Answer to Question 1
B
Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. An acuity recording system determines the hours of nursing care and the number of staff required for a nursing unit. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution's standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration.
Answer to Question 2
C
C. Sedative or analgesic use can alter the client's level of consciousness, making the client unsteady or disoriented and therefore at increased risk for falls.
A. Allergies do not cause an increased risk of falls.
B. Urinary retention would not alter the client's risk for falls.
D. Alternative therapy would not increase the client's fall risk.
The nurse is using Standard Precautions to draw blood.
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