SNLE flashcards
SNLE · Build recall with a focused review session.
32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Scope of practice
- The range of duties a nurse may legally perform, defined by state nurse practice acts and interpreted by the board of nursing.
- Nursing process steps
- Assessment, diagnosis, planning, implementation, and evaluation. Assessment and evaluation cannot be delegated to unlicensed personnel.
- Standard of care
- The degree of care and skill a reasonably prudent nurse with similar training would provide in comparable circumstances.
- Negligence elements
- Duty, breach of duty, causation, and damages. All four must be established for a negligence claim to succeed.
- Informed consent
- A voluntary agreement to treatment made after disclosure of risks, benefits, and alternatives by the provider; the nurse witnesses and verifies understanding.
- Autonomy
- The ethical principle recognizing a patient's right to self-determination, including the right to refuse or accept treatment.
- Nonmaleficence
- The ethical obligation to avoid causing harm. It supports practices such as medication safety checks and error reporting.
- Fidelity and veracity
- Fidelity is keeping promises and commitments to patients; veracity is truthfulness. Both are core professional ethical obligations.
- Late entry documentation
- An entry added after the fact must be labeled as late and include the actual date and time it is written.
- Correcting a chart error
- Draw a single line through the error, initial and date it, and leave the original entry legible. Never obliterate or alter.
- Two patient identifiers
- Verification using two independent identifiers, such as name and date of birth, before medication, procedures, or specimen collection.
- Sentinel event
- An unexpected occurrence involving death or serious physical or psychological harm that triggers root cause analysis.
- Root cause analysis
- A structured review that identifies system and process failures contributing to an adverse event rather than assigning individual blame.
- Hand hygiene
- The single most effective intervention for preventing healthcare-associated infections; performed before and after patient contact.
- SBAR handoff
- A structured communication format: situation, background, assessment, and recommendation, used to convey patient information concisely.
- Teach-back method
- A technique where the patient restates information in their own words to confirm understanding of teaching.
- Therapeutic communication
- Purposeful interaction using active listening, empathy, and open-ended questions while avoiding false reassurance and advice-giving.
- Interpreter use
- Qualified interpreters are required for patients with limited English proficiency; family members should not be used as substitutes.
- Nurse Licensure Compact
- An agreement allowing eligible nurses to hold one multistate license and practice in participating states under residency requirements.
- Continuing education requirement
- Mandated CE hours required for license renewal, with the number and content set by each state board of nursing.
- Lapsed license
- A license that has expired and is not renewed; the nurse may not practice until the license is reinstated.
- Five rights of delegation
- Right task, right circumstance, right person, right direction and communication, and right supervision and evaluation.
- Delegation accountability
- The delegating nurse transfers task performance but retains accountability for the outcome and for appropriate supervision.
- Unlicensed assistive personnel
- Staff who perform stable, predictable tasks under supervision but cannot perform assessment, teaching, or clinical judgment.
- Tasks never delegated
- Assessment, nursing diagnosis, care planning, evaluation, and nursing judgment remain the responsibility of the registered nurse.
- HIPAA minimum necessary
- The requirement to limit use and disclosure of protected health information to the least amount needed for the purpose.
- Patient right to refuse
- A competent patient may decline any treatment; the refusal must be respected, documented, and communicated to the provider.
- Breach notification
- The requirement to notify affected individuals and authorities when unsecured protected health information is compromised.
- Advance directive
- A legal document such as a living will or durable power of attorney expressing a patient's treatment preferences if incapacitated.
- Assault and battery
- Assault is a threat of harm; battery is unauthorized physical contact. Both can arise from unconsented care.
- Mandatory reporting
- A legal obligation to report suspected abuse, certain communicable diseases, and impaired practice to designated authorities.
- Charting by exception
- A documentation method recording only findings that deviate from defined normal standards, requiring clearly established baseline criteria.