An adult client in the intensive care unit (ICU) with a central venous catheter has developed signs and symptoms that are suggestive of a central line-associated bloodstream infection (CLABSI). What is most likely the cause of the infection?

The client was treated for vancomycin-resistant enterococcus (VRE) during a previous admission.

The client had blood cultures drawn from the central line.

The client's central line dressing was changed using clean technique.

The client has received antibiotics and intravenous fluids through the same line.

Answer and Explanation

The Correct Answer is C

A. The treatment for vancomycin-resistant enterococcus (VRE) in a previous admission is not directly related to the development of CLABSI in the current situation. The infection is more likely caused by improper handling or maintenance of the central line.
B. Drawing blood cultures from the central line, while not ideal, is not the most likely cause of CLABSI. Proper technique can mitigate the risk of introducing infection during this procedure.
C. Changing the central line dressing using clean technique instead of sterile technique increases the risk of introducing pathogens to the central line site, leading to a central line-associated bloodstream infection (CLABSI).
D. Receiving antibiotics and intravenous fluids through the same line does not typically cause CLABSI if the line is properly maintained and sterile techniques are observed during administration.

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Correct Answer is A

Explanation

A. Difficulty swallowing in a client with facial burns can indicate airway compromise due to edema and should be reported immediately as it may require urgent intervention to secure the airway.
B. While pain is a significant concern and should be managed, it is not as immediately life-threatening as potential airway obstruction.
C. A respiratory rate of 24 breaths per minute is elevated but within the range of mild tachypnea, which could be due to pain or anxiety, and is not the most urgent finding.
D. Urinary output of 25 mL/hr is below normal and indicates possible hypovolemia or kidney injury, but airway concerns take precedence in this scenario.

A. A change in the Glasgow Coma Scale score from 13 to 10 B. Diplopia C. Ataxia D. A drop in heart rate from 76 to 70/min

Correct Answer is A

Explanation

A. A decrease in the Glasgow Coma Scale score from 13 to 10 indicates a significant change in consciousness and may suggest worsening of the brain injury. This is a critical sign that requires immediate reporting and evaluation.
B. Diplopia (double vision) can be a concerning symptom, but it is not as immediately critical as a significant change in the Glasgow Coma Scale score. It still warrants attention but may not be the highest priority.
C. Ataxia (lack of voluntary coordination of muscle movements) is a serious symptom that could indicate worsening of the brain injury but is not as immediately critical as a significant change in the Glasgow Coma Scale score.
D. A drop in heart rate from 76 to 70/min is generally not significant in the context of mild TBI. Changes in heart rate are less critical compared to changes in the level of consciousness.

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An adult client in the intensive care unit (ICU) with a central venous catheter has developed signs and symptoms that are suggestive of a central line-associated bloodstream infection (CLABSI). What is most likely the cause of the infection?

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