# Situation: A 62-year-old woman with breast cancer that has spread to her bones is admitted with confusion, constipation, thirst, and passing large amounts of urine. Her mucous membranes are dry. Her serum calcium is 13.6 mg/dL (3.39 mmol/L) (8.6–10.2 mg/dL; 2.15–2.55 mmol/L), and her albumin is 3.8 g/dL (38 g/L). Which order should the nurse expect to carry out FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629903  
> 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 62-year-old woman with breast cancer that has spread to her bones is admitted with confusion, constipation, thirst, and passing large amounts of urine. Her mucous membranes are dry. Her serum calcium is 13.6 mg/dL (3.39 mmol/L) (8.6–10.2 mg/dL; 2.15–2.55 mmol/L), and her albumin is 3.8 g/dL (38 g/L).

Which order should the nurse expect to carry out FIRST?

## 보기

1. IV furosemide to increase calcium loss in the urine
2. Oral hydrochlorothiazide to reduce the urine volume
3. IV 0.9% sodium chloride to restore her fluid volume **✔ 정답**
4. Fluid restriction to reduce her large urine output

**정답: 3**

## 해설

Hypercalcemia causes polyuria and volume depletion, which further reduces calcium excretion. The first treatment is IV 0.9% sodium chloride to restore volume and increase calcium excretion. A loop diuretic is used only after volume is restored, and thiazides are avoided because they raise serum calcium.

## 심화 해설

Core Pathophysiology

Hypercalcemia of malignancy develops when tumor-driven bone resorption or humoral factors such as parathyroid hormone-related protein raise the serum calcium. As calcium rises, the kidney loses its ability to concentrate urine, producing an osmotic-type polyuria. That large urine output then causes sodium and water depletion, and once the extracellular fluid volume contracts, the kidney reabsorbs more calcium in the proximal tubule. This creates a dangerous cycle: hypercalcemia drives polyuria, polyuria causes volume depletion, and volume depletion worsens hypercalcemia by reducing renal calcium excretion. The clinical clues in this patient—confusion, constipation, thirst, large urine volume, and dry mucous membranes—reflect the neurologic, gastrointestinal, and renal effects of severe hypercalcemia, with a serum calcium of 13.6 mg/dL (normal 8.6–10.2 mg/dL).

Why Fluid Replacement Comes First

The initial priority is to interrupt the volume-depletion loop. IV 0.9% sodium chloride expands the extracellular fluid volume, improves glomerular filtration, and delivers sodium to the renal tubules. Because sodium and calcium compete for reabsorption in the proximal tubule, the increased sodium load directly promotes urinary calcium excretion. Restoring intravascular volume is the essential first step because it both corrects dehydration and sets the stage for any subsequent calcium-lowering therapy. In hypercalcemia of malignancy, this saline-based volume expansion is the cornerstone of early management before more specific agents are added.

Why the Other Options Are Not First

A loop diuretic such as furosemide does increase urinary calcium excretion by blocking the Na-K-2Cl cotransporter in the thick ascending limb, where calcium reabsorption is sodium-dependent. However, Watch out! giving furosemide before the patient is volume-replete can worsen dehydration, reduce glomerular filtration, and paradoxically lower calcium excretion. Loop diuretics are reserved for after saline has restored volume, and only when needed to prevent fluid overload.

Thiazide diuretics act oppositely: they increase calcium reabsorption in the distal tubule and can raise serum calcium further, so they are contraindicated in hypercalcemia. Key point! thiazides worsen hypercalcemia and must be avoided.

Fluid restriction would be harmful because the patient is already volume-depleted from polyuria. Restricting fluids would intensify the cycle of reduced renal perfusion and reduced calcium excretion.

Clinical Sequence in Hypercalcemia of Malignancy

The management approach follows a logical order: first, aggressive volume expansion with isotonic saline; second, once euvolemia is achieved, consider a loop diuretic if fluid balance requires it; and third, add calcium-lowering therapy such as a bisphosphonate or denosumab, which inhibits osteoclast-mediated bone resorption. Bisphosphonates and denosumab are effective but slow-acting, so they do not replace the immediate need for saline volume expansion in a symptomatic patient. In this scenario, the patient’s confusion and dehydration make rapid volume restoration the clear first nursing priority.

| Intervention | Effect on Calcium | Role in Initial Management |
| --- | --- | --- |
| IV 0.9% sodium chloride | Increases renal calcium excretion by restoring volume and delivering sodium to the tubule | First-line; corrects dehydration and interrupts the hypercalcemia-volume depletion cycle |
| Loop diuretic (furosemide) | Increases urinary calcium loss by blocking sodium-linked calcium reabsorption | Only after volume is restored; prevents fluid overload |
| Thiazide diuretic | Increases distal tubular calcium reabsorption; raises serum calcium | Contraindicated in hypercalcemia |
| Fluid restriction | Reduces renal perfusion and calcium excretion; worsens hypercalcemia | Harmful when polyuria has already caused volume depletion |

Nursing and Examination Focus

For a patient with cancer-related hypercalcemia, the nurse should anticipate the first order to be isotonic saline infusion, monitor urine output and fluid balance closely, and recognize that diuretic therapy follows rather than precedes volume restoration. The presence of neurologic symptoms such as confusion signals severe hypercalcemia and reinforces the urgency of volume expansion. Key point! the sequence is always saline first, then consider loop diuretic, and never thiazides or fluid restriction in this setting.

## 임상 시나리오

Hypercalcemia of Malignancy: First PriorityBreak the volume depletion loop before other therapies
Severe hypercalcemia (13.6 mg/dL) causes nephrogenic diabetes insipidus, leading to polyuria and volume depletion. Dehydration then reduces renal calcium excretion, worsening hypercalcemia.

The first intervention is IV 0.9% sodium chloride to restore intravascular volume, improve glomerular filtration, and deliver sodium to the proximal tubule where it competes with calcium for reabsorption, promoting urinary calcium excretion.

CautionLoop diuretics are given only after volume is restored. Thiazides are contraindicated because they increase renal calcium reabsorption and raise serum calcium. Fluid restriction is inappropriate and would worsen dehydration.

## 핵심 개념

- **Hypercalcemia of malignancy** — Elevated serum calcium caused by tumor-driven bone resorption or humoral factors such as PTHrP, leading to neurologic, GI, and renal dysfunction.
- **Nephrogenic diabetes insipidus** — Kidney's impaired ability to concentrate urine due to hypercalcemia, producing polyuria and subsequent volume depletion.
- **Volume depletion loop** — Cycle in which hypercalcemia causes polyuria, polyuria causes dehydration, and dehydration reduces renal calcium excretion, worsening hypercalcemia.
- **Proximal tubular calcium-sodium competition** — Sodium and calcium compete for reabsorption in the proximal tubule; increased sodium delivery promotes urinary calcium excretion.
- **Loop diuretic** — Medication such as furosemide that inhibits calcium reabsorption in the loop of Henle, used only after volume restoration in hypercalcemia.

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