NCHK RN(G) LE key terms

A nurse's duty to speak up for a patient's rights, wishes, and safety, including when the patient cannot speak for themselves or when care decisions conflict with the patient's values.

The principle that a competent patient has the right to make their own health care decisions, even ones others consider unwise, and that nurses must respect those choices.

A patient's voluntary agreement to a procedure after receiving and understanding information about its purpose, risks, benefits, and alternatives, given by someone competent to decide.

The professional obligation to keep patient health information private and share it only with those directly involved in care or as legally required, such as mandatory reporting.

A legal requirement for nurses to notify designated authorities about certain events, such as suspected child or elder abuse, communicable diseases, or serious clinical incidents.

The range of tasks, decisions, and responsibilities a nurse is legally and professionally permitted to perform at a given level of registration and training.

Transferring a specific nursing task to another worker while the registered nurse retains accountability for deciding what is delegated and for the outcome of care.

The defined line of authority a nurse follows to escalate concerns, obtain decisions, or report unsafe situations when the immediate supervisor cannot resolve the issue.

A systematic five-step framework of assessment, diagnosis, planning, implementation, and evaluation that guides all nursing care and is documented as the care plan.

The contemporaneous, factual, and legally admissible written or electronic record of assessments, interventions, and outcomes, which communicates care and provides evidence of professional practice.

A written, individualized plan of prioritized nursing diagnoses, goals, and interventions that is reviewed and updated as the patient's condition changes.

Measurements of temperature, pulse, respiration, blood pressure, and oxygen saturation used to detect physiological deterioration and to monitor response to treatment.

A numerical score calculated from routine observations such as respiratory rate, blood pressure, and consciousness, used to trigger timely escalation of deteriorating patients.

A set of practices that keep equipment and the clinical field free from microorganisms during invasive procedures, protecting patients from health care-associated infection.

Routine infection-control measures applied to every patient, including hand hygiene, gloves, gowns, and safe handling of sharps and body fluids.

Cleaning hands with soap and water or alcohol-based rub at the correct moments, the single most effective measure for preventing cross-infection in health care settings.

Localized damage to skin and underlying tissue caused by sustained pressure, shear, or friction, usually over bony prominences, and largely preventable with repositioning and support surfaces.

A validated scoring tool that rates risk of pressure injury using six factors, including mobility, moisture, nutrition, and sensory perception, to guide prevention planning.

Regularly changing a patient's position, typically at scheduled intervals, to relieve pressure on vulnerable areas and maintain skin integrity and comfort.

The comparison of fluid taken in and fluid lost over a period, recorded accurately to detect dehydration or overload and to guide fluid therapy.

Administration of fluids, electrolytes, or medicines directly into a vein, requiring correct rate calculation, site assessment, and monitoring for infiltration and infection.

The checks performed before giving any medicine: right patient, drug, dose, route, time, and documentation, plus the patient's right to refuse or to be informed.

A medicine that carries a heightened risk of serious harm if used incorrectly, such as insulin, heparin, opioids, and concentrated electrolytes, requiring independent double checks.

An unintended and harmful response to a medicine given at a normal dose, which must be recognized, documented, reported, and managed promptly.

Any unintended harm to a patient caused by health care rather than by the underlying disease, which is reported through incident systems to improve safety.

Purposeful verbal and nonverbal interaction using active listening, open questions, reflection, and empathy to build trust and help patients express needs and feelings.

A professional, time-limited relationship between nurse and patient built on trust, clear boundaries, and the patient's needs rather than the nurse's.

A structured assessment of appearance, behavior, mood, speech, thought, perception, cognition, and insight used to describe and monitor a patient's mental state.

A direct, structured inquiry into suicidal thoughts, plans, means, intent, and protective factors, used to determine observation level and safety interventions.

A hypertensive disorder of pregnancy, usually after 20 weeks, marked by raised blood pressure with proteinuria or organ dysfunction, threatening mother and fetus.

New high blood pressure arising after 20 weeks of pregnancy without proteinuria or other organ involvement, requiring close monitoring for progression to preeclampsia.

Routine and risk-based care during pregnancy, including history, physical assessment, screening tests, education, and planning for birth and complications.

Observation of fetal heart rate patterns, contractions, and movements to assess fetal wellbeing and tolerance of labour, guiding timely intervention.

Excessive bleeding after birth, commonly defined as more than 500 mL after vaginal birth or 1000 mL after caesarean, and a leading cause of maternal death.

Systematic checking of the mother after birth, including uterine tone, bleeding, vital signs, perineum, pain, and emotional state, to detect complications early.

Teaching and assisting with latch, positioning, frequency, and milk supply, while recognizing and referring problems such as poor attachment or low intake.

Serial measurement of weight, length, and head circumference plotted on growth charts to detect faltering growth, obesity, or developmental concern early.

An expected skill or behaviour, such as sitting, walking, or first words, reached by a typical age range and used to screen for developmental delay.

Assessment of fall risk and implementation of measures such as call bells, non-slip footwear, bed brakes, adequate lighting, and supervision to prevent injury.

An acute, fluctuating disturbance of attention and awareness often caused by infection, medicines, pain, or withdrawal, and frequently mistaken for dementia.

A progressive decline in memory and other cognitive functions that interferes with daily living, requiring structured routines, safety measures, and caregiver support.

First-contact, accessible, and continuous care focused on health promotion, disease prevention, and coordination, delivered close to where people live and work.

Actions that enable people to increase control over and improve their health, through education, policy, supportive environments, and community participation.

A disease that health care providers must report to public health authorities so that surveillance, contact tracing, and outbreak control can be carried out.