CNA Medical-Surgical LPN (MSPNC(C)) key terms

The formal line of authority that tells a nurse whom to notify when a problem exceeds their scope, such as a deteriorating client or an unsafe staffing situation.

A structured communication format using Situation, Background, Assessment, and Recommendation so that a nurse reports a client's condition clearly and briefly to a provider or the next shift.

Transferring the performance of a task to another worker while the nurse keeps accountability for the outcome; the nurse must assess the client and confirm the task fits the worker's training.

A worker trained to perform basic tasks such as bathing, feeding, and vital signs under nurse supervision, but not to assess, teach, or perform procedures requiring a license.

A client's voluntary agreement to a procedure after receiving an explanation of its purpose, risks, benefits, and alternatives; the nurse witnesses the signature and clarifies, but does not obtain consent.

A written document, such as a living will or durable power of attorney for health care, that states a client's wishes for treatment if the client later cannot speak for themselves.

A provider's written order stating that CPR should not be started if the client stops breathing or the heart stops; the nurse confirms the order is documented and follows agency policy.

Infection-control practices applied to every client, including hand hygiene, gloves, and eye protection when splashes are likely, because any body fluid may carry transmissible organisms.

Extra precautions used with known or suspected infection, including contact, droplet, and airborne categories, each with specified barriers, room type, and visitor rules.

Barriers such as gloves, gown, mask, and goggles worn to prevent contact with blood, body fluids, or airborne particles; the nurse removes them in the correct order to avoid self-contamination.

Cleaning hands with soap and water or alcohol-based rub at specific moments, such as before and after client contact, which is the single most effective way to prevent healthcare-associated infection.

An infection a client develops during or shortly after receiving care that was not present on arrival, often linked to invasive devices, surgery, or poor hand hygiene.

Techniques that keep an area completely free of microorganisms, used for procedures such as catheter insertion or dressing changes; anything that touches a nonsterile surface is contaminated.

Measures such as bed in low position, call light within reach, nonskid footwear, and hourly rounding that reduce the chance a client will fall and be injured.

Applying a physical or chemical device to limit movement, permitted only when less restrictive measures fail and ordered by a provider, with frequent monitoring and scheduled release.

Rules for clients receiving supplemental oxygen, including no smoking, keeping open flames and petroleum products away, and securing tanks upright to prevent fire and injury.

Testing people who have no symptoms to find disease early, such as blood pressure checks, glucose tests, or cancer screening, so treatment can begin before complications develop.

Detecting and treating disease in its early stage to limit harm, for example routine mammography, colonoscopy, or blood pressure monitoring in an adult with no complaints.

Planned instruction that gives a client the knowledge and skills to manage their health, such as medication use, wound care, or diet, with a check that learning occurred.

Expected physical, cognitive, and social abilities at a given age, used to judge whether a child's progress is typical and to plan care and teaching at the right level.

Advice given ahead of time about what to expect and how to prevent problems at the next stage, such as safety-proofing a home before a toddler begins walking.

Purposeful conversation that uses open questions, reflection, and silence to help a client express feelings, while avoiding advice, false reassurance, and judgment.

Giving full attention to a client's words and feelings, then showing understanding through eye contact, nodding, and restating the message in the nurse's own words.

Unconscious mental strategies that reduce anxiety, such as denial, projection, or rationalization; the nurse recognizes them without arguing or confronting the client directly.

The emotional response to death or major change, which may include denial, anger, bargaining, depression, and acceptance; the nurse supports the client and family at their own pace.

A feeling of worry or unease that can range from mild alertness to panic, and that may cause physical signs such as rapid heart rate, sweating, or restlessness.

A client's physical and emotional ability and willingness to take in new information; pain, fatigue, or shock blocks learning, so teaching is timed when the client can focus.

Basic self-care tasks such as bathing, dressing, eating, toileting, and moving, which the nurse assesses to plan how much help a client needs and to promote independence.

Localized damage to skin and underlying tissue caused by prolonged pressure, often over bony areas; prevention includes repositioning, dry skin, and adequate nutrition.

Moving a joint through its full normal arc, either by the client alone or with nurse assistance, to keep joints flexible and prevent stiffness and contractures.

Systematic evaluation of a client's pain using location, quality, intensity, timing, and aggravating factors, plus a validated scale suited to the client's age and ability to report.

Non-drug actions such as repositioning, warmth, quiet, oral care, and back rubs that relieve discomfort and support rest alongside prescribed treatment.

Checks performed before giving a drug: right client, drug, dose, route, time, and documentation, with many agencies adding reason and refusal as additional checks.

A drug with a high risk of serious harm when given incorrectly, such as insulin, heparin, or opioids, requiring independent double-checks and clear labeling before administration.

Comparing a client's full medication list across settings and at transitions of care to find omissions, duplicates, and interactions before harm occurs.

Delivering fluid, medication, or nutrition directly into a vein, which requires checking the site for redness, swelling, and patency and controlling the rate as ordered.

A pump that lets a client press a button to deliver a preset opioid dose within safe limits, giving better control of pain while the nurse monitors sedation and breathing.

The state in which intake, output, and body chemicals stay within normal ranges; the nurse watches for signs of too much or too little fluid and for abnormal potassium or sodium levels.

A noninvasive sensor reading the percentage of hemoglobin carrying oxygen, used to detect low oxygen levels; poor circulation or nail polish can make the reading unreliable.

Changes such as rising respiratory rate, falling blood pressure, confusion, or decreasing urine output that signal a client is worsening and require prompt reporting.

A life-threatening whole-body response to infection marked by fever or low temperature, fast heart and breathing rates, and altered mental status; it requires rapid treatment.

Problems that can follow surgery, including atelectasis, pneumonia, wound infection, bleeding, and blood clots, which the nurse prevents through deep breathing, early walking, and monitoring.

The staged repair of injured tissue; the nurse promotes it by keeping the wound clean and moist, protecting it from pressure, and supporting nutrition and blood flow.

Ongoing care that helps a person with a long-term condition such as diabetes or heart failure control symptoms, prevent flare-ups, and keep function and quality of life.