# A 67-year-old client on simvastatin 80 mg orally each evening for 2 years arrives at the emergency department reporting severe diffuse muscle pain, weakness, and dark cola-colored urine that started 3 days ago. Vitals: BP 132/82, HR 96, RR 18, temp 37.4°C. Initial labs: CK 12,400 U/L (10x normal), creatinine 2.1 mg/dL (baseline 0.9), K+ 5.6 mEq/L. Which set of nursing actions is the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374918&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 67-year-old client on simvastatin 80 mg orally each evening for 2 years arrives at the emergency department reporting severe diffuse muscle pain, weakness, and dark cola-colored urine that started 3 days ago. Vitals: BP 132/82, HR 96, RR 18, temp 37.4°C. Initial labs: CK 12,400 U/L (10x normal), creatinine 2.1 mg/dL (baseline 0.9), K+ 5.6 mEq/L. Which set of nursing actions is the priority?

## Option

1. Apply cold compresses to the most painful areas to reduce inflammation, administer an oral nonsteroidal anti-inflammatory medication, and encourage the client to drink clear liquids at home with a follow-up phone call in 24 hours.
2. Administer the oral simvastatin 80 mg now as prescribed, arrange for a muscle biopsy to evaluate for inflammatory myopathy, and initiate high-dose corticosteroid therapy per protocol while monitoring renal function.
3. Prepare the client for emergency hemodialysis due to the acute kidney injury, insert a central venous catheter for fluid management, and begin a continuous infusion of sodium bicarbonate to alkalinize the urine.
4. Hold the simvastatin, place the client on cardiac monitor, establish IV access and start aggressive isotonic IV fluids per provider order, send a urinalysis for myoglobin, and notify the provider of the rising CK·creatinine·K+. **✔ Correct answer**

**Correct answer: 4**

## Explanation

Statin-induced rhabdomyolysis — emergency
This is a textbook presentation: the client takes high-dose simvastatin (80 mg, the only dose with an FDA-recognized myopathy boxed warning), is older, and now has the diagnostic triad of rhabdomyolysis — myalgia, dark "cola" urine (myoglobinuria), CK ≥10x ULN, and acute kidney injury. Hyperkalemia (K+ 5.6) is also present from cell breakdown and AKI, increasing the risk of arrhythmia. Priorities: (1) stop the offending drug immediately and forever, (2) cardiac monitoring (hyperK arrhythmia risk), (3) IV access and aggressive isotonic fluid resuscitation (typically NS at 200-300 mL/hr titrated to urine output 200-300 mL/hr) to flush myoglobin and protect the kidney, (4) urinalysis for myoglobin, BMP/CK trend, ABG, and (5) notify the provider — additional orders may include alkalinization·loop diuretic·calcium gluconate for hyperK·dialysis if AKI progresses. Acetaminophen, heating pads, and discharge are all inappropriate and dangerous.

## In-depth explanation

Clinical reasoning summary
Statin-induced rhabdomyolysis — emergency
This is a textbook presentation: the client takes high-dose simvastatin (80 mg, the only dose with an FDA-recognized myopathy boxed warning), is older, and now has the diagnostic triad of rhabdomyolysis — myalgia, dark "cola" urine (myoglobinuria), CK ≥10x ULN, and acute kidney injury. Hyperkalemia (K+ 5.6) is also present from cell breakdown and AKI, increasing the risk of arrhythmia. Priorities: (1) stop the offending drug immediately and forever, (2) cardiac monitoring (hyperK arrhythmia risk), (3) IV access and aggressive isotonic fluid resuscitation (typically NS at 200-300 mL/hr titrated to urine output 200-300 mL/hr) to flush myoglobin and protect the kidney, (4) urinalysis for myoglobin, BMP/CK trend, ABG, and (5) notify the provider — additional orders may include alkalinization·loop diuretic·calcium gluconate for hyperK·dialysis if AKI progresses. Acetaminophen, heating pads, and discharge are all inappropriate and dangerous.

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