PSB-RNSAE key terms

A written statement, such as a living will or durable power of attorney for health care, made while a client is competent to guide or delegate decisions about future treatment if the client later loses decision-making capacity.

The client's voluntary agreement to a procedure or treatment after receiving and understanding information about its purpose, risks, benefits, and alternatives; the nurse verifies understanding and witnesses the signature rather than obtaining consent.

A federal law requiring hospitals, nursing homes, and other Medicare- or Medicaid-funded facilities to inform clients of their right to accept or refuse treatment and to document advance directives in the medical record.

A physician-written order stating that cardiopulmonary resuscitation should not be attempted if the client's breathing or heartbeat stops; the nurse confirms the order is documented and communicated to the care team.

The formal line of authority from staff nurse through charge nurse, supervisor, and administrator, used to escalate unsafe staffing, unsafe practice, or unresolved client care concerns when the immediate supervisor does not act.

An unexpected occurrence involving death, serious physical or psychological injury, or the risk of such outcomes; it triggers immediate investigation and a root-cause analysis by the facility.

A structured, team-based review conducted after a sentinel event to identify underlying system failures and contributing factors, then design and monitor corrective actions to prevent recurrence.

Annually updated patient safety priorities issued by The Joint Commission covering areas such as client identification, communication among caregivers, medication safety, infection prevention, and fall risk reduction.

Transferring the performance of a specific nursing task to unlicensed assistive personnel or another licensed worker while the nurse retains accountability for assessment, judgment, supervision, and the overall outcome of care.

The criteria a nurse applies before assigning a task: right task, right circumstance, right person, right direction and communication, and right supervision and evaluation.

The legally defined set of activities and responsibilities a nurse may perform at a given licensure level, set by state nurse practice acts and interpreted through regulations, standards, and facility policy.

The transfer of client information and accountability between caregivers, ideally using a structured format such as SBAR, with an opportunity for the receiver to ask questions and clarify.

A structured communication tool that organizes a report into Situation, Background, Assessment, and Recommendation, improving clarity during hand-offs and urgent clinician notifications.

Infection control practices applied to all clients regardless of diagnosis, including hand hygiene, gloves, gown, mask, eye protection when splash is likely, and safe handling of sharps and contaminated equipment.

Additional precautions used with standard precautions for clients with known or suspected pathogens, categorized as contact, droplet, or airborne and matched to how the organism spreads.

Barrier items such as gloves, gowns, masks, respirators, and eye protection worn to prevent contact with blood, body fluids, and infectious agents; removed in a sequence that avoids self-contamination.

Protective measures for clients with severely low neutrophil counts, including hand hygiene, avoiding fresh flowers and standing water, screening visitors for illness, and promptly reporting fever.

Practices that keep objects and areas free of all microorganisms, used for invasive procedures such as catheter insertion, dressing changes, and surgery; sterile items touching nonsterile surfaces are considered contaminated.

Any manual method, physical device, or medication that restricts a client's freedom of movement and is not a standard treatment for the condition; requires a provider order, time limits, monitoring, and frequent reassessment.

Nursing interventions for clients at risk for falling, such as bed in low position, call light within reach, nonskid footwear, hourly rounding, and bed or chair alarms, chosen after a validated risk assessment.

A client's ability to obtain, process, and understand basic health information to make appropriate decisions; low health literacy calls for plain language, teach-back, and avoidance of jargon.

A teaching technique in which the client explains or demonstrates the information in their own words, allowing the nurse to confirm understanding and reteach rather than simply asking whether the client understood.

A client-centered counseling style using open questions, reflective listening, and affirmation to explore ambivalence and strengthen the client's own reasons for changing a health behavior.

A model describing readiness to change behavior through precontemplation, contemplation, preparation, action, and maintenance, with relapse possible; interventions are matched to the client's current stage.

Developmental and safety teaching given to clients and families about what to expect next and how to prevent problems, such as injury-proofing a home or preparing a child for a procedure.

Purposeful verbal and nonverbal techniques such as open-ended questions, reflection, silence, and clarification that support the client's expression of feelings and foster a helping relationship.

Attending fully to a client's words and behavior, using eye contact, posture, and brief encouragers, then reflecting back the content and feeling to confirm understanding.

A communication behavior that blocks client expression, such as false reassurance, giving advice, changing the subject, judging, or asking why, which shifts focus away from the client's experience.

An unconscious mental strategy that reduces anxiety by distorting reality, such as denial, projection, rationalization, or displacement; adaptive in the short term, but problematic when it prevents needed care.

The emotional and behavioral response to loss, commonly described through stages or tasks including denial, anger, bargaining, depression, and acceptance; expressions vary widely across cultures and individuals.

A set of strategies teaching clients to recognize early warning signs, high-risk situations, and coping skills so a return to substance use or an unhealthy behavior is caught and managed early.

Movement of a joint through its full normal arc, performed actively by the client or passively by the nurse to maintain flexibility, prevent contractures, and preserve function during immobility.

A classification of localized skin and tissue damage from pressure, ranging from stage 1 nonblanchable erythema through full-thickness loss, plus unstageable and deep tissue injury categories.

A validated tool scoring six risk factors, including sensory perception, moisture, activity, mobility, nutrition, and friction or shear, to predict pressure injury risk and guide prevention.

The coordinated use of posture, alignment, and large muscle groups to move or lift safely, keeping the load close, bending at the knees, and avoiding twisting to protect the nurse and client.

Measurement and recording of all fluids a client takes in and puts out, including oral, intravenous, and tube feedings versus urine, emesis, and drainage, used to assess fluid balance.

Weighing a client at the same time each day, on the same scale, with similar clothing, because weight change is the most reliable indicator of fluid status and nutritional trend.

How the body handles a drug through absorption, distribution, metabolism, and excretion; changes in organ function alter these processes and can cause drug accumulation or toxicity.

The ratio between a drug's toxic dose and its effective dose; a narrow index means small dose changes or altered clearance can produce toxicity, so serum levels are monitored closely.

Serum drug concentrations drawn to guide dosing of drugs with narrow therapeutic ranges; the trough is drawn just before the next dose and the peak at a specified time after it.

Metabolism of an orally administered drug by the liver before it reaches systemic circulation, reducing bioavailability and explaining why some drugs are given by another route.

A drug carrying a heightened risk of significant harm when used in error, such as insulin, heparin, opioids, and concentrated electrolytes, requiring independent double-checks and standardized labeling.

The verified conditions before giving a drug, including the right client, drug, dose, route, time, documentation, reason, and the client's right to refuse; many facilities add right to know and right assessment.

Leakage of a vesicant or irritating intravenous solution into surrounding tissue, causing pain, swelling, and possible necrosis; the infusion is stopped and the prescribed antidote or protocol is followed.

A catheter whose tip lies in the superior vena cava or right atrium, allowing delivery of irritant or concentrated solutions and measurement of central venous pressure; it requires strict sterile care.

Seepage of a nonvesicant intravenous fluid into surrounding tissue, producing coolness, pallor, and swelling at the site; the infusion is stopped and the limb elevated per policy.

A state in which extracellular fluid is lost or inadequate, producing thirst, tachycardia, hypotension, decreased urine output, and poor skin turgor; treatment replaces fluid and corrects the cause.

A state of expanded extracellular fluid, often from heart or kidney failure or excessive sodium intake, producing edema, weight gain, crackles, and dyspnea; treatment restricts fluid and sodium and promotes diuresis.

A drop in blood pressure on standing, commonly at least 20 mmHg systolic or 10 mmHg diastolic, causing dizziness and fall risk; clients are taught to rise slowly and are assessed before ambulation.

A scoring system combining vital signs such as respiratory rate, oxygen saturation, blood pressure, heart rate, temperature, and consciousness to flag deterioration and trigger escalation.

Life-threatening organ dysfunction caused by a dysregulated response to infection, identified by signs such as fever or hypothermia, tachycardia, tachypnea, altered mentation, and hypotension; treatment begins promptly.

A state of inadequate tissue perfusion that may be hypovolemic, cardiogenic, distributive, or obstructive, producing hypotension, tachycardia, cool or warm skin, and altered mentation; it requires rapid intervention.

A disturbance in blood pH from respiratory or metabolic causes, classified as acidosis or alkalosis and as compensated or uncompensated by interpreting pH, carbon dioxide, bicarbonate, and oxygen values together.

Inadequate oxygen delivery to tissues, signaled by restlessness, confusion, tachycardia, tachypnea, and falling oxygen saturation; late signs include cyanosis and bradycardia, so early signs drive intervention.