# Situation: The nurse cares for clients receiving nutrition support on a surgical ward. On day 9 of parenteral nutrition (PN) through the same peripherally inserted central catheter (PICC), the woman develops a temperature of 38.7 °C with shaking chills, heart rate 108/min, and blood pressure 118/70 mmHg. Her lungs are clear, and her abdominal incision is dry. Her indwelling urinary catheter was removed on day 6; today's urinalysis shows 0–2 white blood cells per high-power field and a negative nitrite. The PICC insertion site shows no redness or drainage. Her capillary glucose is 210 mg/dL (11.7 mmol/L), up from readings of about 150 mg/dL (8.3 mmol/L). Which problem is MOST likely?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630378  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: The nurse cares for clients receiving nutrition support on a surgical ward.

On day 9 of parenteral nutrition (PN) through the same peripherally inserted central catheter (PICC), the woman develops a temperature of 38.7 °C with shaking chills, heart rate 108/min, and blood pressure 118/70 mmHg. Her lungs are clear, and her abdominal incision is dry. Her indwelling urinary catheter was removed on day 6; today's urinalysis shows 0–2 white blood cells per high-power field and a negative nitrite. The PICC insertion site shows no redness or drainage. Her capillary glucose is 210 mg/dL (11.7 mmol/L), up from readings of about 150 mg/dL (8.3 mmol/L). Which problem is MOST likely?

## 보기

1. Hyperglycemia from the dextrose in the infusion
2. Catheter-related bloodstream infection **✔ 정답**
3. Urinary infection after catheter removal
4. Refeeding syndrome from advancing the nutrition

**정답: 2**

## 해설

Fever with chills in a client on parenteral nutrition through a central line is a catheter-related bloodstream infection until proven otherwise; the insertion site often looks normal. Infection also raises blood glucose through the stress response, which explains the new rise. The lungs and wound are clear, and a normal urinalysis argues against a urinary source after catheter removal, so the nurse reports promptly for blood cultures.

## 심화 해설

The most likely problem
On day 9 of parenteral nutrition (PN) through the same peripherally inserted central catheter (PICC), the client develops a temperature of 38.7 °C with shaking chills and a heart rate of 108/min. In a client receiving PN through a central line, fever with chills is a catheter-related bloodstream infection until proven otherwise. The insertion site often looks normal, and the infection also explains the new rise in blood glucose.

Why the line is the likely source
PN is a glucose-rich solution that supports microbial growth, and central catheters give organisms a direct path into the bloodstream, either along the outside of the catheter from the skin or through the hub and lumen during handling. Risk rises with the number of days the line has been in place. A normal-looking insertion site does not rule out infection, because organisms colonizing the inside of the catheter cause bacteremia without local redness. Shaking chills suggest bacteria or toxins entering the blood, sometimes right after the line is used.

| Possible source | Evidence in this client | Conclusion |
| --- | --- | --- |
| Lungs | Clear | Unlikely |
| Surgical wound | Incision dry | Unlikely |
| Urinary tract | Catheter removed on day 6; urinalysis 0–2 WBC/HPF, nitrite negative | Argues against |
| Central line | PN for 9 days; fever, chills, tachycardia; no other source | Most likely |

Why the other problems are less likely
Hyperglycemia from dextrose alone does not cause fever and chills. Here the rise from about 150 mg/dL (8.3 mmol/L) to 210 mg/dL (11.7 mmol/L) is a result of infection, because the stress response increases counter-regulatory hormones and insulin resistance. Watch out! A new unexplained rise in glucose in a client on stable PN is itself a clue to infection. A urinary source is possible after catheter removal, but a urinalysis with 0–2 white cells and a negative nitrite argues against it. Refeeding syndrome causes low phosphate, potassium, and magnesium with weakness, dysrhythmias, and fluid overload, usually in the first days of feeding, not fever with chills on day 9.

Nursing actions
The nurse reports the findings promptly so that blood cultures can be drawn, typically from the catheter and from a peripheral vein, before antibiotics are started. The nurse monitors vital signs closely for sepsis, including blood pressure, mental status, and urine output, follows orders about whether to continue PN or remove the catheter, and checks glucose more often. Prevention relies on strict aseptic technique, scrubbing hubs before each access, dedicating a lumen to PN, and timely dressing and tubing changes.

Exam takeaway
Key point! Fever and chills in a client on PN through a central line = suspect catheter-related bloodstream infection first, even if the site looks clean. A sudden rise in glucose on stable PN can be an early sign of infection.

## 임상 시나리오

Fever on Parenteral NutritionSuspecting a catheter-related bloodstream infection
Fever of 38.7 °C with chills and tachycardia on day 9 of PN through a PICC is a catheter-related bloodstream infection until proven otherwise.

Lungs and wound are clear, and the urinalysis is normal. The insertion site often looks normal in line infections.

The glucose rise to 210 mg/dL (11.7 mmol/L) reflects the stress response to infection. Report promptly for blood cultures.

CautionWatch for sepsis: falling blood pressure, confusion, or low urine output. Use strict asepsis and scrub the hub before every line access.

## 핵심 개념

- **Catheter-related bloodstream infection** — A bloodstream infection originating from an intravascular catheter.
- **Blood culture** — A laboratory test that detects and identifies microorganisms in the blood.
- **Stress hyperglycemia** — A rise in blood glucose caused by hormones released during illness or infection.
- **Refeeding syndrome** — Shifts of phosphate, potassium, and magnesium when feeding starts after malnutrition.
- **Aseptic technique** — Practices that prevent introducing microorganisms during procedures such as line access.

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