CNOR Perioperative Communication and Documentation 5

Question 1

Which of the following best describes the purpose of a surgical safety checklist as recommended by the WHO?

Accepted Answer

To standardize communication and reduce preventable surgical complications across the three perioperative phases

Answer

The WHO Surgical Safety Checklist is designed to improve teamwork and communication across the Sign In, Time Out, and Sign Out phases to reduce preventable harm.

Question 2

Which of the following is an example of an 'error of omission' in perioperative documentation?

Accepted Answer

Failing to document a known allergy discovered during preoperative assessment

Answer

An error of omission occurs when relevant information—such as a newly identified allergy—is discovered but not recorded, leaving a dangerous gap in the medical record.

Question 3

A perioperative nurse documents 'patient tolerated procedure well' without supporting objective data. This type of entry is considered:

Accepted Answer

Subjective and insufficient without objective assessment findings to support it

Answer

Documentation must include objective data such as vital signs, estimated blood loss, and patient responses rather than vague subjective statements.

Question 4

Which situation requires the perioperative nurse to complete an incident report (occurrence report) in addition to the medical record?

Accepted Answer

A patient fall during transfer from the OR table to the stretcher

Answer

A patient fall is an adverse event requiring both an incident/occurrence report for risk management purposes and accurate documentation in the medical record.

Question 5

During the postoperative Sign Out phase of the surgical checklist, which of the following is confirmed?

Accepted Answer

Instrument, sponge, and needle counts; specimen labeling; equipment concerns; and key recovery concerns

Answer

The Sign Out phase of the WHO checklist confirms count correctness, specimen labeling, equipment problems to report, and key concerns for recovery.

CNOR - Certification Exam Practice Test

CNOR - Certification Exam Practice Test

CNOR Perioperative Communication and Documentation 5