# A client received high-dose methotrexate 24 hours ago. The nurse notes urine pH 6.5 and methotrexate level still elevated. Which is the priority nursing intervention?

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> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A client received high-dose methotrexate 24 hours ago. The nurse notes urine pH 6.5 and methotrexate level still elevated. Which is the priority nursing intervention?

## Option

1. Stop the leucovorin rescue and immediately administer activated charcoal to enhance methotrexate elimination.
2. Decrease the IV hydration rate to avoid fluid volume excess because the methotrexate level is still elevated.
3. Prepare the client for urgent hemodialysis to rapidly decrease the elevated methotrexate level and prevent toxicity.
4. Continue scheduled leucovorin rescue and ensure aggressive IV hydration with sodium bicarbonate to maintain urine pH >7.0 **✔ Correct answer**

**Correct answer: 4**

## Explanation

Correct (2): High-dose MTX requires leucovorin (folinic acid) rescue to prevent severe myelosuppression and mucositis. Urine alkalinization (pH >7) with IV bicarbonate increases MTX solubility and prevents tubular precipitation/AKI. Continue until MTX level

## In-depth explanation

Memory Tip Methotrexate = "MTX folate antagonist". Rescue = LEUCOVORIN (folinic acid). Alkalinize urine pH >7. Caution Glucarpidase enzymatically inactivates MTX in toxic levels.

## Clinical scenario

Scenario 14-year-old with osteosarcoma 24h post high-dose methotrexate; urine pH 6.5, MTX level still elevated. Leucovorin rescue ongoing.

## Key concepts

- **Leucovorin rescue** — Folinic acid bypasses dihydrofolate reductase block; rescues normal cells.
- **Urine alkalinization** — Sodium bicarbonate IV to keep urine pH >7; prevents MTX tubular precipitation.
- **Glucarpidase** — Enzyme rescue for delayed MTX clearance with AKI; used in toxic levels.

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