SNLE cheat sheet

Scope of practice is defined by state nurse practice acts, not by employer policy or job description.

The nursing process has five steps: assessment, diagnosis, planning, implementation, and evaluation.

Assessment and nursing diagnosis are independent nursing functions; medical diagnosis and treatment require prescriber authority.

A registered nurse may not delegate any step of the nursing process, including assessment and evaluation.

Standards of practice describe what a reasonably prudent nurse would do in the same or similar circumstances.

Expanded or advanced practice roles require additional licensure, certification, or collaborative agreements per state law.

When a task falls outside the nurse's scope, the nurse must refuse and escalate to a qualified provider.

LPN/LVN scope typically excludes initial assessment, care planning, and intravenous push medications in many states.

The nurse is accountable for the nursing judgment underlying any task, even when the task is delegated.

Negligence requires four elements: duty, breach of duty, causation, and damages.

Malpractice is professional negligence judged against the standard of care for a similarly situated nurse.

Informed consent requires capacity, disclosure of risks and alternatives, voluntariness, and comprehension.

The nurse's role in informed consent is witnessing and verifying understanding; obtaining consent is the provider's duty.

Mandatory reporting duties commonly include suspected abuse, certain communicable diseases, and impaired practice.

A nurse practicing outside licensure authority may face both civil liability and board disciplinary action.

Statutes of limitation set the deadline for filing claims and vary by state and by injury type.

Assault is a threat of harm; battery is actual unauthorized contact; both can arise from unconsented care.

False imprisonment involves unjustified restraint or detention, including preventing a competent patient from leaving.

The four core ethical principles are autonomy, beneficence, nonmaleficence, and justice.

Autonomy honors the patient's right to self-determination, including refusal of treatment.

Beneficence is acting for the patient's benefit; nonmaleficence is avoiding harm.

Justice concerns fair distribution of resources and equal treatment.

Fidelity is keeping promises and commitments; veracity is truthfulness.

Ethical dilemmas are resolved by identifying the problem, gathering facts, weighing principles, deciding, and evaluating.

An ethics committee provides consultation but does not assume decision-making authority from the patient.

Conscientious objection allows refusal to participate in a procedure while ensuring the patient receives care.

Professional boundaries prohibit dual relationships and personal financial involvement with patients.

Documentation is a legal record and is generally admissible as evidence of care delivered.

The rule is: if it was not documented, it is legally treated as not done.

Objective, measurable findings belong in the record; subjective opinions and speculative language do not.

Late entries must be labeled as late with the actual date and time of entry.

Errors are corrected with a single line, initialed and dated, leaving the original entry legible.

Never obliterate, white out, or alter a previous record entry; alteration raises fraud concerns.

Document immediately or as soon as practicable after care; charting by exception requires defined standards.

Use exact quotations for patient statements and avoid abbreviations on the prohibited list.

Only those with a clinical need and legal authorization may access the record.

The Joint Commission identifies national patient safety goals, including patient identification and medication safety.

Two patient identifiers are required before any medication, procedure, or specimen collection.

The chain of infection has six links: pathogen, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host.

Hand hygiene is the single most effective measure to prevent healthcare-associated infection.

A sentinel event is an unexpected occurrence involving death or serious harm; it triggers root cause analysis.

Root cause analysis focuses on system factors rather than individual blame.

High-alert medications require independent double-checks and standardized concentrations.

Speak-up and stop-the-line practices allow any team member to halt an unsafe process.

Quality improvement uses plan-do-study-act cycles and tracks measurable indicators over time.

Active listening involves attending, paraphrasing, and reflecting the patient's meaning.

Open-ended questions elicit more information; closed questions confirm specific facts.

Therapeutic communication avoids false reassurance, advice-giving, and changing the subject.

SBAR structures handoff: situation, background, assessment, recommendation.

Teach-back confirms understanding by asking the patient to restate the information in their own words.

Interpreters are required for limited-English-proficiency patients; family members should not substitute.

Silence and empathy can be therapeutic when used purposefully.

Conflict resolution uses I-statements, focuses on the issue, and seeks mutual goals.

Nonverbal cues such as eye contact and body posture convey meaning alongside words.

Licensure is granted by the state board of nursing and is required to practice.

Licensure by compact (NLC) allows multistate practice for nurses meeting residency and eligibility requirements.

Continuing education hours are mandated for renewal and vary by state.

Competence is maintained through practice hours, CE, and periodic self-assessment.

A lapsed license means the nurse must not practice until reinstated.

Discipline may include reprimand, probation, suspension, or revocation.

Impaired practice programs allow monitoring and rehabilitation in lieu of or alongside discipline.

Verification of licensure is a shared responsibility of employer and nurse.

Certification is voluntary and distinct from licensure, conferred by professional bodies.

Delegation transfers task performance, not accountability; the delegator remains accountable.

The five rights of delegation are right task, right circumstance, right person, right direction and communication, and right supervision and evaluation.

Tasks delegated must be within the delegatee's training, competence, and legal scope.

The nurse may not delegate assessment, planning, evaluation, or nursing judgment.

Unlicensed assistive personnel can perform stable, predictable tasks but not teaching or clinical decision-making.

Supervision includes clear instructions, monitoring, and follow-up evaluation of the delegated task.

Factors affecting delegation include patient stability, complexity, and predictability of outcomes.

The nurse documents the delegation, the instructions given, and the outcome.

HIPAA protects individually identifiable health information and sets permitted uses and disclosures.

Minimum necessary standard limits access to the least information needed for the purpose.

Patients have the right to access their records and to request amendments.

The patient's right to refuse treatment must be respected and documented.

Confidential information may be shared with the care team on a need-to-know basis.

Disclosure without authorization is permitted for certain public health, legal, and safety exceptions.

Breach notification is required when unsecured protected health information is compromised.

Advance directives, including living wills and durable powers of attorney, express patient preferences.

Privacy extends to conversations, screens, and printed materials in public areas.