A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take?

 

Choice A reason: You Can Expect Swelling of the Ankles While Taking This Medication

Swelling of the ankles, or peripheral edema, is a known side effect of verapamil. This calcium channel blocker can cause fluid retention, leading to swelling in the lower extremities. While this is a common side effect, it is not an instruction that the nurse should include in discharge teaching. Instead, the nurse should inform the client to report any significant swelling to their healthcare provider.

Choice B reason: Do Not Take This Medication on an Empty Stomach

Verapamil can be taken with or without food, but taking it with food may help reduce stomach upset. Therefore, the instruction to avoid taking it on an empty stomach is not strictly necessary. The nurse should advise the client to follow their healthcare provider’s specific instructions regarding medication administration.

Choice C reason: Limit Your Fluid Intake to Meal Times

Limiting fluid intake to meal times is not a standard recommendation for clients taking verapamil. Adequate hydration is important for overall health, and there is no specific reason to restrict fluid intake while on this medication. The nurse should encourage the client to maintain a balanced fluid intake throughout the day.

Choice D reason: Increase Your Daily Intake of Dietary Fiber

Increasing daily intake of dietary fiber is a beneficial instruction for clients taking verapamil. Verapamil can cause constipation as a side effect, and a high-fiber diet can help mitigate this issue. Foods rich in fiber, such as fruits, vegetables, and whole grains, can promote regular bowel movements and improve digestive health.

1. a) Inspect the abdomen for skin integrity: The first step in an abdominal assessment is inspection. The nurse should visually examine the abdomen for any abnormalities such as skin changes, scars, distention, or masses.
2. b) Ask the client about having a history of abdominal pain: Gathering a history of abdominal pain is crucial as it provides context for the physical findings. This step helps identify any underlying conditions that may influence the assessment.
3. c) Auscultate the abdomen for bowel sounds: Auscultation should be performed before palpation and percussion to avoid altering the bowel sounds. The nurse listens for the presence, frequency, and character of bowel sounds in all four quadrants.
4. d) Percuss the abdomen in each of the four quadrants: Percussion helps to assess the presence of fluid, air, or masses in the abdomen. The nurse taps on the abdomen to listen for sounds that indicate the underlying structures.
5. e) Palpate the abdomen gently for tenderness: Palpation is the final step and involves gently pressing on the abdomen to check for tenderness, masses, or organ enlargement. This step should be done last to avoid causing discomfort or altering the findings of the other steps.