Question

When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse plan to do?

a. Discontinue the catheter and culture the tip.
b. Use the catheter only for fluid administration.
c. Change the flush system and monitor the site.
d. Check the site more frequently for any swelling.

Answer 1

In response to signs of an infection at the central venous catheter site, the nurse should discontinue the catheter and culture the tip to prevent potential bloodstream infections and further complications.

Step-by-step explanation:

When evaluating a patient with a central venous catheter who presents with redness and tenderness at the insertion site and a fever of 101.8° F, the nurse should prioritize infection control measures. The appropriate action would be to discontinue the catheter and culture the tip. This action is crucial for identifying the potential pathogens responsible for the infection, particularly in the context of bloodstream infections which can be life-threatening. The increase in temperature coupled with the signs of local infection at the site suggests a possible catheter-related bloodstream infection, which requires prompt intervention to mitigate risks of sepsis and other complications.