# Situation: A 19-year-old man is admitted with dark, cola-colored urine, puffy eyelids on waking, and a blood pressure of 158/98 mmHg. Three weeks ago he had infected sores on his legs that healed without treatment. His anti-deoxyribonuclease B (anti-DNase B) titer is high and his serum complement (C3) is low. Acute post-streptococcal glomerulonephritis (PSGN) is diagnosed. His urine output over the past 24 hours was 120 mL (7:00 AM–3:00 PM shift), 90 mL (3:00–11:00 PM shift), and 140 mL (11:00 PM–7:00 AM shift). The provider orders a 24-hour fluid allowance equal to the previous 24-hour urine output plus 500 mL for insensible losses, with half of the allowance given during the 7:00 AM–3:00 PM shift and the rest divided between the other two shifts. How much fluid may he take during the 7:00 AM–3:00 PM shift? Round off to the nearest whole number.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629924  
> 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 19-year-old man is admitted with dark, cola-colored urine, puffy eyelids on waking, and a blood pressure of 158/98 mmHg. Three weeks ago he had infected sores on his legs that healed without treatment. His anti-deoxyribonuclease B (anti-DNase B) titer is high and his serum complement (C3) is low. Acute post-streptococcal glomerulonephritis (PSGN) is diagnosed.

His urine output over the past 24 hours was 120 mL (7:00 AM–3:00 PM shift), 90 mL (3:00–11:00 PM shift), and 140 mL (11:00 PM–7:00 AM shift). The provider orders a 24-hour fluid allowance equal to the previous 24-hour urine output plus 500 mL for insensible losses, with half of the allowance given during the 7:00 AM–3:00 PM shift and the rest divided between the other two shifts. How much fluid may he take during the 7:00 AM–3:00 PM shift? Round off to the nearest whole number.

## 보기

1. 850 mL
2. 175 mL
3. 283 mL
4. 425 mL **✔ 정답**

**정답: 4**

## 해설

The 24-hour urine output is 120 + 90 + 140 = 350 mL. The 24-hour allowance is 350 + 500 = 850 mL. Half of it is given on the day shift: 850 ÷ 2 = 425 mL.

## 심화 해설

Core calculation

The previous 24-hour urine output is the sum of the three shift volumes: 120 mL + 90 mL + 140 mL = 350 mL. The provider orders a total daily fluid allowance of urine output plus 500 mL for insensible losses, so 350 mL + 500 mL = 850 mL per 24 hours. Half of that allowance is assigned to the 7:00 AM–3:00 PM shift: 850 mL ÷ 2 = 425 mL. The correct answer is 425 mL.

Why fluid restriction matters in PSGN

In acute post-streptococcal glomerulonephritis, glomerular inflammation reduces the filtration surface and traps sodium and water. The result is oliguria, edema, and hypertension—exactly the findings in this patient: puffy eyelids, dark urine, and a blood pressure of 158/98 mmHg. Fluid is restricted to match output plus insensible losses so that intravascular volume does not expand further and worsen hypertension or pulmonary edema. The insensible loss allowance of 500 mL accounts for water lost through skin and respiration, which cannot be measured directly.

How the shift distribution protects the patient

Giving half of the daily allowance on the day shift is a practical nursing strategy. The largest fluid portion is provided during waking hours when the patient is more likely to eat, take oral medications, and be monitored closely. The remaining 425 mL is divided between the evening and night shifts, which reduces the risk of excessive intake during sleep and allows for ongoing assessment of urine output and blood pressure before the next day’s allowance is recalculated.

Clinical monitoring tied to the calculation

This fluid prescription is not a one-time order. The nurse must measure each shift’s urine output accurately because tomorrow’s allowance depends on today’s total. Key point! If output improves, the allowance increases; if oliguria worsens, the allowance decreases. In PSGN, oliguria may persist for several days, so daily recalculation is essential. Watch out! Do not confuse the 500 mL insensible-loss add-on with the half-share calculation—the 500 mL is added first, then the total is split.

Pathophysiology link to assessment

The low serum C3 reflects complement activation by immune complexes deposited in the glomeruli, while the elevated anti-DNase B titer confirms a recent streptococcal infection. These findings support the diagnosis but do not change the fluid calculation. The fluid restriction targets the hemodynamic consequence of glomerular injury—sodium and water retention—rather than the immune process itself. Monitoring daily weight, lung sounds, edema, and blood pressure alongside strict intake and output is the core nursing responsibility in this setting.

## 임상 시나리오

PSGN Fluid Restriction: Shift CalculationMatching intake to output plus insensible losses
In acute post-streptococcal glomerulonephritis, oliguria and sodium retention drive edema and hypertension. Fluid is restricted to urine output + 500 mL for insensible losses to prevent volume overload.

For this patient, 24-hour urine output is 350 mL. Total daily allowance is 850 mL. Half is given on the day shift: 425 mL.

CautionReassess urine output, blood pressure, and edema before each shift. If output remains very low or hypertension worsens, notify the provider before continuing the current fluid allowance.

## 핵심 개념

- **Oliguria** — Abnormally low urine output, often defined as less than 400 mL per 24 hours in adults.
- **Insensible loss** — Fluid lost through skin and respiration that cannot be directly measured, commonly estimated as 500 mL per day.
- **Anti-DNase B titer** — A serologic marker of recent streptococcal infection, often elevated in post-streptococcal glomerulonephritis.
- **Hypocomplementemia** — Low serum complement levels, such as C3, seen in acute post-streptococcal glomerulonephritis due to immune complex deposition.
- **Fluid restriction** — Limiting fluid intake to match urine output plus insensible losses to prevent volume overload in oliguric patients.

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