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Sudden dimmed vision: Sudden dimmed vision may indicate other ocular issues, such as retinal detachment or macular degeneration, but it is not a specific indicator of cataracts. Cataracts typically cause a gradual clouding of vision.

Intermittent flashes of light: Intermittent flashes of light are more commonly associated with conditions such as retinal detachment or migraine aura, rather than cataracts.

Pain in the eyes: Pain in the eyes is not typically associated with cataracts unless there are complications such as increased intraocular pressure or inflammation.

Amniotic fluid color: While the color of amniotic fluid can provide important information about fetal well-being and possible complications, the priority immediately following an amniotomy is to assess the fetal heart rate to ensure fetal well-being and monitor for any signs of fetal distress.

The client's temperature: While maternal temperature should be monitored regularly during labor to detect signs of infection, it is not the priority immediately following an amniotomy. Fetal well-being takes precedence.

Frequency of contractions: Monitoring the frequency of contractions is important for assessing progress in labor and identifying any abnormalities, but it is not the priority immediately following an amniotomy. Fetal well-being should be assessed first.

Birth date and mother's name: While important for identification, this information alone may not be sufficient to accurately identify a newborn, especially in situations where there may be multiple newborns with similar birth dates or mothers with the same name.

Age and diagnosis: Age and diagnosis are important clinical information but are not typically used as primary identifiers for medication administration.

Footprints and identification number: While footprints and identification numbers may be used as supplemental identifiers, they are not as reliable or commonly used as name and medical record number for medication administration.

The formula infusion rate of the feeding was too slow: While an incorrect infusion rate can affect gastrointestinal function, it is unlikely to cause diarrhea unless the rate is too fast, leading to intolerance.

The feeding tube was partially obstructed during the infusion: Tube obstruction can lead to inadequate delivery of formula, but it is unlikely to cause diarrhea unless it results in significant changes in feeding volume or composition.

The client is experiencing delayed gastric emptying: Delayed gastric emptying can lead to symptoms such as bloating and nausea but is less likely to cause diarrhea unless it results in bacterial overgrowth or malabsorption.

Delegate complicated tasks to an RN: Delegating tasks to a registered nurse may not always be feasible, especially if the RN is also busy with their own tasks. Delegation should be done based on the nurse's scope of practice and the complexity of the task, not solely to manage time. B. Document all client care at the end of the shift: Documenting all client care at the end of the shift can lead to errors or omissions in documentation. It is important to document care in a timely manner to ensure accuracy and continuity of care.

Delegate complicated tasks to an RN: Delegating tasks to a registered nurse may not always be feasible, especially if the RN is also busy with their own tasks. Delegation should be done based on the nurse's scope of practice and the complexity of the task, not solely to manage time. B. Document all client care at the end of the shift: Documenting all client care at the end of the shift can lead to errors or omissions in documentation. It is important to document care in a timely manner to ensure accuracy and continuity of care.

Try to complete a task before moving on to the next: While it is important to complete tasks in a timely manner, focusing solely on completing one task before moving on to the next can lead to inefficiencies, especially if there are multiple tasks that can be completed concurrently.

Hypernatremia: Hypernatremia (elevated sodium levels) is not typically associated with the emergent phase of burn injuries.

Hypercalcemia: Hypercalcemia (elevated calcium levels) is not typically associated with the emergent phase of burn injuries.

Hypermagnesemia: Hypermagnesemia (elevated magnesium levels) is not typically associated with the emergent phase of burn injuries.

The client's foot feels cooler than in the previous assessment: While decreased temperature can indicate decreased perfusion, the absence of a palpable pedal pulse is a more concerning finding.

The client's capillary refill time is 5 seconds in the toes: While prolonged capillary refill time can indicate impaired circulation, the absence of a palpable pedal pulse is a more concerning finding.

The client reports a pain level of 8 on a scale from 3 to 10: Pain is subjective and can be managed with analgesics, but the absence of a palpable pedal pulse indicates a more serious issue related to perfusion.

Allow the infant to have soft foods: Following cleft palate repair, infants may need to avoid certain foods until they have healed sufficiently. Soft foods may be appropriate depending on the recommendations of the healthcare provider, but this should be determined on an individual basis.

Maintain elbow restraints on the infant: Elbow restraints are typically used to prevent the infant from accessing the surgical site with their hands. However, the use of restraints should be based on the healthcare provider's orders and individual assessment, not a routine practice.

Tell the parents to avoid brushing the infant's teeth for two weeks: While it is important to be gentle around the surgical site, proper oral hygiene should still be maintained. Brushing the infant's teeth should be done gently and as tolerated, following the guidance of the healthcare provider.

Instruct the client to report the theft to the police: While reporting theft to the police may be necessary, the immediate concern is the safety and well-being of the client, especially if financial exploitation or abuse is suspected.

Ask the client if there is another family member they can call for financial help: While involving other family members may be appropriate in some situations, suspected abuse or exploitation requires intervention from trained professionals.

Restrict visitation for the client's family until discharge: Restricting visitation should only be done if there is a clear risk to the client's safety, and it should not be the first action taken in response to suspected abuse.

Wear a gown when delivering the client's food tray: Gowns are not typically necessary for routine care of clients with tuberculosis unless there is potential for contact with respiratory secretions.

Prohibit visitors while the client's infection is active: Visitors should be educated about tuberculosis precautions and provided with appropriate personal protective equipment if necessary, but prohibiting visitors may not be necessary.

Administer a tuberculin skin test prior to discharge: Tuberculin skin testing is used for screening and diagnosis of tuberculosis infection, not for management of active tuberculosis.