CNOR - Certification Perioperative Communication and Documentation Questions and Answers

Question 1

A circulating nurse is completing the handoff report for a patient transferring to the PACU.
Using the SBAR (Situation, Background, Assessment, Recommendation) format, which statement best represents the 'Assessment' component?

Accepted Answer

"The patient's vital signs are stable, the surgical dressing is dry and intact, and estimated blood loss was 150 mL."

Answer

"The patient is Jane Doe, post-op right total knee arthroplasty performed by Dr. Smith."

Answer

"The patient has a history of hypertension and received 100 mcg of fentanyl and 2 mg of midazolam intraoperatively."

Answer

"I recommend monitoring the patient's neurovascular status hourly and administering the prescribed analgesic as needed for pain."

Question 2

Which of the following is an essential documented element required for a valid surgical informed consent?

Accepted Answer

A discussion of the procedure's risks, benefits, and alternatives.

Answer

A list of all perioperative nursing staff present in the room.

Answer

The patient's insurance and billing information.

Answer

The brand name of any anticipated prosthetic implants.

Question 3

During a spinal fusion procedure, a pedicle screw is implanted. Which set of information is MOST critical for the circulating nurse to document on the intraoperative record for this implant?

Accepted Answer

The manufacturer, lot number, serial number, and size/type of the screw.

Answer

The name of the sales representative and the time they entered the OR.

Answer

The surgeon's verbal confirmation of placement and the torque setting used.

Answer

The cost of the implant and the corresponding billing code.

Question 4

At the conclusion of a complex aortic valve replacement, the surgeon initiates a debriefing. What is a primary objective of this communication process?

Accepted Answer

To identify opportunities for improving teamwork and patient safety on future cases.

Answer

To finalize the instrument count and sign out of the room.

Answer

To assign blame for any intraoperative complications that occurred.

Answer

To provide a detailed report to the patient's waiting family members.

Question 5

A medication on the sterile field is drawn into a syringe but not immediately labeled. The error is caught before administration, and the medication is discarded. According to patient safety principles, why is it important for the perioperative nurse to complete an incident report for this 'near miss'?

Accepted Answer

To collect data that can identify system vulnerabilities and prevent future errors.

Answer

To ensure the involved staff member receives punitive action.

Answer

To allow the hospital to bill the patient for the wasted medication.

Answer

To document the event for potential future litigation against the hospital.

Question 6

During a surgical emergency, the surgeon gives the circulating nurse a verbal order for a critical medication. To ensure patient safety and proper documentation, what is the nurse's MOST important immediate action after receiving the order?

Accepted Answer

Write down the order and then read it back to the surgeon for verification.

Answer

Administer the medication as quickly as possible.

Answer

Ask the scrub person to confirm they also heard the order.

Answer

Wait for the surgeon to enter the order into the electronic health record before acting.