Perioperative Communication and Documentation Flashcards
7 cards from real CNOR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Perioperative Communication and Documentation flashcards as text
Which element of the intraoperative nursing record documents the patient's position during surgery?
Answer: Positioning devices and body alignment used
The intraoperative record must document positioning devices, supports, and body alignment to track potential pressure injury risks.
A scrub technician notices a sponge count discrepancy before wound closure. What is the FIRST action the perioperative nurse should take?
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.
Which abbreviation has been identified by The Joint Commission as 'Do Not Use' in medical documentation?
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.
What is the primary purpose of the perioperative handoff report when transferring a patient from the OR to the PACU?
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.
During a surgical timeout, which team member has the authority to call a stop if a safety concern is raised?
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.
Which documentation practice best supports accurate accounting of implantable devices used during surgery?
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.
A patient arrives in the preoperative area speaking only Spanish and no interpreter is present. What should the perioperative nurse do?
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.