A nurse is administering the disease-modifying anti-rheumatic medication hydroxychloroquine to a client who has rheumatoid arthritis.
Which of the following potential health conditions should the nurse inform the client may occur?

Choice A rationale

Methotrexate, a disease-modifying antirheumatic drug (DMARD), can cause significant gastrointestinal and hematological toxicity. Taking it concurrently with a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen, may increase the risk of severe NSAID side effects like gastrointestinal bleeding or nephrotoxicity due to drug interactions, and is often avoided or used with caution.

Choice B rationale

Methotrexate is primarily eliminated by the kidneys, and a significant adverse effect is nephrotoxicity and crystal formation in the renal tubules, particularly at higher doses. Drinking 2 to 3 liters of water per day ensures adequate hydration and promotes diuresis, which helps to flush the drug and its metabolites from the body, thereby reducing the risk of renal damage.

Choice C rationale

Methotrexate is known to cause nausea and vomiting, which is typically managed with antiemetics like ondansetron. However, the antiemetic should be taken before or concurrently with the methotrexate to be most effective in preventing the onset of nausea, not an hour following administration when the symptoms may have already started.

Choice D rationale

Methotrexate can cause oral mucositis or stomatitis (inflammation of the mucous membranes of the mouth). Rinsing the mouth regularly can help with hygiene, but an alcohol-based mouthwash is irritating and should be avoided as it can worsen the existing mucosal damage and increase pain, further contributing to discomfort.

Choice A rationale

Talking to the client involves no direct physical contact with blood, body fluids, or non-intact skin. HIV transmission requires contact with specific body fluids, and casual conversation poses no risk of exposure, thus making the use of a gown unnecessary and inconsistent with Standard Precautions.

Choice B rationale

A dressing change involves potential contact with wound drainage, which may be serosanguinous or purulent and thus could be contaminated with blood-borne pathogens, including HIV. Applying a gown provides a liquid barrier to protect the nurse's clothing and skin from potential splatter or saturation, adhering to the principles of Standard Precautions.

Choice C rationale

Administering an IM injection involves skin puncture, but the direct exposure to body fluids is minimal and contained by the syringe/needle. A gown is not typically required for this brief, contained procedure, as the risk of extensive body fluid spray or contamination of clothing is negligible under Standard Precautions.

Choice D rationale

Administering an intermittent IV bolus involves accessing a closed intravenous system, which has a minimal risk of blood or body fluid exposure. A gown is generally not necessary unless the tubing is being disconnected or there is an anticipated high risk of blood spurt or fluid leakage beyond the scope of a brief access.