# Situation: The infection prevention and control committee reports that the catheter-associated urinary tract infection (CAUTI) rate on a 32-bed adult surgical ward has been above the hospital target for two quarters. The head nurse forms an improvement team of staff nurses, a urologist, and an infection control nurse. During an audit, a staff nurse finds a client's drainage bag hanging on the bed rail above the level of the bladder. Why does this finding raise the client's infection risk?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629957  
> 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: The infection prevention and control committee reports that the catheter-associated urinary tract infection (CAUTI) rate on a 32-bed adult surgical ward has been above the hospital target for two quarters. The head nurse forms an improvement team of staff nurses, a urologist, and an infection control nurse.

During an audit, a staff nurse finds a client's drainage bag hanging on the bed rail above the level of the bladder. Why does this finding raise the client's infection risk?

## 보기

1. The bag must be opened more often to keep it from overfilling
2. Pull on the catheter can injure the lining of the urethra
3. Urine in the bag and tubing can flow back into the bladder **✔ 정답**
4. Urine that pools in the tubing gives a false culture result

**정답: 3**

## 해설

The drainage bag must stay below the level of the bladder and off the floor so that urine drains by gravity. When the bag is higher than the bladder, urine that has collected in the bag and tubing, where bacteria multiply, can flow back into the bladder and cause infection.

## 심화 해설

Why a drainage bag above the bladder raises infection risk

The correct answer is 3. Urine in the bag and tubing can flow back into the bladder.

An indwelling urinary catheter is a closed drainage system. Under normal conditions, urine flows downward by gravity from the bladder through the tubing into the collection bag. The bag must always remain below the level of the bladder and off the floor to preserve this one-way, gravity-dependent flow. When the bag is hung on the bed rail above the level of the bladder, the direction of flow can reverse. Urine that has already drained into the bag or tubing—where bacteria multiply rapidly—can flow retrograde back into the bladder, introducing organisms directly into the urinary tract.

This mechanism matters because the distal portion of the catheter system is not sterile. Even with meticulous insertion technique, the drainage bag and the lower segment of tubing become colonized over time. Bacteria ascend along the internal lumen of the catheter or are carried by urine reflux. Retrograde urine flow converts a closed, one-way system into a pathway for bacterial inoculation of the bladder, which is the direct precursor to catheter-associated urinary tract infection (CAUTI).

The other options do not explain the infection mechanism. Option 1 is incorrect because the bag does not need to be opened more often when positioned high; opening the system would actually create an additional break in the closed system, but that is not the primary issue here. Option 2 describes mechanical trauma from traction on the catheter, which can injure the urethral mucosa, but the question asks specifically about infection risk from the bag position, not from tension on the catheter. Option 4 is incorrect because pooled urine in the tubing can alter the quality of a specimen, but false culture results are a diagnostic concern, not the direct mechanism by which the patient develops an infection.

| Position of drainage bag | Effect on urine flow | Infection risk |
| --- | --- | --- |
| Below bladder, off floor | Gravity drainage maintained; one-way flow | Lowest risk; closed system preserved |
| Above bladder (e.g., on bed rail) | Urine can flow retrograde into bladder | High risk; bacteria in bag/tubing reflux into bladder |
| On floor | Contamination of bag outlet; tension on catheter | High risk; environmental contamination and mechanical irritation |

Key point! The drainage bag must be positioned below the bladder at all times, including during transport and ambulation. Watch out! Hanging the bag on the bed rail is a common practice error because it seems convenient, but any elevation above the bladder compromises the gravity-dependent closed system.

In the context of the surgical ward audit described in the scenario, this single finding is significant because CAUTI prevention depends on consistent adherence to basic maintenance practices. Evidence syntheses on CAUTI prevention emphasize that maintaining a closed drainage system and keeping the collection bag below the bladder are core nursing interventions . When the bag is elevated, the physical barrier of the closed system is functionally lost, and the stagnant urine in the tubing becomes a reservoir for bacterial growth that can be delivered directly into the bladder . This is why the audit finding warrants immediate correction and staff education.

## 임상 시나리오

CAUTI Prevention: Drainage Bag PositionKeep the bag below the bladder and off the floor
An indwelling catheter is a closed drainage system that depends on gravity drainage. The collection bag must remain below the level of the bladder and off the floor at all times.

If the bag is hung on the bed rail above the bladder, retrograde urine flow can occur. Urine that has already drained into the bag and tubing, where bacteria multiply, can flow back into the bladder and introduce organisms directly into the urinary tract.

CautionThe distal catheter system becomes colonized over time even with proper insertion. Reflux converts the one-way system into a pathway for bacterial inoculation of the bladder, directly increasing CAUTI risk.

## 핵심 개념

- **CAUTI** — Catheter-associated urinary tract infection; infection arising from an indwelling urinary catheter
- **Closed drainage system** — A sealed catheter-tubing-bag system designed to maintain one-way urine flow and prevent bacterial entry
- **Retrograde urine flow** — Backward movement of urine from bag or tubing into the bladder when the bag is above bladder level
- **Gravity drainage** — Dependent positioning of the drainage bag below the bladder so urine flows downward
- **Colonization** — Bacterial multiplication in the distal catheter system, especially in the bag and lower tubing

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