A patient with an indwelling urinary catheter has a drainage bag hanging on the bed rail above the level of the bladder. What should the nurse do?

Lower the bag to below the level of the bladder. The drainage bag must ALWAYS be kept below the level of the bladder to maintain gravity drainage and prevent backflow of urine into the bladder, which increases infection risk. Lower the bag immediately. Clamping is not necessary and could cause bladder distention.

A patient has not voided for 8 hours after surgery. What is the most appropriate initial nursing action?

Perform a bladder scan to assess urine volume. A bladder scan is a non-invasive way to assess bladder volume and determine if retention is occurring. If the bladder is distended, the nurse can then implement interventions. Catheterization should be avoided if possible to reduce CAUTI risk. Waiting longer risks bladder overdistention.

Which nursing intervention is most important for preventing catheter-associated urinary tract infections (CAUTI)?

Remove the catheter as soon as it is no longer needed. The most important intervention for CAUTI prevention is removing the catheter as soon as it is no longer medically necessary. Every day a catheter remains in place increases infection risk. Antiseptic irrigation, antibiotic ointment, and routine cultures are NOT recommended—they do not reduce CAUTI rates and may contribute to resistance.

6.6 Urinary Elimination and Catheter Care | NCLEX-RN (Registered Nurse) | Free Exam Prep

Urinary Elimination and Catheter Care

Urinary elimination is essential for waste removal and fluid balance. The nurse must assess urinary patterns, recognize problems, manage urinary catheters safely, and prevent catheter-associated urinary tract infections (CAUTIs).

Normal Urinary Function

Normal Urinary Output

Parameter	Normal Range
Daily output	1,500-2,000 mL (average)
Minimum output	30 mL/hour (0.5 mL/kg/hr)
Voiding frequency	6-8 times per day
Nocturia	0-1 times per night

Characteristics of Normal Urine

Characteristic	Normal	Abnormal
Color	Pale yellow to amber	Dark amber (concentrated), red/pink (blood), orange (medications)
Clarity	Clear	Cloudy (infection, sediment)
Odor	Mild, ammonia-like	Foul (infection), sweet/fruity (diabetes)
Specific gravity	1.005-1.030	<1.005 (overhydration), >1.030 (dehydration)

Urinary Retention

Urinary retention is the inability to empty the bladder completely.

Causes

Category	Examples
Obstruction	Enlarged prostate (BPH), urethral stricture
Neurological	Spinal cord injury, stroke, MS, diabetic neuropathy
Medications	Anticholinergics, opioids, anesthesia
Post-operative	Anesthesia effects, pain, immobility
Psychological	Inability to void in public, anxiety

Assessment

Bladder distention: Palpable above symphysis pubis
Suprapubic discomfort
Frequent voiding of small amounts (overflow incontinence)
Bladder scanner: Non-invasive measurement of bladder volume

Post-void residual (PVR): Volume remaining after voiding

Normal: <50 mL
Abnormal: >100-150 mL may indicate retention

Nursing Interventions

Non-invasive measures first:
- Provide privacy
- Run water, pour warm water over perineum
- Position comfortably (sitting for women, standing for men if able)
- Allow adequate time
Bladder scanning: Assess volume non-invasively
Intermittent catheterization: If non-invasive measures fail and bladder is distended
Indwelling catheter: Only if necessary and for shortest duration possible

Urinary Incontinence

Urinary incontinence is the involuntary loss of urine.

Types of Incontinence

Type	Description	Causes
Stress	Leakage with coughing, sneezing, laughing	Weak pelvic floor muscles, childbirth
Urge	Sudden, intense urge followed by involuntary loss	Overactive bladder, UTI, neurological conditions
Overflow	Continuous dribbling from overfull bladder	Obstruction, neurogenic bladder
Functional	Normal bladder function but unable to reach toilet	Cognitive impairment, mobility limitations
Mixed	Combination of types	Multiple factors

Nursing Interventions

Intervention	Rationale
Bladder training	Scheduled voiding to increase capacity
Pelvic floor exercises (Kegels)	Strengthen sphincter muscles
Prompted voiding	Remind cognitively impaired patients
Toileting schedule	Prevent accidents, especially before bed
Fluid management	Adequate intake, limit before bed
Skin protection	Barrier creams, incontinence products

Urinary Catheterization

Indications for Indwelling Catheter

Catheters should only be used for appropriate indications:

Acute urinary retention or obstruction
Accurate urine output monitoring in critically ill patients
Perioperative use for selected surgeries
Healing of open sacral or perineal wounds with incontinence
Prolonged immobilization (unstable spine, pelvic fractures)
End-of-life comfort care

Catheter Insertion: Sterile Technique

CRITICAL: Maintaining sterile technique during insertion prevents CAUTI.

Key Steps:

Perform hand hygiene, don sterile gloves
Prepare sterile field
Clean meatus with antiseptic solution
Insert lubricated catheter using sterile technique
Advance until urine flows, then advance 2-3 more inches (adults)
Inflate balloon with sterile water per manufacturer guidelines
Gently pull back to seat balloon at bladder neck
Secure catheter to thigh (women) or upper thigh/lower abdomen (men)
Hang drainage bag below bladder level

Female vs. Male Catheterization

Aspect	Female	Male
Anatomy	Short urethra (3-4 cm)	Long urethra (15-20 cm)
Insertion depth	5-7.5 cm (2-3 inches)	17-22.5 cm (7-9 inches)
Common difficulty	Locating meatus	Navigating prostatic curve
Position	Dorsal recumbent, knees bent	Supine, legs slightly apart

CAUTI Prevention Bundle

Catheter-Associated Urinary Tract Infection (CAUTI) is one of the most common healthcare-associated infections. Prevention focuses on reducing catheter use and proper maintenance.

CAUTI Prevention Strategies

Strategy	Implementation
Avoid unnecessary catheters	Use only for appropriate indications
Remove catheters promptly	Evaluate continued need daily
Use sterile technique for insertion	Strict aseptic technique
Maintain closed drainage system	Never disconnect tubing
Keep bag below bladder level	Prevents reflux of urine
Daily meatal care	Soap and water cleansing
Secure catheter	Prevents traction and urethral trauma
Empty bag regularly	When 2/3 full, use clean technique

Daily Catheter Care

Perform perineal hygiene with soap and water
Cleanse around meatus (front to back in females)
Check that catheter is secured and not pulling
Ensure drainage tubing is not kinked
Empty drainage bag when 2/3 full
Evaluate daily: Does the patient still need the catheter?

Signs of CAUTI

Fever
Suprapubic tenderness
Flank pain
Cloudy, foul-smelling urine
New confusion (in elderly)
Hematuria

Note: Do NOT collect urine cultures routinely. Culture only if symptomatic.

Bladder Irrigation

Indications

Post-urological surgery (TURP)
Blood clots in bladder
Bladder instillations (medications)

Types

Type	Description
Continuous bladder irrigation (CBI)	Constant flow of irrigating solution; 3-way catheter required
Intermittent irrigation	Periodic instillation and drainage

Nursing Considerations

Use sterile normal saline (or prescribed solution)
Monitor for clots, obstruction
Calculate true urine output: Output - Irrigant infused = Urine output
Watch for signs of bladder distention if outflow blocked

Urine Output Monitoring

Critical Findings

Finding	Indicates	Action
<30 mL/hour	Decreased renal perfusion, dehydration	Assess fluid status, notify provider
<0.5 mL/kg/hour	Oliguria—possible renal failure	Urgent evaluation
No output	Anuria—possible obstruction or renal failure	Emergency—check catheter patency, notify provider
Sudden increase	Diuretic effect, post-obstruction	Monitor for fluid/electrolyte shifts

On the Exam

NCLEX tests:

CAUTI prevention: Sterile insertion, keep bag below bladder, daily need assessment
Signs of retention: Distended bladder, small frequent voids, bladder scanner
Catheter care: Soap and water (not antiseptic solutions), keep system closed
Urine output: Normal >30 mL/hr, oliguria is <0.5 mL/kg/hr

Key Takeaways

Sterile technique for catheter insertion prevents CAUTI
Keep drainage bag below bladder level at all times
Assess for retention with bladder scanner if no void in 6-8 hours
Daily meatal care with soap and water—no routine antiseptics
Remove catheters as soon as no longer needed
Normal output: >30 mL/hour; oliguria: <0.5 mL/kg/hour

NCLEX-RN

1Introduction

2Chapter 2: Management of Care

3Chapter 3: Safety and Infection Prevention and Control

4Chapter 4: Health Promotion and Maintenance

5Chapter 5: Psychosocial Integrity

6Chapter 6: Basic Care and Comfort

7Chapter 7: Pharmacological and Parenteral Therapies

8Chapter 8: Reduction of Risk Potential

9Chapter 9: Physiological Adaptation

Key Takeaways

Urinary Elimination and Catheter Care

Normal Urinary Function

Normal Urinary Output

Characteristics of Normal Urine

Urinary Retention

Causes

Assessment

Nursing Interventions

Urinary Incontinence

Types of Incontinence

Nursing Interventions

Urinary Catheterization

Indications for Indwelling Catheter

Catheter Insertion: Sterile Technique

Female vs. Male Catheterization

CAUTI Prevention Bundle

CAUTI Prevention Strategies

Daily Catheter Care

Signs of CAUTI

Bladder Irrigation

Indications

Types

Nursing Considerations

Urine Output Monitoring

Critical Findings

On the Exam

Key Takeaways