UNB IDR Entrance key terms

The range of roles, activities, and procedures a nurse is legally permitted to perform, set by legislation, regulatory bodies, and employer policy, and limited by the nurse's education, competence, and licensure level.

The system through which a licensing body sets entry requirements, standards of practice, and a code of ethics, then grants, restricts, or removes the right to practise nursing in order to protect the public.

A patient's voluntary agreement to a treatment or procedure after receiving and understanding information about its nature, benefits, risks, alternatives, and the consequences of refusing it.

A legal duty to notify a designated authority about certain events, such as suspected child or elder abuse, impaired colleagues, or serious adverse incidents, even when the patient objects.

The ethical and legal obligation to keep a patient's personal health information private and to share it only with those who need it for care, or when disclosure is required or permitted by law.

Transferring the performance of a specific task to another team member while the nurse retains accountability for judging whether the task is appropriate, the person is competent, and the outcome is monitored.

A systematic, cyclic method of planning and delivering care consisting of assessment, diagnosis, outcome identification and planning, implementation, and evaluation, used to organize clinical reasoning and actions.

A clinical judgement about a patient's response to health conditions or life processes that provides the basis for selecting interventions; it is not a medical disease label.

The observed outcome of critical thinking and decision-making in which a nurse interprets patient data, identifies concerns, and chooses actions that are most likely to produce safe, effective results.

The nursing process step in which the nurse compares the patient's current status with the expected outcomes and decides whether to continue, revise, or discontinue the plan of care.

A brief, focused screening process that ranks patients by urgency so that those with immediately life-threatening conditions receive care before those with less urgent needs.

Measured indicators of physiologic status, typically temperature, pulse, respiratory rate, blood pressure, and oxygen saturation, interpreted against the patient's baseline and clinical context.

A targeted examination of one body system or problem area, performed on an ongoing basis or when a specific concern arises, rather than a complete head-to-toe review.

Listening with a stethoscope to internal body sounds, such as heart, lung, and bowel sounds, to identify normal patterns and abnormal findings like murmurs, crackles, or absent bowel activity.

Abnormal lung sounds heard on auscultation, including crackles, wheezes, rhonchi, and pleural friction rubs, each suggesting a different underlying airway or lung problem.

A noninvasive method of estimating arterial oxygen saturation by measuring light absorption through a pulsating vascular bed, which can be misleading in poor perfusion, motion, or nail-product interference.

A safety checklist confirming the right patient, drug, dose, route, and time, commonly extended to include the right reason and right documentation before a medication is given.

A drug that carries a heightened risk of significant patient harm when used in error, requiring extra safeguards such as independent double-checks, standardized concentrations, and limited access.

Any injury resulting from medication use, whether or not the medicine was prescribed correctly, including allergic reactions, harmful effects, and errors in prescribing, dispensing, or administration.

A structured process of comparing a patient's current medication list with newly ordered medicines at transitions of care to identify omissions, duplications, and interactions.

A ratio describing the margin of safety between a drug's beneficial dose and its toxic dose; a narrow index means small changes in blood level can cause harm.

The relationship between intake and output of water and electrolytes, assessed through daily weights, intake and output records, and signs of overload or dehydration.

The administration of supplemental oxygen by devices such as nasal cannula or mask to treat or prevent hypoxemia, with flow and concentration matched to the patient's needs and monitored for effect.

Problems arising after surgery, such as hemorrhage, infection, atelectasis, deep vein thrombosis, and wound dehiscence, which nurses prevent and detect through monitoring and early mobilization.

The length of a pregnancy measured from the first day of the last menstrual period, usually expressed in completed weeks and used to classify newborns as preterm, term, or post-term.

A structured evaluation of a newborn's breathing, heart rate, tone, reflexes, temperature, and appearance, including Apgar scoring at birth and a full physical examination shortly afterward.

New or worsening high blood pressure arising during pregnancy, which may progress to pre-eclampsia with protein in the urine and organ involvement, threatening both parent and fetus.

Yellow discoloration of skin and sclera caused by elevated bilirubin, common and usually harmless in newborns but needing investigation when early, severe, or persistent.

Purposeful use of verbal and nonverbal techniques, such as open questions, silence, and reflection, to build trust and help a patient express thoughts and feelings.

Fully attending to a speaker by concentrating on content and feeling, observing nonverbal cues, and reflecting back understanding without interrupting or judging.

A professional, goal-directed connection between nurse and patient built on trust, respect, and clear boundaries, in which the patient's needs remain the focus rather than the nurse's.

A structured inquiry into a person's thoughts, plans, means, and intent to end their life, along with protective factors, used to determine the level of observation and safety measures needed.

The conditions in which people are born, grow, live, work, and age, such as income, housing, education, and food access, that shape health outcomes and access to care.

Activities that help people increase control over and improve their health, including education, policy change, and supportive environments, rather than only preventing specific diseases.

Deliberate efforts to contact and engage people who are underserved or not accessing services, often through community settings, home visits, or mobile programs.

The defined line of authority a nurse follows to escalate a concern, starting with the immediate supervisor and moving upward until the issue is resolved.

A structured handover format covering situation, background, assessment, and recommendation, used to communicate patient information clearly and concisely between care providers.

The written or electronic record of assessments, interventions, and outcomes, which must be accurate, timely, objective, and complete because it supports care, communication, and legal accountability.

Practices that eliminate all microorganisms from objects and areas used in invasive procedures, including sterile technique, sterile fields, and sterile gloves and instruments.

Clean technique that reduces the number and spread of microorganisms, including hand hygiene, clean gloves, and environmental cleaning, but does not eliminate all organisms.

Cleaning hands with soap and water or alcohol-based rub at specified moments during care, the single most effective measure for preventing transmission of infections.

An internal record of an unexpected event or near miss, completed to support safety review and quality improvement; it is not part of the clinical chart and does not assign blame.