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FREE SAMPLE · READ ONLINEChapter 3

Management of Intraoperative Activities — Patient Care and Safety

This is Chapter 3 of the CNOR Study Guide — 2026 Edition — one complete chapter, free to read right here; no download, no email. It is the same text as the eBook. When you reach the end, the complete guide is one click away.

We didn't give you the easy intro — this free chapter opens on one of the hardest-working parts of the book, so you can judge the teaching where the exam gets difficult.

This is the largest subject area on the exam: 25% of the scored questions, 46 of 185[1]. It covers everything the circulating nurse does between the patient's arrival in the room and the handoff to PACU. CCI lists 24 task statements for it[2]; the headings below group them. Across all of them, the exam rewards the answer that protects a patient who cannot protect themselves.

3.1 Universal Protocol: verification, marking and the time-out

The concept. The Universal Protocol has three parts — preprocedure verification, site marking, and the time-out — and "the preprocedure verification and site marking precede the final verification in the time-out"[3]. Verification confirms that required items are available, including "labeled diagnostic and radiology test results ... that are properly displayed" and "any required blood products, implants, devices, and/or special equipment"[4].

Marking. The site is marked by the accountable practitioner who will be present[4]. The mark must be "sufficiently permanent to be visible after skin preparation and draping," and adhesive markers "are not the sole means of marking the site"[4]. Bilateral structures that are both removed, such as tonsils or ovaries, need no mark[4], and there must be a written alternative process when a patient refuses marking or a site cannot be marked[4].

The time-out. It is conducted "immediately before starting the invasive procedure or making the incision"[3]; "a designated member of the team initiates the time-out and it includes active communication among all relevant members of the procedure team"[3]; its completion is documented[3]. The WHO version opens with every team member introducing themselves "by name and role"[5] and confirms antibiotic prophylaxis "within the last 60 minutes"[5]. At sign-out the nurse verbally confirms the procedure, "completion of instrument, sponge and needle counts," and "specimen labelling (read specimen labels aloud, including patient name)"[6].

How it is tested. A surgeon who wants to skip or shorten the time-out; a second procedure on the same patient (it needs its own time-out); imaging not displayed; a team member who noticed something but stayed quiet. "The procedure is not started until all questions or concerns are resolved"[7].

The trap. Believing any one person — surgeon, anesthesia provider, nurse — can waive the check.

3.2 Maintain patient and personnel safety: environmental hazards

Fire. Surgical fires need "the 'fire triangle'—a heat/ignition source, an oxidizer, and a fuel"[8]. Oxygen "above 30%" significantly increases fire risk[8], so the goal is "the lowest feasible fraction of inspired oxygen to sustain adequate oxygen saturation"[8]. Alcohol-based preps are a contributing factor "when proper drying times were not followed"[8]; active electrodes not in use go "in a nonconductive holster"[8]. Chapter 7 covers what to do when a fire starts.

Surgical smoke. The plume "can contain toxic gases and vapors such as benzene, hydrogen cyanide, and formaldehyde, bioaerosols, dead and live cellular material (including blood fragments), and viruses"[9]. The evacuator inlet "must be kept within 2 inches of the surgical site"[9].

Radiation. ALARA means "making every reasonable effort to maintain exposures to radiation as far below the dose limits ... as is practical"[10] — time, distance and shielding (lead aprons, thyroid shields) while still caring for the patient.

Chemicals. Formaldehyde exposure "is highly irritating to the eyes, nose, and throat"[11]; specimen handling with formalin is covered in 3.9.

3.3 Provide comfort measures, and maintain dignity, privacy and patients' rights

The anesthetized patient cannot speak for themselves, so the nurse does. "The nurse's primary commitment is to the patient"[12], and the nurse "promotes, advocates for, and strives to protect the health, safety, and rights of the patient"[12]. In practice: keep the patient covered and "exposed only during surgical preparation"[13]; stop disrespectful talk about a sedated patient; answer the awake patient's questions and fears; warm the patient who is cold; and hold the line on safety checks when the schedule is pressing.

3.4 Prepare the surgical site

Hair is removed only if it interferes, and never with a razor: "do not use razors – If necessary, remove by clipping or by use of a depilatory agent"[14]. The skin is prepped with "appropriate antiseptic agent and technique"[14], moving from the incision site "in concentric circles moving toward the periphery"[15]. Alcohol-based preps must dry fully and must not pool under the patient or drapes[8]. Check allergies first: chlorhexidine is a recognised cause of perioperative anaphylaxis[16].

3.5 Select protective barrier materials

Barriers protect both the patient and the team: lead aprons and shields during imaging (ALARA[10]); face shields or masks with goggles for procedures that "generate splashes or sprays of blood, body fluids, secretions, or excretions"[17]; and drapes and gowns that stay intact — "any puncture, moisture, or tear that passes through a sterile barrier must be considered contaminated"[18].

3.6 Evaluate the patient's response to pharmacological agents and assist with anesthesia

Monitoring. ASA's standard is that "the patient's oxygenation, ventilation, circulation and temperature shall be continually evaluated"[19]. An RN monitoring a patient under moderate sedation applies the same principle.

Spinal anesthesia. "Sympathetic blockade due to spinal anesthesia may result in peripheral vasodilation and hypotension," which "may be controlled by administration of vasoconstrictor agents in titrated dosages"[20]. Nausea is often the first sign.

Local anesthetics. Watch for early CNS toxicity: "restlessness, anxiety, incoherent speech, lightheadedness, numbness and tingling of the mouth and lips, metallic taste, tinnitus"[21]. Stop the injection and call for help; Chapter 7 covers treatment.

Airway. Have difficult-airway equipment and help ready when the assessment predicts a problem[5], and protect the eyes: "during general anesthesia, eyes need protection either by tape or ointment to avoid corneal injuries"[22].

3.7 Control environmental factors

Operating rooms "should be maintained at positive pressure with respect to corridors and adjacent areas"[23]. Doors stay closed "except for the passage of equipment, personnel, and patients," with entry limited to essential personnel[23]; "excessive OR traffic" is itself an SSI risk factor[14]. CDC's environmental guideline associates operating rooms with "cool temperature standards (68°F–73°F [20°C–23°C])"[24], while NICE asks for an ambient temperature of "at least 21°C while the patient is exposed"[13] — the two meet once active warming is established.

3.8 Maintain a sterile field using aseptic technique

  • "Sterile items that are below the waist level, or items held below waist level, are considered to be non-sterile"[18].
  • "Sterile fields must always be kept in sight to be considered sterile"[18].
  • "The front of the sterile gown is sterile between the shoulders and the waist"[18]; the back is not, so scrubbed people pass front to front or back to back.
  • "A sterile object becomes non-sterile when touched by a non-sterile object"[18], and "whenever the sterility of an object is questionable, consider it non-sterile"[18].
  • "Do not sneeze, cough, laugh, or talk over the sterile field"[18].

When a break occurs, correct it at once. A break that nobody else saw is still a break.

3.9 Utilize equipment according to the manufacturer's instructions

Electrosurgery. In monopolar surgery "the circuit is composed of the patient, the electrosurgical generator, the active electrode and the return electrodes"[25]. The return electrode goes on well-perfused muscle — "muscle and skin are good conductors of electricity" — and away from "excessive hair, adipose tissue, bony prominences, and the presence of fluid and scar tissue"[25], because a pad not "completely in contact with the patient's skin" can concentrate current enough to burn[25]. Return-electrode monitoring "inactivates the generator if a condition develops at the patient return electrode site that could result in a burn"[25]. "Inspect insulation carefully" and "use the lowest possible power setting"[25]. In bipolar surgery "the active and return electrodes are located at the site of surgery, typically within the instrument tip"[25]. For patients with implanted cardiac devices, keep the current path away from the device[26].

Tourniquets. "Nerve injury is the most common complication"[27]. "Tissue edema develops if the tourniquet time exceeds 60 min"[27], and one review concludes the cuff "should be deflated after 2 h for the lower limb and after 1½ h for the upper limb"[27]. Report elapsed time to the surgeon at intervals, and watch for reperfusion effects after release[27].

Insufflation. A review recommends keeping intraperitoneal pressure "at 12 mmHg or less" to limit hemodynamic change, and notes that complications "seem to easily develop" when pressure "passes over 15 mmHg"[28]. Subcutaneous emphysema is a recognised complication whose risk rises with longer surgery and more trocars[28].

Equipment that fails. It "is removed from service and labeled"[29].

3.10 Verify specimens

The circulator writes the label in the room: "type of specimen," "site of specimen including left or right side," and "two unique identifiers"[30], plus the preservative and surgeon's name[30]. The label goes "on the side of the container and not the lid"[30], and containers are labeled "in the presence of the patient"[31]. Frozen-section specimens "should not be placed in a preservative solution"[32], and cultures need "immediately delivered to laboratory" handling[33]. With formalin, use prepoured containers — "formalin should not be poured directly over a specimen" — and wear eye and face protection and impervious gloves[33].

3.11 Verify implants, prepare them, and prepare explants

Before an implant is opened, confirm type, size and expiration with the surgeon. The FDA's unique device identifier has a device identifier naming "the labeler and the specific version or model of a device" and a production identifier that carries the "lot or batch number," "serial number," and "expiration date"[34]. Implant loads should have a biological indicator and be quarantined "whenever possible, until the biologic indicator is negative"[35]; if flash sterilization of an implant is unavoidable, record "load identification, patient's name/hospital identifier, and biological indicator result"[35]. Human tissue must be traceable "from the donor to the receiving facility (consignee) or final disposition and back to the donor"[36]. Explants are handled as specimens or devices according to facility policy, with the same labeling discipline.

3.12 Label solutions, medications and containers

Label every medication and solution on and off the field that is not immediately administered — "this applies even if there is only one medication being used"[4] — at the moment it is transferred to another container[4]. Labels include "medication or solution name," "strength," and the amount[3]. At a handoff, "verify all medication or solution labels both verbally and visually"[4]. "Medications or other solutions in unlabeled containers are unidentifiable"[3] and are discarded.

3.13 Perform appropriate surgical counts

Counts are done before the procedure, when items are added, and before closure, and each count and discrepancy is documented. Retained items are associated with "emergency operations, operations involving unexpected change in procedure, raised body mass index, and a failure to perform accurate sponge and instrument counts"[37]. A correct count is not proof: in one AHRQ case the team "called the sponge count 'correct'" while a sponge remained in the patient[38]. An unresolved count is never closed over, and near misses are reported: "the accurate reporting of all RSI events and near miss events is a critical step" in prevention[39].

3.14 Anticipate intraoperative blood transfusion or salvage

At sign-in the WHO checklist asks about a "risk of >500ml blood loss (7ml/kg in children)" and expects "two IVs/central access and fluids planned"[5]. During the case, "surgeons and anaesthetists must communicate frequently on the ongoing situation so that the team can stay on top of the blood loss and transfuse if needed"[40]. Before any unit is hung, "the identification of the patient, using the unit tag on the bag, must be checked by two people at the patient's bedside"[41], and blood is warmed with a fluid warmer[13].

Sources cited in this excerpt

  1. CCI CNOR Examination Handbook (Updated 05/2026; last updated 05.01.2026). Competency & Credentialing Institute (CCI). https://www.cc-institute.org/cnor
  2. CCI CNOR Task & Knowledge Statements (Updated 12/2023; linked from the CNOR Examination Handbook). Competency & Credentialing Institute. https://2447632.fs1.hubspotusercontent-na1.net/hubfs/2447632/Handbook%20Supplement%20Docs/CNOR%20Task%20&%20Knowledge%20Statements.pdf
  3. Joint Commission Universal Protocol (from NPSG materials, 2025). https://www.jointcommission.org
  4. The Joint Commission, National Patient Safety Goals and Universal Protocol, Hospital Program, effective January 2025. https://www.jointcommission.org
  5. WHO Surgical Safety Checklist (2009). https://www.who.int
  6. WHO Surgical Safety Checklist (revised 1/2009). World Health Organization. https://www.who.int
  7. Joint Commission Universal Protocol (from NPSG materials, 2025). The Joint Commission. https://www.jointcommission.org
  8. ALES: Surgical fire review. https://pubmed.ncbi.nlm.nih.gov
  9. NIOSH: Surgical smoke (archived mirror, not current CDC domain). https://www.cdc.gov/niosh
  10. eCFR 10 CFR 20.1003 — Definitions. U.S. Federal Government (eCFR). https://www.ecfr.gov/current/title-10/chapter-I/part-20/subpart-A/section-20.1003
  11. OSHA Fact Sheet — Formaldehyde. U.S. Occupational Safety and Health Administration. https://www.osha.gov/sites/default/files/publications/formaldehyde-factsheet.pdf
  12. ANA: Code of Ethics for Nurses. American Nurses Association. https://www.plu.edu/nursing/wp-content/uploads/sites/96/2014/10/ANA-Code-of-Ethics.pdf
  13. NICE clinical guideline CG65: Hypothermia: prevention and management in adults having surgery (2008, updated 2016). National Institute for Health and Care Excellence. https://alpha.nice.org.uk/guidance/cg65/resources/hypothermia-prevention-and-management-in-adults-having-surgery-pdf-975569636293
  14. CDC Surgical Site Infection Toolkit (Draft 12/21/09). https://www.cdc.gov
  15. CDC 1999 SSI Prevention Guideline (via HARTMANN). https://www.hartmann.info/en/topic/surgical-site-infection/ssi-knowledge-hub/or-team/surgical-site-preparation
  16. PMC: Perioperative anaphylaxis review. https://pmc.ncbi.nlm.nih.gov
  17. CDC/HICPAC 2007 Guideline for Isolation Precautions. https://www.cdc.gov
  18. 1.5 Surgical Asepsis and the Principles of Sterile Technique – Clinical Procedures for Safer Patient Care. BCcampus / Thompson Rivers University. https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn/chapter/1-5-surgical-asepsis-and-the-principles-of-sterile-technique/
  19. ASA Standards for Basic Anesthetic Monitoring. https://www.asahq.org
  20. DailyMed — MARCAINE SPINAL (bupivacaine in dextrose) injection, prescribing information (Hospira). U.S. National Library of Medicine — DailyMed (FDA-approved labeling). https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=9679cc05-2f8a-4e88-53b5-6e9122c8b8c0
  21. DailyMed — MARCAINE (bupivacaine HCl) injection, prescribing information (Hospira). U.S. National Library of Medicine — DailyMed (FDA-approved labeling). https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=67578b56-7540-487e-1fba-481255620e78
  22. Perioperative eye protection under general anesthesia (J Anaesthesiol Clin Pharmacol, PMC3590532). Europe PMC. https://europepmc.org/article/PMC/PMC3590532
  23. CDC Guidelines for Environmental Infection Control in Health-Care Facilities. https://www.cdc.gov
  24. CDC/HICPAC Guidelines for Environmental Infection Control in Health-Care Facilities, 2003 (update July 2019). https://www.cdc.gov
  25. PMC: Electrosurgery safety review. https://pmc.ncbi.nlm.nih.gov
  26. Perioperative Management of Patients with Cardiac Implantable Electronic Devices and Utility of Magnet Application (J Clin Med 2022; open access, via Europe PMC PMC8836758). https://europepmc.org/article/PMC/PMC8836758
  27. PMC: Tourniquet complications review. https://pmc.ncbi.nlm.nih.gov
  28. Kim et al. Carbon dioxide embolism during laparoscopic surgery (Korean J Anesthesiol, PMC3030037). Europe PMC. https://europepmc.org/article/PMC/PMC3030037
  29. Duke University: Medical Equipment Management Plan. https://www.safety.duke.edu/sites/default/files/Medical-Equipment-Management-Plan.pdf
  30. AST Standard of Practice: Handling and Care of Surgical Specimens. https://www.ast.org
  31. The Joint Commission, National Patient Safety Goals, Hospital Program, effective January 2025. https://www.jointcommission.org
  32. AST: Surgical Specimens Standard. Association of Surgical Technologists. https://www.ast.org
  33. AST Standards of Practice for Handling and Care of Surgical Specimens. Association of Surgical Technologists. https://www.ast.org
  34. UDI Basics | FDA. U.S. Food and Drug Administration. https://www.fda.gov/medical-devices/unique-device-identification-system-udi-system/udi-basics
  35. CDC/HICPAC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (update June 2024). https://www.cdc.gov
  36. Current Good Tissue Practice (CGTP) and Additional Requirements for Manufacturers of Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/Ps); Guidance for Industry. U.S. Food and Drug Administration. https://www.FDA.gov/media/82724/download
  37. Retained surgical sponges, needles and instruments (Ann R Coll Surg Engl 2013, PMC4098594). Europe PMC. https://europepmc.org/article/PMC/PMC4098594
  38. AHRQ PSNet: Retained surgical items. https://psnet.ahrq.gov
  39. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review (Patient Saf Surg 2021, PMC8276389). Europe PMC. https://europepmc.org/article/PMC/PMC8276389
  40. Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus (PMC11251377). Europe PMC. https://europepmc.org/article/PMC/PMC11251377
  41. Transfusion Services: Blood Administration (Clinical Nursing Standards). Children’s Hospitals and Clinics of Minnesota.
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