimumab is a tumor necrosis factor (TNF) alpha inhibitor, a
biological disease-modifying antirheumatic drug (DMARD) that
suppresses the immune system to reduce inflammation in
autoimmune diseases like rheumatoid arthritis. Because TNF-
alpha plays a critical role in the body's defense against
infections and in wound healing, biologic DMARDs significantly
increase the risk of serious post-operative infections and
delayed surgical wound healing. Current clinical guidelines
generally recommend withholding biological therapies prior to
major elective surgeries, typically scheduling the surgery at the
,end of the dosing interval (e.g., 2 weeks after the last dose of
adalimumab) to ensure drug levels have declined.
Option A is incorrect because administering an extra or
premature dose would further elevate immunosuppression
right before a surgical insult, drastically raising infection risks.
Option C is incorrect because permanent discontinuation is
unwarranted; biologic DMARDs are crucial for managing
debilitating autoimmune diseases and are typically resumed
post-operatively once the wound shows advanced healing and
no signs of infection are present. Option D is incorrect because
an extended 7-day course of prophylactic broad-spectrum
antibiotics is not a standard substitute for appropriate
perioperative management of immunosuppressive agents; it
increases the risk of antibiotic resistance, Clostridioides difficile
infection, and drug toxicity without mitigating the impaired
wound healing caused by the TNF inhibitor.
Learning Objective
After completing this question, the learner should be able to:
• Prioritize perioperative nursing actions for clients receiving
biological disease-modifying antirheumatic drugs
(DMARDs).
• Explain the impact of tumor necrosis factor (TNF) inhibitors
on infection risks and wound healing during the surgical
period.
, • Demonstrate appropriate collaborative practice in
medication reconciliation for immunosuppressed surgical
clients.
Medication Safety Focus
High-alert medication / Medication administration
Question 2
Clinical Scenario
A 29-year-old male client is receiving an intravenous infusion of
infliximab for the treatment of moderate-to-severe Crohn's
disease. Forty-five minutes into the scheduled 2-hour infusion,
the client calls the nurse and reports sudden shortness of
breath, chest tightness, and a warm, itchy feeling across his face
and neck. The nurse notes diffuse erythema on the chest and
an oxygen saturation dropping from 98% to 91% on room air.
Question Stem
Which action should the nurse take first?
A. Slow the infusion rate by half and reassess the client's vital
signs in 15 minutes.
B. Administer the prescribed PRN dose of oral acetaminophen
and diphenhydramine.
C. Stop the infusion immediately and disconnect the infusion
tubing from the IV access site.
