# A client with metastatic breast cancer presents with confusion, polyuria, dehydration, and corrected calcium 14.6 mg/dL. Which interventions should the nurse anticipate? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375025&lang=en  
> language: en  
> subject: Management of Care  
> category: MOC

## Question

A client with metastatic breast cancer presents with confusion, polyuria, dehydration, and corrected calcium 14.6 mg/dL. Which interventions should the nurse anticipate? Select all that apply.

1

Initiate IV zoledronic acid for sustained calcium lowering over days

2

Restrict fluids to limit further calcium delivery to the kidneys

3

Begin aggressive IV isotonic saline at 200 to 300 mL per hour with goal urine output 100 to 150 mL per hour

4

Consider denosumab if renal insufficiency precludes bisphosphonate

5

Administer subcutaneous calcitonin for rapid 12 to 48 hour calcium reduction

## Explanation

Severe hypercalcemia of malignancy needs volume expansion FIRST with isotonic saline 200-300 mL/hr targeting urine output 100-150 mL/hr to enhance calciuresis. Calcitonin gives a rapid but tachyphylactic calcium drop within 12-48 hours bridging to bisphosphonate. Zoledronic acid provides sustained reduction over days but is renally cleared — denosumab is preferred if creatinine clearance under 30. Fluid restriction WORSENS hypercalcemia by reducing renal calcium clearance. Loop diuretics are NOT routinely used unless there is fluid overload from rehydration.

## In-depth explanation

Stones, bones, abdominal groans, psychic moans. Rapid corrected calcium 14+ requires immediate intervention; over 18 = emergency.

## Clinical scenario

Lethargic, intermittently oriented. Orthostatic. EKG shortened QT.

## Key concepts

- **hypercalcemia of malignancy** — Often PTHrP-mediated; common with breast, lung, multiple myeloma.
- **zoledronic acid** — IV bisphosphonate inhibiting osteoclast activity.
- **denosumab** — Anti-RANKL monoclonal antibody; safe in renal failure.

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