PN Level 1 key terms

The licensed nurse's transfer of a specific nursing task to a competent assistive personnel while retaining accountability for the outcome and for the assessment, planning, and evaluation of care.

A decision framework covering the right task, right circumstance, right person, right direction and communication, and right supervision and evaluation before any nursing task is handed to another worker.

A worker trained to perform delegated, routine client care such as bathing, ambulating, vital signs on stable clients, and intake and output recording, but not nursing assessment, teaching, or evaluation.

The formal line of authority a nurse follows to escalate a concern, beginning with the immediate supervisor and moving upward until the issue is resolved or the client is safe.

A structured transfer of client information between caregivers using a consistent format such as SBAR, including opportunity for questions so that essential data are not lost between shifts or units.

A standardized communication tool with four parts: situation, background, assessment, and recommendation, used to report a client's condition concisely and completely to a provider or the next nurse.

A collaborative process that assesses, plans, coordinates, and monitors services to meet a client's needs, promoting quality outcomes and efficient use of resources across settings and episodes of care.

A process begun at admission that identifies the client's needs after leaving the facility and arranges equipment, referrals, teaching, and follow-up so the transition is safe and continuous.

Coordination of services over time so that a client moves between providers, units, and settings without gaps, duplication, or loss of information relevant to treatment and safety.

A client's voluntary agreement to a procedure after receiving and understanding its nature, risks, benefits, and alternatives; the nurse verifies understanding and witnesses the signature rather than obtaining consent.

Acting to protect and promote a client's rights, preferences, and safety, including speaking up when care is unsafe, supporting informed choices, and ensuring the client's voice is heard in decisions.

The ethical and legal duty to protect a client's health information from disclosure to people not involved in care, sharing only what is necessary for treatment, payment, or permitted operations.

United States federal law that sets national standards for protecting identifiable health information and defines permitted disclosures, client rights, and penalties for improper use or release.

The legally defined activities a nurse may perform at a given licensure level, shaped by state law, facility policy, education, and demonstrated competence, and never exceeded regardless of physician request.

Failure to provide the care a reasonably prudent nurse would provide in similar circumstances, resulting in harm; proof requires duty, breach, causation, and damages.

Professional negligence by a nurse whose care fell below accepted standards and caused injury; it may lead to civil liability and license discipline.

A factual, objective internal record of an unusual event or near miss used for quality improvement; it is not placed in the client's chart and is not mentioned in the chart.

A structured review after a serious event that traces contributing system factors rather than blaming individuals, aiming to redesign processes and prevent recurrence.

Annually updated, evidence-based priorities from a national accrediting body that target high-risk problems such as client identification, medication safety, infection prevention, and communication failures.

Confirming a client's identity using two independent identifiers, such as full name and date of birth or medical record number, before medication, procedures, specimens, or treatments; the room number is never used.

Infection-control practices applied to every client regardless of diagnosis, including hand hygiene, gloves, and eye or face protection when contact with blood or body fluids is anticipated.

Additional contact, droplet, or airborne measures used for known or suspected pathogens, requiring appropriate personal protective equipment, room placement, and sometimes dedicated equipment.

Barrier items such as gloves, gown, mask, respirator, and eye protection worn to prevent exposure to infectious agents, removed in the correct sequence to avoid self-contamination.

The single most effective way to prevent infection transmission, performed before and after client contact, after body fluid exposure, and after removing gloves, using soap and water or alcohol-based rub.

Physical or chemical measures that limit a client's freedom of movement, used only when less restrictive alternatives fail and ordered, monitored, and reassessed according to strict legal and safety requirements.

Nursing measures that reduce injury from falls, such as bed in low position, call light in reach, nonskid footwear, hourly rounding, and orienting the client to the environment.

Activities that help clients maintain or improve well-being and prevent disease, including education, immunizations, screening, nutrition, exercise, and lifestyle counseling across the lifespan.

Interventions that act before disease develops, such as immunization, seat belt use, and health teaching, aimed at reducing risk in a currently healthy population.

Early detection and prompt treatment of disease while it is still treatable, such as screening tests, blood pressure checks, and Pap smears, to limit severity and complications.

Rehabilitation and support that minimize disability and restore function after disease or injury, such as cardiac rehabilitation, physical therapy, and chronic disease self-management programs.

Structured teaching that gives clients knowledge and skills to manage their health, planned around readiness, literacy, culture, and barriers, then confirmed by return demonstration or teach-back.

Purposeful verbal and nonverbal techniques such as open-ended questions, reflection, and silence that build trust and help clients express feelings, used instead of false reassurance or advice-giving.

Attending fully to a client's verbal and nonverbal message and confirming understanding through paraphrasing and clarifying, conveying respect and encouraging fuller disclosure of concerns.

The limits that keep a nurse-client relationship professional and focused on the client's needs, excluding personal involvement, favors, gifts, or social contact that could harm or exploit.

A normal emotional response to loss that may include denial, anger, bargaining, depression, and acceptance; nursing supports expression and recognizes pathologic patterns such as prolonged inability to function.

Behaviors and thoughts a client uses to manage stress and anxiety; some are adaptive, such as exercise or problem-solving, while others such as denial or substance use may be maladaptive.

A systematic comparison of a client's complete medication list with newly prescribed orders at admission, transfer, and discharge to prevent omissions, duplications, and dangerous interactions.

Drugs carrying heightened risk of serious harm when used in error, such as insulin, anticoagulants, opioids, and concentrated electrolytes, requiring independent double checks and standardized safeguards.

Administration of fluids, medications, or nutrition through a route other than the digestive tract, such as intravenous, intramuscular, or subcutaneous, requiring aseptic technique and site monitoring.

The volume of intravenous fluid delivered per unit of time, calculated from prescribed volume and hours and set by gravity or pump, then verified against the order and the client's response.

Maintenance of normal body water volume and solute concentrations, assessed through intake and output, daily weights, vital signs, and laboratory values, with imbalances corrected cautiously.

Weighing a client at the same time each day, on the same scale, with similar clothing, to detect fluid shifts; a gain of about 1 kilogram suggests roughly 1 liter of retained fluid.

Recording all fluid entering and leaving the body, including oral, intravenous, and tube feedings and urine, emesis, and drainage, to evaluate hydration and organ function.

Systematic evaluation of a client's pain using a valid scale appropriate to age and cognition, covering location, quality, intensity, timing, aggravating factors, and effect on function.

Comfort measures used with or instead of analgesics, such as repositioning, heat or cold, relaxation, distraction, and guided imagery, chosen to fit the client's preference and condition.

Temperature, pulse, respiration, blood pressure, and oxygen saturation measured to detect change in physiologic status; frequency is set by the client's condition, orders, and stability.

Subtle changes such as rising respiratory rate, restlessness, or falling urine output that precede serious deterioration and should prompt assessment and escalation before crisis.

Inadequate tissue perfusion from causes such as hemorrhage, sepsis, or pump failure, signaled by hypotension, tachycardia, cool or mottled skin, altered mentation, and falling urine output.

Problems after surgery such as hemorrhage, infection, atelectasis, deep vein thrombosis, and dehiscence, prevented and detected through monitoring, early ambulation, and respiratory exercises.

Repositioning, skin inspection, moisture management, support surfaces, and nutrition to prevent localized skin and tissue damage over bony prominences in clients with limited mobility.

Precautions during oxygen therapy that include no smoking, keeping flames and oil-based products away, securing tubing, and monitoring for skin breakdown and oxygen-induced drying.