The nurse changes the subclavian dressing of a client receiving total parenteral nutrition and notes the presence of yellow drainage around the sutures anchoring the catheter. What should the nurse do first?

Rationale: A. While obtaining a culture may be indicated if infection is suspected, this is not the first action. The nurse must first assess the client for signs of systemic infection before taking any samples. Cultures will be guided by clinical findings such as fever, chills, or elevated white blood cell count. B. Cleaning and redressing the site is part of standard care, but if the client is showing signs of infection (e.g., fever, elevated heart rate), immediate assessment of systemic involvement takes priority over routine site care. C. The presence of yellow drainage around a central line catheter may indicate local infection, and fever could indicate systemic infection or sepsis, a life-threatening complication in clients receiving TPN. According to priority frameworks (ABCs and Maslow’s hierarchy), assessing for signs of infection or sepsis takes precedence before taking further steps like cultures or cleaning. D. Documentation is important, but it is secondary to assessing for immediate threats to the client’s health. First, the nurse must determine whether the client is experiencing systemic infection.