The nurse is providing care for a patient who has had a splenectomy. Which of the following nursing actions has the highest priority?
a. Assess pain every shift.
b. Encourage the patient to look at the incision during dressing changes.
c. Teach the patient to cough and deep breathe every hour.
d. Provide a diet rich in fruits and vegetables.
ANS: C
Coughing and deep breathing will mobilize secretions and help prevent respiratory infection. Patients are at risk for serious infection following splenectomy. Pain should be assessed more frequently than every shift. Body image changes are considered a lower priority than the physical risk of respiratory infection. Fruits and vegetables are a good idea but will not directly prevent infection.
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