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 C

Explanation

A. Restricting sodium intake is essential in managing ascites and edema in cirrhosis, but it does not directly reduce ammonia levels. Sodium restriction is more related to fluid management rather than ammonia reduction.
B. Administering vitamin K may be necessary for correcting coagulation issues in liver disease, but it does not address the elevated ammonia levels causing encephalopathy.
C. Reducing protein intake is crucial for decreasing ammonia production. In clients with hepatic encephalopathy, proteins are broken down into ammonia, which the impaired liver cannot detoxify effectively, leading to worsened symptoms. Therefore, reducing dietary protein can help lower ammonia levels.
D. Administering diuretics is used to manage fluid retention and ascites in cirrhosis, but it does not directly impact ammonia levels. Diuretics are not the primary intervention for hepatic encephalopathy.

A. Bloating B. Postmenopausal vaginal bleeding C. Feeling full quickly after eating D. Unexplained recent weight gain

Correct Answer is B

Explanation

B. Postmenopausal vaginal bleeding is a common symptom of endometrial cancer. It is one of the most significant warning signs for this condition in older women, as it may indicate abnormal growth in the endometrial lining.
A. Bloating is more commonly associated with ovarian cancer and gastrointestinal issues rather than endometrial cancer specifically.
C. Feeling full quickly after eating is more indicative of ovarian cancer or other gastrointestinal problems.
D. Unexplained weight gain is not a typical primary symptom of endometrial cancer; it is less specific and can be associated with various other conditions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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