OMSB Nurse Exam key terms

A patient's voluntary agreement to a procedure or treatment after receiving and understanding information about its purpose, benefits, risks, and alternatives. Consent must be given by a competent person and documented before care begins.

The ethical principle that competent patients have the right to make their own healthcare decisions, including the right to refuse treatment, even when staff disagree with the choice. It underpins informed consent and confidentiality.

Two linked ethical principles: beneficence means acting in the patient's best interest, while non-maleficence means avoiding harm. Nurses balance both when weighing whether a treatment's likely benefit justifies its risks and discomfort.

The legal and professional obligation to provide a reasonable standard of care and to protect patients from foreseeable harm. Breaching this duty, causing harm, and failing to meet the standard can establish negligence.

Failure to provide the standard of care a reasonable nurse would give, resulting in harm. Four elements must be shown: a duty existed, the duty was breached, the breach caused injury, and actual damages occurred.

The range of activities a nurse is legally and professionally permitted to perform, set by law, regulation, and employer policy. Working outside it exposes patients to risk and the nurse to disciplinary or legal action.

A written statement made while a person is competent that records future treatment preferences, such as a living will or a nominated healthcare proxy. It guides care if the patient later loses decision-making capacity.

Reporting unsafe practice, misconduct, or patient harm to an appropriate authority inside or outside the organisation. Many jurisdictions protect nurses who report in good faith from retaliation when proper channels are used.

Acting on a patient's behalf to protect their rights, safety, and preferences, especially when they cannot speak for themselves. It includes raising concerns, supporting informed choices, and ensuring care respects dignity and culture.

A confidential internal record completed after an unexpected event such as a fall, medication error, or needlestick. It documents facts for risk management and quality improvement and is not placed in the patient's clinical notes.

Transferring a specific task to another competent person while the nurse retains accountability for appropriate selection, instruction, supervision, and follow-up. Tasks are matched to the delegate's training and to local rules.

A checklist for safe delegation: right task, right circumstance, right person, right direction and communication, and right supervision and evaluation. The nurse remains responsible for outcomes even after handing over a task.

Six linked elements that must all be present for infection to spread: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. Breaking any link prevents transmission.

Infection-control measures applied to every patient regardless of diagnosis, including hand hygiene, gloves, gowns, masks, eye protection, and safe sharps handling. They assume any body fluid may carry transmissible organisms.

Cleaning hands with soap and water or alcohol-based rub at defined moments, such as before patient contact and after body-fluid exposure. It is the single most effective measure for preventing healthcare-associated infection.

Barrier items such as gloves, gown, mask, respirator, and eye protection worn to prevent contact with blood, body fluids, or airborne organisms. Selection depends on the anticipated exposure and the mode of transmission.

Extra precautions for specific infections, grouped as contact, droplet, and airborne, used alongside standard precautions. Each type specifies the barrier equipment, room type, and visitor and transport rules required.

An infection acquired during healthcare that was not present or incubating at admission. Common examples include catheter-associated urinary tract infection, central line-associated bloodstream infection, and ventilator-associated pneumonia.

Practices that keep equipment and wounds free of microorganisms, used for procedures such as catheterisation, dressing changes, and injections. It includes sterile field preparation, sterile gloves, and avoiding contact with non-sterile surfaces.

Measurements of temperature, pulse, respiration, blood pressure, and often oxygen saturation and pain. Trends and changes are more informative than single readings and guide escalation of care.

A scoring system that combines routine observations such as respiratory rate, oxygen saturation, blood pressure, pulse, temperature, and consciousness to flag deterioration. Higher scores trigger defined escalation responses.

A team that can be called to the bedside when a patient deteriorates outside critical care, bringing advanced assessment and support. Early calls aim to prevent cardiac arrest and unplanned intensive care admission.

Emergency measures to restore circulation and breathing in cardiac arrest, including chest compressions, rescue breaths, defibrillation, and drugs. High-quality compressions at the recommended rate and depth strongly influence survival.

Delivery of a controlled electrical shock to terminate a shockable rhythm such as ventricular fibrillation or pulseless ventricular tachycardia. It is most effective when performed early, so shock delivery should not be delayed.

Life-threatening organ dysfunction caused by a dysregulated response to infection. Warning signs include fever or low temperature, tachycardia, tachypnoea, hypotension, confusion, and reduced urine output; early antibiotics and fluids are critical.

Sorting patients by urgency so that those with the greatest threat to life or limb are treated first. It uses a validated scale, is repeated as conditions change, and applies in emergency departments and mass-casualty events.

Recording all fluid intake and output, including oral, intravenous, and drain losses, over a defined period. Accurate charts help detect dehydration, overload, and poor renal perfusion and guide fluid therapy.

Localised damage to skin and underlying tissue, usually over a bony prominence, caused by pressure, shear, friction, or moisture. Prevention includes risk assessment, repositioning, support surfaces, and skin care.

Systematic evaluation of a patient's pain using self-report where possible, plus validated scales, location, quality, timing, and impact on function. Findings are documented and reassessed after each intervention.

Any preventable event that may cause or lead to inappropriate medication use or patient harm, such as wrong drug, dose, route, or time. The five rights and independent double checks reduce risk.

A drug that carries a heightened risk of significant harm when used in error, such as insulin, heparin, opioids, and concentrated electrolytes. These require independent double checks, clear labelling, and standardised protocols.

A documented instruction, agreed with a competent patient or valid substitute decision-maker, that CPR should not be attempted. It does not withhold comfort care, and staff must confirm its scope and validity.

Excessive bleeding after birth, commonly defined as more than 500 mL after vaginal delivery or 1000 mL after caesarean. Causes are grouped as tone, trauma, tissue, and thrombin; it is a leading cause of maternal death.

Failure of the uterus to contract firmly after delivery, causing heavy bleeding from the placental site. Management includes uterine massage, oxytocic drugs, bladder emptying, and escalation if bleeding continues.

New hypertension and proteinuria or other organ dysfunction after 20 weeks' gestation. Warning features include severe headache, visual disturbance, epigastric pain, and rapid weight gain; untreated it can progress to eclampsia.

A quick assessment at 1 and 5 minutes after birth scoring heart rate, respiratory effort, muscle tone, reflex response, and colour from 0 to 2 each. It guides immediate newborn care rather than predicting long-term outcome.

The newborn's limited ability to maintain body temperature, making them prone to heat loss by evaporation, conduction, convection, and radiation. Drying, skin-to-skin contact, hats, and warm environments prevent hypothermia.

Yellow discolouration from raised bilirubin in the first weeks of life, common and often physiological. Pathological features include early onset, rapid rise, high levels, or prolonged course, and require investigation and treatment.

Enabling people to increase control over and improve their health through education, supportive environments, and policy. It addresses determinants of health and often targets populations rather than individual patients.

Action taken before disease develops to reduce its incidence, such as immunisation, safe water, physical activity promotion, and smoking prevention. It contrasts with secondary prevention, which detects disease early.

Testing apparently healthy people to identify those at higher risk of a condition so that early intervention can reduce harm. It requires a suitable test, a treatable condition, and acceptable follow-up and consent.

A condition that clinicians and laboratories must report to public health authorities, enabling surveillance, outbreak investigation, and control measures. Requirements and lists vary by country and are set in law.

A person's ability to obtain, understand, and use health information to make decisions. Nurses support it through plain language, teach-back, visual aids, and checking understanding rather than assuming it.