CNOR Perioperative Communication and Documentation 2 — Questions and Answers
Question 1: Which element of the intraoperative nursing record documents the patient's position during surgery?
- Anesthesia type administered
- Positioning devices and body alignment used (Correct answer)
- Surgeon's operative technique
- Medication allergies
Correct answer: Positioning devices and body alignment used
The intraoperative record must document positioning devices, supports, and body alignment to track potential pressure injury risks.
Question 2: A scrub technician notices a sponge count discrepancy before wound closure. What is the FIRST action the perioperative nurse should take?
- Proceed with closure and document the discrepancy
- Notify the surgeon immediately and repeat the count (Correct answer)
- Call the charge nurse before telling the surgeon
- Document 'count incorrect' and complete closure
Correct answer: Notify the surgeon immediately and repeat the count
The surgeon must be notified immediately so the wound can be explored before closure when a count discrepancy occurs.
Question 3: Which abbreviation has been identified by The Joint Commission as 'Do Not Use' in medical documentation?
- PRN
- NPO
- U (for units) (Correct answer)
- BID
Correct answer: U (for units)
'U' for units is on The Joint Commission's Do Not Use list because it can be mistaken for the number zero or four.
Question 4: What is the primary purpose of the perioperative handoff report when transferring a patient from the OR to the PACU?
- To fulfill billing requirements
- To ensure continuity of care by communicating critical patient information (Correct answer)
- To document surgeon preferences for future cases
- To record room turnover time
Correct answer: To ensure continuity of care by communicating critical patient information
The handoff report ensures the receiving PACU nurse has all critical information needed to safely continue patient care.
Question 5: During a surgical timeout, which team member has the authority to call a stop if a safety concern is raised?
- Only the surgeon
- Only the anesthesiologist
- Only the circulating nurse
- Any member of the surgical team (Correct answer)
Correct answer: Any member of the surgical team
Any member of the surgical team has both the authority and the responsibility to call a stop when a safety concern arises during the timeout.
Question 6: Which documentation practice best supports accurate accounting of implantable devices used during surgery?
- Recording the device brand in the nurse's notes
- Affixing the manufacturer's label/sticker to the operative record (Correct answer)
- Verbally reporting the device to the PACU nurse
- Photographing the device before implantation
Correct answer: Affixing the manufacturer's label/sticker to the operative record
Affixing the manufacturer's label with lot number and device identification to the operative record provides a permanent, traceable implant record.
Question 7: A patient arrives in the preoperative area speaking only Spanish and no interpreter is present. What should the perioperative nurse do?
- Ask a family member to interpret the consent
- Proceed with the case since consent was previously signed
- Obtain a qualified interpreter before proceeding with assessment and consent verification (Correct answer)
- Use gestures and diagrams to communicate
Correct answer: Obtain a qualified interpreter before proceeding with assessment and consent verification
A qualified interpreter must be used to ensure informed consent and accurate preoperative assessment; using family members is not a recommended standard.
CNOR Perioperative Communication and Documentation 2
Which element of the intraoperative nursing record documents the patient's position during surgery?