A nurse is caring for a 28-year-old female client diagnosed with acute cystitis. Which nursing intervention should be the priority?
1Administer prescribed antibiotics on schedule
2Monitor intake and output every 8 hours
3Encourage increased fluid intake to 2-3 liters per day✓ 정답
4Apply heat to the suprapubic area for comfort
해설
Encouraging increased fluid intake is the priority as it flushes bacteria from the urinary tract and dilutes urine, providing immediate symptom relief. Antibiotics treat infection but are not the immediate priority; monitoring and heat application are supportive.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a patient with acute cystitis, which is a bacterial infection of the urinary bladder. The core pathophysiology involves bacterial colonization (often E. coli) in the bladder, leading to inflammation, irritation of the bladder mucosa, and symptoms like dysuria (painful urination), urgency, frequency, and suprapubic pain. The nursing priority is to address the most immediate patient need and promote the body's natural defense mechanisms.
Answer Rationale: Key Point! The priority intervention is Encouraging increased fluid intake to 2-3 liters per day. This is a non-pharmacological, independent nursing action that provides immediate benefit. Increased fluids dilute the urine, reducing its concentration and acidity, which decreases the burning sensation during urination (dysuria). More importantly, it promotes frequent voiding, which mechanically flushes bacteria out of the urinary tract. This intervention can be initiated immediately upon assessment, even before the first dose of antibiotics is administered, and is fundamental to symptom management and infection control.
Distractor Analysis:
Watch out for confusion! While Administering prescribed antibiotics on schedule (Option 1) is a critical dependent nursing intervention to eradicate the infection, it is not the immediate nursing priority. The nurse's independent action to promote fluid intake addresses symptom relief and supports the treatment's effectiveness from the moment of care.
Option 2, Monitoring intake and output every 8 hours, is an important assessment but is more of a routine monitoring activity. It does not provide an active therapeutic benefit to relieve the patient's acute discomfort or directly combat the infection like increased fluid intake does.
Option 4, Applying heat to the suprapubic area for comfort, is a supportive comfort measure for pain relief. However, it is a secondary intervention that addresses a symptom (pain) rather than the underlying cause (bacterial concentration and irritation). The flushing action of fluids is more directly therapeutic.
Related Concepts: The principle of independent vs. dependent nursing actions is key here. NCLEX-RN often prioritizes independent nursing interventions that can be implemented immediately to promote health or prevent complications. Understanding the pathophysiology of UTIs (Urinary Tract Infections) and the rationale for hydration as a first-line supportive measure is essential.Nursing Clinical Practice GuideClinical Scenario: You are assigned to care for Ms. Johnson, a 28-year-old teacher who presents to the clinic with complaints of burning with urination, feeling like she needs to urinate constantly, and mild lower abdominal pressure for the past 24 hours. A urinalysis confirms acute cystitis.
Nursing Intervention Strategy:
Assessment: Perform a focused assessment. Ask about the character of her pain, frequency of urination, and any fever or flank pain (to rule out pyelonephritis). Assess her current fluid intake habits.
Priority Action (Implementation): Immediately educate and encourage her to increase her fluid intake. Provide a large water pitcher and a goal sheet. Explain the "why": "Drinking more water will help flush the bacteria out of your bladder and make it less painful when you go to the bathroom."
Medication Administration: Administer the first dose of the prescribed antibiotic (e.g., Trimethoprim-sulfamethoxazole or Nitrofurantoin) promptly, ensuring you review for allergies. Provide education on completing the entire course.
Comfort Measures & Education: Offer a warm pack for her suprapubic area. Educate on preventive measures: wipe from front to back, urinate before and after intercourse, avoid irritating products (douches, powders), and wear cotton underwear.
Evaluation: Monitor for a decrease in dysuria and frequency. Evaluate her understanding of fluid goals and medication regimen. A follow-up urinalysis may be ordered to confirm infection clearance.
Patient Safety and Precautions: Be vigilant for signs of ascending infection, such as fever, chills, flank pain, nausea, or vomiting, which may indicate pyelonephritis (kidney infection) and require immediate intervention. Ensure antibiotic administration does not coincide with meals for certain drugs (e.g., give Nitrofurantoin with food to avoid GI upset).
Calculate and set a realistic hourly fluid goal (e.g., 200-250 mL per hour while awake to reach 2-3 L/day).
Offer a variety of fluids: water, cranberry juice (may acidify urine and inhibit bacterial adhesion), and non-caffeinated beverages (caffeine can irritate the bladder).
Document intake and output accurately to assess effectiveness.
Antibiotic Administration:
Trimethoprim-sulfamethoxazole (Bactrim): Monitor for rash (sulfa allergy) and take with a full glass of water. Contraindicated in pregnancy (third trimester).
Nitrofurantoin (Macrobid): Administer with food/milk. Inform patient urine may turn brownish. Contraindicated in renal impairment (CrCl < 60 mL/min) and at term pregnancy.
Phenazopyridine (Pyridium): A urinary analgesic sometimes prescribed for pain relief. Educate that it will turn urine orange/red and can stain clothing.
A Word from Your Senior Nurse
"In the real world, a patient with cystitis is miserable. That burning pain is all-consuming. While getting the antibiotic from the Pyxis and transcribed is important, the very first thing I do is hand them a big bottle of water and say, 'Start drinking, this is your best medicine right now.' It's an act of immediate empathy and effective care. On the NCLEX, they want you to think like a nurse—what can you do right now, independently, to make the biggest impact? Never underestimate the power of simple, evidence-based nursing actions like hydration."
Acute Cystitis — A bacterial infection of the urinary bladder, commonly caused by E. coli, characterized by dysuria, urgency, frequency, and suprapubic pain.
Dysuria — Painful or difficult urination, a hallmark symptom of lower urinary tract infections like cystitis.
Pyelonephritis — An infection of the kidney parenchyma and renal pelvis, often an ascending infection from the bladder. Symptoms include fever, chills, flank pain, and nausea.
Independent Nursing Intervention — Actions a nurse can initiate based on their clinical judgment and knowledge without a physician's order (e.g., patient education, comfort measures, promoting fluid intake).
Urinalysis — A diagnostic test of urine. Findings in cystitis often include positive leukocyte esterase, nitrites, and pyuria (white blood cells in urine).