CNOR Perioperative Communication and Documentation 3 — Questions and Answers
Question 1: Which component of SBAR communication represents the nurse's assessment of the patient's condition?
- Situation — what is happening now
- Background — relevant clinical history
- Assessment — the nurse's clinical judgment (Correct answer)
- Recommendation — proposed action needed
Correct answer: Assessment — the nurse's clinical judgment
The 'A' in SBAR stands for Assessment, where the nurse communicates her clinical interpretation of the situation.
Question 2: An incorrect needle count is discovered after wound closure in a laparoscopic case. What is the most appropriate next step?
- Document the discrepancy and notify risk management after the case
- Notify the surgeon so an X-ray can be obtained before the patient leaves the OR (Correct answer)
- Recount needles and if still incorrect, proceed with patient transfer
- File an incident report and notify the charge nurse only
Correct answer: Notify the surgeon so an X-ray can be obtained before the patient leaves the OR
An incorrect needle count after closure requires immediate surgeon notification and an intraoperative X-ray to locate the missing needle.
Question 3: Which document serves as the legal operative record and must be signed by the operating surgeon?
- Perioperative nursing care plan
- Operative report / dictated operative note (Correct answer)
- Anesthesia induction record
- Pre-admission testing results
Correct answer: Operative report / dictated operative note
The operative report, dictated or written by the surgeon, is the legal document describing the procedure performed and must be completed promptly.
Question 4: When documenting irrigation fluid used during a procedure, the perioperative nurse should record which of the following?
- Color of the fluid only
- Type, volume instilled, and volume returned (Correct answer)
- Brand name of the irrigant only
- Temperature of the irrigation fluid only
Correct answer: Type, volume instilled, and volume returned
Accurate fluid balance documentation requires recording the type of irrigant, the volume instilled, and the volume retrieved to track fluid absorption.
Question 5: A surgeon requests a change in the surgical procedure after the timeout is complete. What action must the perioperative team take?
- Proceed with the change and document it postoperatively
- Conduct a new timeout to verify the change before proceeding (Correct answer)
- Notify anesthesia only and continue
- Document the change on the anesthesia record
Correct answer: Conduct a new timeout to verify the change before proceeding
Any significant change in the planned procedure requires repeating the surgical timeout to ensure all team members are aligned.
Question 6: What is the purpose of the preoperative checklist in perioperative documentation?
- To bill insurance for preoperative services
- To verify completion of required safety checks before transferring the patient to the OR (Correct answer)
- To document the surgeon's postoperative orders
- To record the patient's diet history
Correct answer: To verify completion of required safety checks before transferring the patient to the OR
The preoperative checklist ensures all required safety verifications—consent, labs, allergies, NPO status—are completed before the patient enters the OR.
Question 7: Which principle guides the documentation of a critical event such as unexpected hemorrhage during surgery?
- Document only the final outcome of the event
- Record events in real time or as close to real time as possible with accurate timestamps (Correct answer)
- Delay documentation until after the patient is stable
- Have the surgeon document the event to avoid liability
Correct answer: Record events in real time or as close to real time as possible with accurate timestamps
Real-time or near-real-time documentation with accurate timestamps provides the most legally defensible and clinically accurate account of critical intraoperative events.
CNOR Perioperative Communication and Documentation 3
Which component of SBAR communication represents the nurse's assessment of the patient's condition?