Correct Answer: C

Rationale: Administering a diuretic like furosemide is the priority intervention for a client with cirrhosis, ascites, and peripheral edema. Furosemide helps reduce fluid overload by promoting diuresis. Elevating the legs may provide some symptomatic relief but does not address the underlying issue of fluid overload. Restricting fluids is not appropriate initially as the client needs proper hydration while managing fluid balance. Monitoring intake and output is important but not the first action to address the immediate fluid overload in this client.

Correct Answer: D

Rationale: The correct first action for the nurse to take when a client receiving TPN is experiencing nausea and vomiting is to check the client's TPN bag for solution accuracy. This is crucial to ensure that the correct solution is being administered and to address any potential errors. Checking the blood glucose level or administering an antiemetic may be necessary interventions but addressing the TPN bag's accuracy should be the priority to prevent any complications related to incorrect TPN solution.

Correct Answer: D

Rationale: The correct action for the nurse to implement while awaiting surgery for a client with muscle spasms due to a broken femur is to encourage oral fluid intake to relieve muscle tension. Dehydration can exacerbate muscle spasms, so increasing fluid intake can help alleviate them. Checking electrolyte levels may not directly address muscle spasms in this situation. Administering a muscle relaxant should be based on a healthcare provider's prescription, and traction weight adjustments should only be made by the provider overseeing the client's care.

Correct Answer: B

Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.

Correct Answer: C

Rationale: Administering a diuretic like furosemide is the priority intervention for a client with cirrhosis, ascites, and peripheral edema. Furosemide helps reduce fluid overload by promoting diuresis. Elevating the legs may provide some symptomatic relief but does not address the underlying issue of fluid overload. Restricting fluids is not appropriate initially as the client needs proper hydration while managing fluid balance. Monitoring intake and output is important but not the first action to address the immediate fluid overload in this client.