A nurse is assessing a 72-year-old female client who has had… | 마이메르시 MyMerci
Fundamentals
문제

A nurse is assessing a 72-year-old female client who has had an indwelling urinary catheter in place for 5 days following a hysterectomy. Which assessment finding would be the priority concern requiring immediate intervention?

The nurse notices cloudy, foul-smelling urine in the drainage bag with visible sediment.
해설
Cloudy, foul-smelling urine with sediment indicates catheter-associated urinary tract infection (CAUTI), requiring immediate intervention to prevent sepsis. Other findings like adequate urine output or mild discomfort are less urgent.

심화 해설

Core Nursing Explanation This question tests the nurse's ability to prioritize assessment findings in a patient with an indwelling urinary catheter, specifically identifying signs of a developing infection that requires immediate action to prevent serious complications. Key Concept Analysis The core theme is recognizing early signs of Catheter-associated urinary tract infection (CAUTI). An indwelling catheter bypasses the body's natural defenses, providing a direct pathway for bacteria to enter the bladder. The longer the catheter is in place, the higher the risk. Key symptoms of CAUTI include changes in urine character (cloudiness, foul odor, sediment), which indicate the presence of bacteria, white blood cells (WBCs), and debris. Answer Rationale Key Point! Cloudy, foul-smelling urine with visible sediment is a classic, objective sign of a urinary tract infection (UTI). In a postoperative patient with a catheter in place for 5 days, this finding is highly suggestive of CAUTI. Left untreated, a CAUTI can ascend to the kidneys, causing pyelonephritis, or lead to urosepsis, a life-threatening systemic infection. Therefore, this finding requires immediate intervention, such as notifying the provider, potentially obtaining a urine culture, and reviewing the need for continued catheterization. Distractor Analysis Watch out for confusion! Prioritization requires distinguishing between expected post-procedure findings and signs of a new, dangerous complication.
② Urine output of 30 mL per hour: This equals 120 mL over 4 hours, which meets the minimum acceptable output of >30 mL/hr (or >0.5 mL/kg/hr). This indicates adequate renal perfusion and is not a concern.
③ Mild discomfort at the insertion site: Some irritation is common with an indwelling device. It requires monitoring and comfort measures but is not an immediate priority unless signs of infection (redness, swelling, purulent drainage) are present.
④ Small amount of blood-tinged urine: A small amount of old, blood-tinged urine can be expected following a hysterectomy due to tissue trauma and healing. It should be monitored but is typically less urgent than signs of active infection. Related Concepts The nursing priority follows the ABCs (Airway, Breathing, Circulation) and infection/sepsis frameworks. A developing CAUTI is a threat to circulation and overall systemic stability if it progresses to sepsis. Prevention of CAUTI is a major nursing responsibility and includes maintaining a closed drainage system, ensuring the bag is below the bladder level, and advocating for early catheter removal.
Concept Summary
ConceptKey Points
CAUTI SignsCloudy/foul urine, fever, suprapubic pain, sediment, increased WBCs.
Normal Urine OutputMinimum 0.5 mL/kg/hr (approx. 30-50 mL/hr for adults).
Catheter Care PrinciplesClosed system, bag below bladder, daily perineal care, early removal.
Post-Hysterectomy ExpectationsVaginal bleeding/spotting, mild incisional pain, possible bladder irritation.

Side-by-Side Comparison!
Assessment FindingLikely Cause & PriorityNursing Action
Cloudy, foul urineHigh: Infection (CAUTI)Immediate: Notify provider, consider culture, assess for fever.
Low urine output (500 mL.
High-Frequency NCLEX Topics CAUTI prevention and identification are High-Yield topics. NCLEX loves to test:
1. Priority recognition of infection signs vs. expected findings.
2. Proper catheter care techniques to prevent infection.
3. Patient education for clients going home with catheters.
Watch Out for Question Variations! The same concept can be tested differently:
• "Which finding requires immediate notification?" → Cloudy, foul urine.
• "Which action is priority for CAUTI prevention?" → Maintain a closed drainage system.
• "The nurse suspects CAUTI. Which order should the nurse anticipate?" → Urine for culture and sensitivity, followed by antibiotic administration.

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario You are caring for Mrs. Johnson, day 5 post-total abdominal hysterectomy. During your morning assessment, you note her urinary drainage bag has cloudy, strong-smelling urine with visible particles. She has a low-grade fever of 100.4°F (38.0°C) and reports new, vague lower abdominal discomfort. Nursing Intervention Strategy 1. Assessment: Perform a focused assessment: Vital signs (especially temperature), pain location/character, inspect the catheter tubing for kinks, ensure the bag is dependent, and check the insertion site for redness or drainage. 2. Action: Immediately notify the surgeon or covering provider. Report your findings objectively: "Cloudy, foul-smelling urine in the catheter bag, temp 100.4°F, complaining of new suprapubic discomfort." 3. Collaboration: Anticipate orders for a urinalysis and urine culture (obtained via a fresh specimen port, NOT from the bag), blood cultures if sepsis is suspected, and possibly starting IV antibiotics. 4. Patient Care: Advocate for catheter removal if the patient can void independently. Increase fluid intake (if not contraindicated) to help flush the urinary tract. Provide comfort measures for fever and pain. Patient Safety and Precautions • Specimen Collection: To obtain an accurate urine culture from an indwelling catheter, clamp the tubing below the port for 15-30 minutes, then cleanse the port with antiseptic and aspirate urine with a sterile syringe/needle. Never collect from the drainage bag. • Sepsis Alert: Monitor for systemic signs of sepsis: tachycardia, tachypnea, hypotension, altered mental status. This is a medical emergency.
Nursing Procedure & Medication Flow If Antibiotics are Ordered: • Administer the first dose STAT as ordered. • Know the drug's mechanism, common side effects (e.g., GI upset with amoxicillin, tendon rupture risk with fluoroquinolones in elderly), and monitor for allergic reaction. • Ensure therapeutic levels by administering on time.
A Word from Your Senior Nurse "Trust your senses! That foul smell and cloudy appearance are your patient's body sending a clear signal that something is wrong. In clinical practice, catching a CAUTI early is a huge win—it prevents days of added suffering, extra antibiotics, and potential ICU time from sepsis. When you see it, act on it promptly and confidently. Remember, you are the patient's first line of defense against hospital-acquired infections. This vigilant, assessment-driven mindset is exactly what will make you a safe nurse and help you ace those priority questions on the NCLEX!"

핵심 개념

  • Catheter-associated urinary tract infection — An infection of the urinary tract that occurs in a person with an indwelling urinary catheter. It is one of the most common healthcare-associated infections.
  • Indwelling urinary catheter — A flexible tube inserted through the urethra into the bladder to drain urine, which remains in place continuously.
  • Urinalysis — A test of a urine sample to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease, and diabetes. It examines appearance, concentration, and content.
  • Sepsis — A life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. It can lead to shock, multiple organ failure, and death.
  • Closed drainage system — A urinary catheter system that is sealed to prevent the entry of microorganisms, crucial for preventing CAUTI. The bag should always be kept below the level of the bladder.

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