# A nurse is caring for a client diagnosed with acute pyelonephritis. Which nursing intervention should be the priority?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541458  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a client diagnosed with acute pyelonephritis. Which nursing intervention should be the priority?

## 보기

1. Encourage the client to drink cranberry juice to acidify the urine
2. Monitor vital signs frequently and assess for signs of sepsis **✔ 정답**
3. Apply heat to the flank area to reduce pain and discomfort
4. Restrict fluid intake to prevent kidney overload

**정답: 2**

## 해설

Monitoring vital signs for sepsis is the priority because pyelonephritis can rapidly progress to life-threatening sepsis. Other interventions are supportive but secondary.

## 심화 해설

Clinical Reasoning and Priority Setting

The priority nursing intervention for a client diagnosed with acute pyelonephritis is to monitor vital signs frequently and assess for signs of sepsis. This decision is rooted in the fundamental principle of the nursing process and the high-risk pathophysiology of upper urinary tract infections. Acute pyelonephritis is an infection of the renal parenchyma and collecting system, which carries a significant risk of progressing from a localized infection to bacteremia and urosepsis. The physiological connection lies in the kidney's rich vascular supply; bacteria can easily translocate from the infected renal tissue into the bloodstream, triggering a systemic inflammatory response that can rapidly destabilize a patient.

The Surviving Sepsis Campaign guidelines provide a framework for managing this risk, emphasizing that early recognition and intervention are critical to preventing organ dysfunction and mortality [3, 4]. A cornerstone of this early recognition is the vigilant monitoring of hemodynamic status. By assessing vital signs frequently, the nurse is screening for the earliest indicators of systemic involvement, such as a widening pulse pressure, unexplained tachycardia (heart rate >90 bpm), tachypnea (respiratory rate >20/min), hypotension (systolic blood pressure

## 임상 시나리오

Clinical Practice Guide: Acute Pyelonephritis & Sepsis Surveillance

For a client with acute pyelonephritis, the immediate clinical priority is surveillance for systemic decompensation. The kidney's extensive vascular network provides a direct pathway for bacteria to enter the bloodstream, making urosepsis the most critical and time-sensitive threat. Nursing care must be structured around early detection and hemodynamic support.

Priority Nursing Actions

- **Hemodynamic Monitoring (q1-4h):** Track temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation. Screen for SIRS/sepsis criteria: fever/hypothermia, tachycardia (>90 bpm), tachypnea (>20/min), or altered WBC count.

- **Fluid Management:** Encourage high fluid intake (2-3 L/day unless contraindicated) to flush bacteria and maintain renal perfusion. In cases of suspected sepsis, anticipate IV fluid boluses per protocol.

- **Antibiotic Administration:** Obtain blood and urine cultures prior to the first dose, then administer broad-spectrum IV antibiotics promptly as ordered. Delays in antimicrobial therapy increase mortality risk.

- **Comfort Measures:** Once hemodynamic stability is confirmed, apply warm compresses to the flank and administer prescribed analgesics/antipyretics for pain and fever.

Key Safety Checks

- **Never restrict fluids** in an attempt to "rest" the kidney; this can worsen acute kidney injury and concentrate bacteria.

- **Monitor I&O strictly.** Report urine output less than 0.5 mL/kg/hr immediately, as it may signal acute kidney injury secondary to sepsis.

- **Reassess after interventions.** If the patient remains hypotensive or develops altered mental status, escalate care immediately for potential ICU transfer.

## 핵심 개념

- **Pyelonephritis** — A bacterial infection of the renal pelvis and kidney parenchyma, often ascending from a lower urinary tract infection, carrying a high risk of bacteremia.
- **Urosepsis** — Sepsis resulting from a urinary tract infection; a systemic, life-threatening response to infection that can lead to organ dysfunction and shock.
- **Priority Setting** — A clinical judgment framework (e.g., Maslow's hierarchy, ABCs) used to rank nursing actions, prioritizing life-threatening physiological risks like sepsis over comfort measures.

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