NCLEX-RNSafety and Infection Prevention and ControlHard
A nurse is caring for a client with a new peripherally inserted central catheter (PICC) line. The nurse notes redness, swelling, and purulent drainage at the insertion site. Which action should the nurse take first?
- ACulture the drainage and apply a warm compress.
- BAdminister a prescribed antibiotic and elevate the extremity.
- CNotify the healthcare provider and prepare for PICC line removal.
- DRemove the PICC line and apply pressure to the site.
Show answer & explanationAnswer & explanation
Correct answer: C. Notify the healthcare provider and prepare for PICC line removal.
The signs of redness, swelling, and purulent drainage at a PICC line insertion site are indicative of a severe local infection, potentially leading to a bloodstream infection. The immediate priority is to notify the healthcare provider, as the PICC line may need to be removed to prevent further systemic infection and a new access site established. While culturing is important, removing the source of infection is paramount.
Why the other options are wrong
- A. Culturing is important, but applying a warm compress could worsen infection spread and does not address the need for line removal.
- B. Administering antibiotics requires a prescription and doesn't address the immediate need to remove the infected line, which is the source.
- D. Removing the PICC line is likely necessary, but it is a medical procedure that requires a healthcare provider's order unless there is an immediate life-threatening emergency. The nurse's first step is to notify the provider.
PICC Line Infection Management
Interventions for identifying and managing local or systemic infections associated with a peripherally inserted central catheter (PICC).
- Signs of local infection include redness, swelling, pain, warmth, and purulent drainage at the insertion site.
- PICC line infections can quickly lead to bloodstream infections (sepsis).
- Prompt notification of the healthcare provider and potential line removal are critical.
Memory trick: INFECTED line? ALERT the DOC, it's GOT to GO!