A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

Choice A reason:

The statement “Rinse mouth 2 times per day with an alcohol-based mouthwash” is incorrect. Methotrexate can cause mouth sores and irritation, and using an alcohol-based mouthwash can exacerbate these symptoms. Instead, patients are often advised to use a non-alcoholic mouthwash or a saline rinse to help prevent and soothe mouth sores.

Choice B reason:

The statement “Take the medication with an NSAID” is incorrect. Methotrexate should not be taken with nonsteroidal anti-inflammatory drugs (NSAIDs) without medical supervision because this combination can increase the risk of severe side effects, including bone marrow suppression and gastrointestinal toxicity. Patients should always consult their healthcare provider before combining these medications.

Choice C reason:

The statement “Take an antiemetic 1 hour following administration” is not standard advice for methotrexate. While methotrexate can cause nausea, antiemetics are typically taken before or at the same time as the methotrexate dose to prevent nausea, not after. Patients should follow their healthcare provider’s instructions regarding the timing of antiemetics.

Choice D reason:

The statement “Drink 2 to 3 liters of water per day” is correct. Methotrexate can cause kidney damage, and staying well-hydrated helps to prevent this by promoting the excretion of the drug and reducing its concentration in the kidneys. Drinking plenty of fluids is an important part of managing methotrexate therapy safely.

The correct answer is: The nurse has reviewed the client’s medical record. The client is at risk for developing

Hypotension and Metabolic Acidosis

Choice A: Hyperkalemia

Hyperkalemia refers to an elevated level of potassium in the blood. The normal range for potassium is 3.5 to 5.0 mEq/L. In this case, the client’s potassium level is 5.0 mEq/L, which is at the upper limit of normal. While the client is not currently hyperkalemic, they are at risk due to their condition. However, hyperkalemia is not the most immediate concern based on the provided data. The client’s symptoms and diagnostic results point more directly to other conditions.

Choice B: Hypertension

Hypertension is high blood pressure. The client’s blood pressure is 96/68 mm Hg, which is below the normal range (typically around 120/80 mm Hg). This indicates hypotension rather than hypertension. Given the client’s history of hypertension, the current low blood pressure is concerning and suggests a different issue, such as dehydration or fluid loss from diarrhea.

Choice C: Hypokalemia

Hypokalemia is a condition where potassium levels are below normal. The client’s potassium level is 5.0 mEq/L, which is within the normal range. Therefore, hypokalemia is not a concern in this scenario. The client’s potassium level does not indicate a risk for hypokalemia, and their symptoms do not align with this condition.

Choice D: Hypernatremia

Hypernatremia is an elevated sodium level in the blood. The normal range for sodium is 136 to 145 mEq/L. The client’s sodium level is 149 mEq/L, which is above the normal range, indicating hypernatremia. This condition can result from dehydration, which is consistent with the client’s symptoms of diarrhea and poor skin turgor. However, while hypernatremia is a concern, it is not the most critical issue compared to hypotension and metabolic acidosis.

Choice E: Hypotension

Hypotension is low blood pressure. The client’s blood pressure is 96/68 mm Hg, which is below the normal range. This low blood pressure, combined with symptoms of weakness, dizziness, and poor skin turgor, suggests significant fluid loss and dehydration. Hypotension is a critical concern as it can lead to inadequate perfusion of organs and tissues, potentially causing further complications.

Choice F: Renal Failure

Renal failure refers to the kidneys’ inability to filter waste from the blood effectively. While the client’s urine output is low (30 mL/hr), which could indicate renal impairment, there is no direct evidence from the provided data to confirm renal failure. The client’s basic metabolic profile does not show elevated creatinine or BUN levels, which are typical indicators of renal function.

Choice G: Metabolic Acidosis

Metabolic acidosis is a condition where there is too much acid in the body fluids. The normal range for blood pH is 7.35 to 7.45. The client’s pH is 7.33, which is below the normal range, indicating acidosis. Additionally, the bicarbonate (HCO3) level is 19 mEq/L, which is below the normal range of 21 to 28 mEq/L. These findings confirm metabolic acidosis, likely due to the loss of bicarbonate through diarrhea.