The nurse is providing care to a patient with a fractured femur who is in traction. Which of the following nursing interventions is the highest priority for the nurse to implement?
a. Increase daily fluid intake.
b. Weigh patient each morning.
c. Teach patient to cough and deep breathe.
d. Teach patient to cover mouth when coughing.
ANS: C
A patient who is immobile is at increased risk for atelectasis and pneumonia. Encourage coughing and deep breathing to keep airways clear and prevent atelectasis. Fluid intake may be increased if the patient is at risk for fat emboli or renal calculi, but it is not the highest priority over oxygenation. Daily weights indicate fluid and nutritional status but are not the priority for this patient because there is no indication of an increased risk for dehydration, fluid overload, or malnutrition. Teaching the patient to cover the mouth when coughing prevents the spread of contagious disease and is not the priority for this patient.
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