NHRA Nurse Exam key terms

A five-step framework used to guide nursing care: assessment, diagnosis, planning, implementation, and evaluation. Each step depends on accurate data from the step before it.

The observed outcome of critical thinking and decision-making in nursing practice. It involves noticing relevant cues, interpreting their meaning, responding appropriately, and reflecting on the result.

A clinical judgment about a patient's response to actual or potential health problems. It differs from a medical diagnosis, which names a disease rather than the patient's response to it.

A targeted evaluation of one body system or problem, usually performed after a broader initial assessment. It gathers detail needed to monitor change or guide a specific intervention.

A systematic physical examination covering all body systems in a consistent order. It establishes a baseline, detects abnormalities, and is typically performed on admission or when a patient's condition changes.

The first set of temperature, pulse, respiration, blood pressure, and oxygen saturation measurements recorded for a patient. Later readings are compared against these values to detect deterioration.

A numerical tool that combines routine vital signs to flag patients whose condition may be deteriorating. Rising scores prompt escalating review and intervention before a crisis develops.

The process of sorting patients by urgency so that limited resources go first to those with the greatest immediate need. It is used in emergency departments, disasters, and mass-casualty events.

An emergency team activated by any staff member when a patient shows signs of serious deterioration. Its purpose is to bring critical care expertise to the bedside quickly.

A preventable death or serious harm resulting from a clinician's failure to recognize or act on a deteriorating patient. It is a recognized nursing-sensitive quality indicator.

A written document that lists a patient's identified problems, measurable goals, planned interventions, and how progress will be evaluated. It directs and coordinates the care team's work.

The step in which a nurse judges whether a patient met the goals set in the care plan. Findings determine whether interventions continue, change, or are discontinued.

Using the best available research, clinical expertise, and patient preferences together to guide care decisions. It reduces reliance on habit or tradition when safer proven options exist.

A systematically developed statement that helps clinicians and patients decide on appropriate care for specific circumstances. Guidelines summarize evidence but do not replace individualized judgment.

The degree of care and skill that a reasonably prudent nurse with similar training would provide in similar circumstances. It is the benchmark used to judge professional conduct.

The tasks, decisions, and responsibilities a nurse is legally and professionally permitted to perform given their license, training, and setting. Acting outside it can endanger patients and invite discipline.

Transferring responsibility for a task to a competent person while the delegating nurse retains accountability for the overall outcome. The nurse must assess patient stability and the delegate's ability first.

The defined line of authority a nurse follows to escalate concerns when a patient safety issue is not being resolved. Using it protects the patient and documents appropriate professional action.

Acting on a patient's behalf to protect their rights, preferences, and safety, including when the patient cannot speak for themselves. It may require voicing concerns to other members of the team.

A patient's voluntary agreement to a procedure after receiving and understanding information about its purpose, risks, benefits, and alternatives. The nurse verifies and witnesses consent but does not obtain it.

The right of capable patients to make their own healthcare decisions, including refusing recommended treatment. Care must respect these choices even when clinicians disagree with them.

A legal document stating a person's wishes about future medical care in case they lose decision-making capacity. Common forms include living wills and durable powers of attorney for healthcare.

The duty to protect a patient's private health information from unauthorized disclosure. It applies to conversations, records, and digital systems and may only be breached where law requires.

Failure to provide the care a reasonably prudent nurse would give, resulting in harm. Four elements must be shown: duty, breach, causation, and damages.

A factual internal document describing an unexpected event such as a fall or medication error. It supports safety improvement and is generally not placed in the patient's chart.

A workplace philosophy that distinguishes human error from reckless behavior when responding to mistakes. It encourages reporting while still holding people accountable for unsafe choices.

Any preventable event that may cause or lead to inappropriate medication use or patient harm. Errors can occur in prescribing, transcribing, dispensing, administering, or monitoring.

A checking routine confirming the right patient, drug, dose, route, and time before administration. Many facilities add documentation and reason as additional rights.

A drug that carries an elevated risk of significant patient harm if used incorrectly. Examples include insulin, anticoagulants, opioids, and concentrated electrolytes, which require independent double-checks.

The ratio between a drug's toxic dose and its effective dose. A narrow index means small changes in blood level can cause toxicity, so monitoring is essential.

Measuring drug levels in the blood to keep concentrations within a safe and effective range. It is used for drugs with narrow therapeutic indices and unpredictable clearance.

The formal process of comparing a patient's current medication list with new orders across transitions of care. It identifies omissions, duplications, and interactions before harm occurs.

The transfer of patient information and responsibility between caregivers. A structured format reduces omissions and misunderstandings that can compromise the next caregiver's decisions.

A structured communication format covering situation, background, assessment, and recommendation. It organizes urgent reports so the listener quickly grasps the problem and the requested action.

The written or electronic record of assessments, interventions, and patient responses. Timely, factual entries support continuity of care and serve as legal evidence of the care provided.

An unexpected occurrence involving death or serious physical or psychological harm, or the risk of such harm. Such events trigger immediate investigation and root-cause analysis.

Infection control practices applied to all patients regardless of diagnosis. They include hand hygiene, gloves, gowns, masks, and safe handling of sharps and body fluids.

Additional precautions used for specific infections, categorized as contact, droplet, or airborne. They are added to standard precautions based on how the organism spreads.

Cleaning hands with soap and water or alcohol-based rub at defined moments of patient care. It is the single most effective measure for preventing healthcare-associated infection.

Barrier items such as gloves, gowns, masks, and eye protection worn to prevent exposure to infectious agents or hazardous substances. It must be removed carefully to avoid self-contamination.

An infection a patient acquires during care for another condition that was not present or incubating at admission. Prevention relies on hygiene, device care, and prudent antibiotic use.

Any physical or chemical means of restricting a patient's freedom of movement and used only for safety when less restrictive measures fail. It requires a provider order, monitoring, and frequent reassessment.

The likelihood a patient will fall because of factors such as medications, mobility limits, confusion, or incontinence. Screening at admission directs preventive measures like bed alarms and assistance with ambulation.