A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations?

(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Notify provider to increase TPN rate/hr.

Contraindicated

Rationale: Increasing the TPN rate without a clear medical indication can cause fluid overload and complications such as hyperglycemia or electrolyte imbalances, especially in a patient with an already abnormal potassium level.

Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula.

Contraindicated

Rationale: The client's current oxygen saturation is 90%, which is low. Reducing oxygen delivery could further decrease oxygen saturation and exacerbate hypoxia.

Obtain client weight twice daily.

Anticipated

Rationale: Monitoring weight is important in clients receiving TPN to assess fluid balance, nutritional status, and to detect signs of fluid overload or dehydration.

Request a prescription for insulin.

Anticipated

Rationale: The client's fasting blood glucose level is elevated (140 mg/dL). Insulin therapy may be necessary to manage hyperglycemia, which can occur with TPN.

Request an antibiotic to be administered.

Anticipated

Rationale: The client has a fever, elevated WBC count, and signs of infection (productive cough with yellow sputum). Antibiotic therapy may be necessary to treat a suspected infection.

Have 3 nurses verify the TPN solution prescription.

Nonessential

Rationale: Typically, two nurses are sufficient to verify TPN prescriptions. While an additional nurse may add an extra layer of safety, it is not a standard practice and is considered nonessential unless specified by the facility's policy.

A. The client’s blood glucose in this scenario is within the normal range.
B. The bowel sounds in this scenario are present in all the 4 quadrants which is normal.
C. The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
D. The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
E. The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
F. The lungs are clear on auscultation of all the lobes which is normal.
G. The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.