# Situation: A 48-year-old woman with stage IIB squamous cell carcinoma of the cervix is receiving external beam pelvic radiation with weekly cisplatin. Low-dose-rate intracavitary brachytherapy is planned after the external beam course. The room is prepared according to the radiation safety protocol. In the third week of external beam radiation, she reports five loose stools a day for 3 days. Her findings are: Temperature: 37.2 °C Blood pressure: 104/68 mmHg lying and 88/60 mmHg standing (baseline 118/76) Urine output: 90 mL over the past 4 hours Serum creatinine: 1.5 mg/dL (0.5–1.1); 0.8 mg/dL last week Absolute neutrophil count: 1,900/mm³ Her weekly cisplatin dose is due today. What should the nurse do FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629739  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 48-year-old woman with stage IIB squamous cell carcinoma of the cervix is receiving external beam pelvic radiation with weekly cisplatin. Low-dose-rate intracavitary brachytherapy is planned after the external beam course. The room is prepared according to the radiation safety protocol.

In the third week of external beam radiation, she reports five loose stools a day for 3 days. Her findings are:
Temperature: 37.2 °C
Blood pressure: 104/68 mmHg lying and 88/60 mmHg standing (baseline 118/76)
Urine output: 90 mL over the past 4 hours
Serum creatinine: 1.5 mg/dL (0.5–1.1); 0.8 mg/dL last week
Absolute neutrophil count: 1,900/mm³
Her weekly cisplatin dose is due today. What should the nurse do FIRST?

## 보기

1. Give the prescribed loperamide and recheck in 4 hours
2. Obtain blood cultures for possible neutropenic fever
3. Teach a low-residue, low-lactose diet with plenty of fluids
4. Report the fluid loss and creatinine before the cisplatin **✔ 정답**

**정답: 4**

## 해설

Radiation enteritis has led to fluid loss: she has an orthostatic drop in blood pressure, a urine output of about 22 mL/h, and a creatinine that has nearly doubled. Cisplatin is nephrotoxic and needs good hydration and kidney function, so giving it now could worsen acute kidney injury. The nurse reports these findings before the dose; diet teaching and antidiarrheals follow, and she does not meet the criteria for neutropenic fever.

## 심화 해설

Why reporting comes before the dose
This client is in the third week of pelvic radiation with weekly cisplatin, and she now has five loose stools a day for 3 days. The diarrhea itself is an expected effect of radiation enteritis, but the data show that it has gone beyond a comfort problem. She has an orthostatic drop in blood pressure (from 104/68 lying to 88/60 mmHg standing, against a baseline of 118/76), a urine output of 90 mL in 4 hours (about 22 mL/h), and a serum creatinine that rose from 0.8 to 1.5 mg/dL in a week. Together these findings describe fluid volume deficit with acute kidney injury, and the next scheduled drug is a nephrotoxic one. The nurse therefore reports the fluid loss and the creatinine to the prescriber before the cisplatin is hung.

Mechanism: why cisplatin and dehydration do not mix
Cisplatin is a platinum chemotherapy drug that is cleared by the kidneys and is directly toxic to the renal tubules. For this reason it is given only with good hydration and after kidney function has been checked; the dose may be delayed, reduced, or changed when the creatinine rises. In a client who is already volume depleted, renal blood flow falls, the drug concentrates in the tubules, and injury that is still reversible can become established. A nearly doubled creatinine with low urine output is exactly the warning sign that makes the prescriber reconsider the dose. The nurse does not decide whether cisplatin is cancelled, but must make sure the prescriber sees the data before the drug is given.

Why the other actions come later
Loperamide and a low-residue, low-lactose diet are reasonable parts of managing radiation enteritis, and fluid teaching will be needed. However, waiting 4 hours to recheck after an antidiarrheal, or spending the time on teaching, leaves a nephrotoxic dose on schedule while kidney injury is developing. Blood cultures are not indicated: her temperature is 37.2 °C and her absolute neutrophil count is 1,900/mm³, so she does not meet the criteria for neutropenic fever. These options are not wrong in themselves; they are wrong as the first action.

| Finding | Value | What it means |
| --- | --- | --- |
| Orthostatic BP | 104/68 lying, 88/60 standing | Intravascular volume deficit |
| Urine output | 90 mL in 4 h (about 22 mL/h) | Below the usual 30 mL/h minimum |
| Creatinine | 0.8 to 1.5 mg/dL in 1 week | Acute kidney injury |
| Temperature / ANC | 37.2 °C / 1,900/mm³ | No neutropenic fever |

Watch out! In chemoradiation questions, look at what is due next. A routine weekly dose becomes a safety issue when kidney function, blood counts, or hydration status change, and the nurse's role is to hold the dose until the prescriber has reviewed the new data.

Exam takeaway
When diarrhea, vomiting, or poor intake occurs in a client on a nephrotoxic drug, connect the fluid loss to kidney function. Key point! Orthostatic hypotension, low urine output, and a rising creatinine are reported before cisplatin; symptom relief, diet teaching, and infection workup follow according to the actual findings.

## 임상 시나리오

Fluid Loss Before CisplatinRadiation enteritis with early kidney injury
Five loose stools a day in week 3 of pelvic radiation fits radiation enteritis. Check for volume deficit: orthostatic BP, urine output below 30 mL/h, and the trend in creatinine.

Cisplatin is nephrotoxic and needs good hydration and kidney function. A creatinine that rose from 0.8 to 1.5 mg/dL is reported to the prescriber before the dose is given.

Antidiarrheals, a low-residue and low-lactose diet, and fluid teaching follow. A neutropenic fever workup is not needed when she is afebrile with an ANC of 1,900/mm³.

CautionDo not give a scheduled nephrotoxic dose on routine timing when new data show dehydration or a rising creatinine.

## 핵심 개념

- **Radiation enteritis** — Inflammation of the bowel lining caused by abdominal or pelvic radiation, producing diarrhea, cramping, and fluid loss.
- **Cisplatin** — A platinum chemotherapy drug that is toxic to the kidney tubules and requires hydration and kidney checks before each dose.
- **Orthostatic hypotension** — A fall in blood pressure on standing that suggests reduced circulating volume.
- **Acute kidney injury** — A rapid fall in kidney function shown by a rising serum creatinine and often reduced urine output.
- **Neutropenic fever** — Fever in a client with a very low absolute neutrophil count, needing urgent cultures and antibiotics.

## 같은 주제 문제

- [Situation: A 52-year-old woman has invasive ductal carcinoma of the left breast, stage IIB…](https://mymerci.kr/pages/nclex_q.php?qn_id=629730)
- [Situation: A 52-year-old woman has invasive ductal carcinoma of the left breast, stage IIB…](https://mymerci.kr/pages/nclex_q.php?qn_id=629731)
- [Situation: A 52-year-old woman has invasive ductal carcinoma of the left breast, stage IIB…](https://mymerci.kr/pages/nclex_q.php?qn_id=629732)
- [Situation: A 52-year-old woman has invasive ductal carcinoma of the left breast, stage IIB…](https://mymerci.kr/pages/nclex_q.php?qn_id=629733)
- [Situation: A 52-year-old woman has invasive ductal carcinoma of the left breast, stage IIB…](https://mymerci.kr/pages/nclex_q.php?qn_id=629734)
- [Situation: A 66-year-old man with adenocarcinoma of the lower rectum undergoes abdominoper…](https://mymerci.kr/pages/nclex_q.php?qn_id=629735)
- [Situation: A 66-year-old man with adenocarcinoma of the lower rectum undergoes abdominoper…](https://mymerci.kr/pages/nclex_q.php?qn_id=629736)
- [Situation: A 66-year-old man with adenocarcinoma of the lower rectum undergoes abdominoper…](https://mymerci.kr/pages/nclex_q.php?qn_id=629737)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._