The nurse cares for a client with a triple lumen central line who develops a fever, which the nurse suspects is from the central line. Which nursing actions are appropriate? Select all that apply.
A. Replace the infusing TPN with normal saline.
B. Change the IV tubing.
C. Remove the IV using sterile technique.
D. Change the IV dressing.
E. Culture the insertion site using sterile technique.
Answer:
A. Replace the infusing TPN with normal saline.
B. Change the IV tubing.
D. Change the IV dressing.
E. Culture the insertion site using sterile technique.
Explanation: If the nurse suspects the central line may be the cause of infection, the nurse will replace any nutrition or blood infusing with normal saline, change both the IV tubing and dressing, and culture the insertion site using sterile technique. The nurse will not remove the IV without the order of the health care provider.
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