NCLEX-RN Pharmacology: Immune System
Questions |
ATI & NGN Style MCQs with Rationales
Question 1
Clinical Scenario
A 42-year-old male client who underwent a renal transplant 6
months ago presents to the outpatient clinic for a routine
follow-up. His current immunosuppressive regimen includes
cyclosporine, mycophenolate mofetil, and low-dose prednisone.
During the assessment, the client reports starting a new dietary
cleanse that includes fresh grapefruit juice every morning. His
vital signs are: blood pressure 158/94 mm Hg, heart rate
72/min, respiratory rate 16/min, and temperature 36.8°C
(98.2°F). Laboratory results reveal a serum creatinine of 2.1
mg/dL (baseline was 1.1 mg/dL) and a trough serum
,cyclosporine level significantly above the therapeutic reference
range.
Question Stem
Which action should the nurse take first?
A. Instruct the client to double his fluid intake to flush out the
excess medication.
B. Advise the client to immediately stop consuming grapefruit
juice and notify the transplant provider.
C. Administer an immediate dose of an antihypertensive
medication to lower his blood pressure.
D. Hold the next scheduled dose of mycophenolate mofetil.
Correct Answer: B. Advise the client to immediately stop
consuming grapefruit juice and notify the transplant provider.
Detailed Rationale
Cyclosporine is a calcineurin inhibitor and a narrow therapeutic
index immunosuppressant widely used to prevent organ
rejection. Grapefruit juice inhibits the cytochrome P450 3A4
(CYP3A4) enzyme system and P-glycoprotein in the intestinal
mucosa. By blocking CYP3A4-mediated first-pass metabolism,
grapefruit juice significantly increases the oral bioavailability
and serum concentrations of cyclosporine, leading to drug
toxicity. Symptoms of cyclosporine toxicity include
,nephrotoxicity (evidenced by the elevated serum creatinine),
hypertension, neurotoxicity (tremors), and hyperkalemia.
The immediate priority intervention is to stop the causative
agent—grapefruit juice—and alert the transplant provider so
that serum trough levels can be closely monitored and dose
adjustments made. Telling the client to double fluid intake
without provider guidance does not address the underlying
CYP3A4 enzyme inhibition and may cause fluid overload in a
client with acute kidney injury. Administering an
antihypertensive medication treats the symptom rather than
the primary cause of drug-induced nephrotoxicity and
hypertension. Mycophenolate mofetil does not interact with
grapefruit juice in this CYP3A4-dependent manner, so holding it
is inappropriate and increases the risk of organ rejection.
Learning Objective
After completing this question, the learner should be able to:
• Identify drug-food interactions involving CYP3A4 inhibitors
like grapefruit juice and calcineurin inhibitors.
• Recognize signs of cyclosporine toxicity, including
nephrotoxicity and hypertension.
• Prioritize nursing interventions when drug interactions
cause elevated immunosuppressant levels.
Medication Safety Focus
, Drug interaction
Question 2
Clinical Scenario
A 35-year-old female client with moderate-to-severe Crohn’s
disease is scheduled to initiate therapy with infliximab, a tumor
necrosis factor (TNF) alpha inhibitor. The client has failed
primary therapy with 5-aminosalicylates and systemic
corticosteroids. During the pre-infusion screening, the nurse
reviews her chart for baseline diagnostic studies.
Question Stem
Which diagnostic evaluation must the nurse verify as completed
and negative prior to administering the first dose of infliximab?
A. Serum creatinine and blood urea nitrogen (BUN)
B. Tuberculin skin test (TST) or Interferon-Gamma Release Assay
(IGRA)
C. Serum amylase and lipase levels
D. 12-lead electrocardiogram (ECG) for QTc prolongation
Correct Answer: B. Tuberculin skin test (TST) or Interferon-
Gamma Release Assay (IGRA)
Detailed Rationale
Questions |
ATI & NGN Style MCQs with Rationales
Question 1
Clinical Scenario
A 42-year-old male client who underwent a renal transplant 6
months ago presents to the outpatient clinic for a routine
follow-up. His current immunosuppressive regimen includes
cyclosporine, mycophenolate mofetil, and low-dose prednisone.
During the assessment, the client reports starting a new dietary
cleanse that includes fresh grapefruit juice every morning. His
vital signs are: blood pressure 158/94 mm Hg, heart rate
72/min, respiratory rate 16/min, and temperature 36.8°C
(98.2°F). Laboratory results reveal a serum creatinine of 2.1
mg/dL (baseline was 1.1 mg/dL) and a trough serum
,cyclosporine level significantly above the therapeutic reference
range.
Question Stem
Which action should the nurse take first?
A. Instruct the client to double his fluid intake to flush out the
excess medication.
B. Advise the client to immediately stop consuming grapefruit
juice and notify the transplant provider.
C. Administer an immediate dose of an antihypertensive
medication to lower his blood pressure.
D. Hold the next scheduled dose of mycophenolate mofetil.
Correct Answer: B. Advise the client to immediately stop
consuming grapefruit juice and notify the transplant provider.
Detailed Rationale
Cyclosporine is a calcineurin inhibitor and a narrow therapeutic
index immunosuppressant widely used to prevent organ
rejection. Grapefruit juice inhibits the cytochrome P450 3A4
(CYP3A4) enzyme system and P-glycoprotein in the intestinal
mucosa. By blocking CYP3A4-mediated first-pass metabolism,
grapefruit juice significantly increases the oral bioavailability
and serum concentrations of cyclosporine, leading to drug
toxicity. Symptoms of cyclosporine toxicity include
,nephrotoxicity (evidenced by the elevated serum creatinine),
hypertension, neurotoxicity (tremors), and hyperkalemia.
The immediate priority intervention is to stop the causative
agent—grapefruit juice—and alert the transplant provider so
that serum trough levels can be closely monitored and dose
adjustments made. Telling the client to double fluid intake
without provider guidance does not address the underlying
CYP3A4 enzyme inhibition and may cause fluid overload in a
client with acute kidney injury. Administering an
antihypertensive medication treats the symptom rather than
the primary cause of drug-induced nephrotoxicity and
hypertension. Mycophenolate mofetil does not interact with
grapefruit juice in this CYP3A4-dependent manner, so holding it
is inappropriate and increases the risk of organ rejection.
Learning Objective
After completing this question, the learner should be able to:
• Identify drug-food interactions involving CYP3A4 inhibitors
like grapefruit juice and calcineurin inhibitors.
• Recognize signs of cyclosporine toxicity, including
nephrotoxicity and hypertension.
• Prioritize nursing interventions when drug interactions
cause elevated immunosuppressant levels.
Medication Safety Focus
, Drug interaction
Question 2
Clinical Scenario
A 35-year-old female client with moderate-to-severe Crohn’s
disease is scheduled to initiate therapy with infliximab, a tumor
necrosis factor (TNF) alpha inhibitor. The client has failed
primary therapy with 5-aminosalicylates and systemic
corticosteroids. During the pre-infusion screening, the nurse
reviews her chart for baseline diagnostic studies.
Question Stem
Which diagnostic evaluation must the nurse verify as completed
and negative prior to administering the first dose of infliximab?
A. Serum creatinine and blood urea nitrogen (BUN)
B. Tuberculin skin test (TST) or Interferon-Gamma Release Assay
(IGRA)
C. Serum amylase and lipase levels
D. 12-lead electrocardiogram (ECG) for QTc prolongation
Correct Answer: B. Tuberculin skin test (TST) or Interferon-
Gamma Release Assay (IGRA)
Detailed Rationale
