NCRE Practical Examination Guide for Students

The exam currently consists of three (3) parts:

i) Management of a Small Group of 3-4 Patients

ii) Management of a Category III Patient
iii) Administration of Medication

Students must pass each part of the exam in order to progress to the RENR Written exam. If a
student fails any part of the exam they will only be required to re-sit that part.

Practical examinations are held twice in each calendar year – January/ February and
June/July. Students of the UWISoN usually have their first attempt at this practical exam at
the June-July sitting.

The Nursing Council of Trinidad and Tobago is responsible to the administration of these
exams to eligible students from all Nursing Schools in Trinidad and Tobago. Their role
includes the collection of examination fees, setting the dates for the exam, developing an
exam schedule and assigning qualified nurses to carry out the exam.

The school and the NCTT must be notified if for any reason you are unable to sit your exam
on the designated day.

Students must be attired in their full uniform on the day of the exam.

The duration of the exam is usually 4 to 5 hours (8am to 1pm).

N.B. The examination can be stopped if patient safety is compromised in any way

i) Management of a Small Group of 3-4 Patients (Cubicle Management)

General Instructions

On the day of your exam you will be required to manage a group of 3 to 4 patients one of
whom MUST be a Category III Patient. In addition to your duties as manager you will do
total patient care for this category III patient. While there are no rules regarding the acuity
level of the other three patients in the cubicle, a good mix could include Category Two x 2
and Category One x 1 or Category Two x 1 and Category One x 2.

Students are allowed to choose the group of patients to be managed. You are however
encouraged to do so in consultation with the Head Nurse or Registered Nurse who will serve
as your Resource Nurse on the day of the exam.

The Resource Nurse is an RN who oversees technical tasks such as the administration of
medication; she is not to be assigned to care for a patient.

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In preparation for the Cubicle Management portion of the exam you should utilize the
Patient Classification Form to categorize each patient in the cubicle. Fill out the
Disposition Sheet indicating when each member of your team will be proceeding on break
and lunch, the person responsible for Doctors rounds and at what time you will be having
your cubicle conference. When delegating duties to other members of your team you must
ensure that it is clearly understood and that the person is capable of carry out the desired
action.

As cubicle manager you are to ensure that diet sheet for all patients in your group are sent
down to the Dietary Department, and that all referrals to other departments are duly
dispatched.

You will also need to ensure that all IV lines, O 2 humidifiers and O2 lines are labelled with
the date and time. Urine bags must be securely suspended off the floor. Ensure that all fluid
balance charts and observation charts are updated and that IVI are running according to
regime.

Orientation of the Examiner:

The student introduces him/herself to the examiner and orients them to the ward environment.
Information should include but is not limited to: the name of the Head Nurse, number of staff
attached to the ward, the type of ward (medical, surgical, orthopaedic); ward capacity, current
bed state, location of emergency exits, wards routines e.g. (surgery days, admission days,
medical teams attached to ward).

Students should be familiar with procedures for ordering stocks including medications and
with general ward policies regarding DAMA, Incident Reports, admissions, discharges,
deaths etc.

Introduction to Resource Nurse and Cubicle Team

Students are expected to show proficiency in assigning an appropriate mix of staff to care for
the patients in the chosen cubicle. This is usually based on the acuity level of your patients
and the type of care that they require.

You should introduce the examiner to your Resource Nurse and the other students that will be
working in the cubicle with you, indicating their name and year group to which they belong.

There usually should not be more than three students, including yourself, in the exam cubicle.

Handing Over the Cubicle

As Cubicle Manager you need to be familiar with all the patients in the cubicle and the
specific care that they require for the day.

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Giving over of the cubicle should begin with the student indicating the number of patients
and their acuity level; the examiner may ask to see the classification at this time or else wait
until the handing over is complete. The student hands the cubicle over with her team present,
indicating as he/she goes along who has been assigned to care for the patient. The Category 3
patient that the student is to be examined on will be given over last and only to the examiner.

The student should give specific instructions to the team members assigned to each client
regarding what care they are to receive during the 8 hour shift. He/she should also indicate
breaks, arrangements for Doctors’ rounds and the time for Cubicle Conference.

Hand over each patient indicating their name, date of admission, current diagnosis,
significant medical history, and current medical plan including medication. Indicate what
general and specific care is needed for the patient, including medications due, and special
tests to be done.

Once team members have been informed of their assignments and break times, the student
can now proceed to hand over the Category 3 Patient they will be managing.

Doctor’s Rounds

The student/manager must participate in the Doctor’s rounds for their Category III patient.
Rounds with the other patients in the cubicle may be delegated to another senior student in
the cubicle if time constraints with the exam inhibit their ability to do so personally.

Participating in the Doctor’s rounds by making insightful contributions regarding the

patient’s condition is important.

Team Leadership and Time Management

The student/manager must show leadership/managerial qualities by interacting with other

members of the team to ensure the patient care needs are being met, that they are adhering to
their designated break times.

Remind team members to update the notes and charts of their designated patient, and follow
up to ensure that meals, medications, tests, and treatments were carried out.

Remind team members of the time for the Cubicle Conference and ensure that all notes and
charts are brought. As the report is given on each patient, the student/manager must as
questions where necessary to clarify what was said and check notes to ascertain that all
documentation was properly done.

Ward Report

The student/manager must prepare a cubicle report utilizing guidelines designated forms
according to the policy of the institution/ward.

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 ii) Management of a Category III Patient

Candidates are assessed on their ability to extract critical data from the patient’s notes,
perform a thorough assessment of a critically ill patient, and utilize assessment data to
formulate relevant nursing diagnoses and develop a suitable plan of care.

The student/manager must assume responsibility for Total Patient Care of a Category III
Patient. This patient is chosen in consultation with the Head Nurse or Resource Nurse.

The patient can be chosen prior to the exam day however, the NCTT Examiner has the
right to change the chosen patient if she/he determines that the patient is not suitable for
exam. The Examiner can, independently or in consultation with the Head Nurse or
Resource Nurse, chose another patient on the ward who in their assessment is more
suitable.

If the patient chosen has to be changed for any reason, then the student will be allowed
sufficient time to familiarise themself with the patient’s history and to carry out a nursing
assessment and plan of care.

Students are to avoid choosing patients that have to leave the ward for diagnostic
procedures on the day of exams.

The student/manager must be able to justify their categorization of the patient and be
thoroughly familiar with the patient’s past history and current status.

Handing Over a Category III Patient

Handover should be comprehensive and include the following.

 Patient Name
 Age
 Date & Place of Admission:

(Mrs Doe was admitted two weeks ago on the 10th June via the A&E)

 Reason for Admission: (2/7 history of abdominal pain and vomiting bile stained fluid)
 Major A&E Events: (only if admitted within the last week [she was seen by the ER
physician and had bloods taken for LFT & CBC, she had abdominal ultrasound…]
 Admission Diagnosis:
(after ___ test and examination Mr X was diagnosed with ___ and admitted to Ward
52 under Dr. Spock’s team)
 Tests done and significant results:

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  PMH, PSH, Drug History, Allergies – if the client has other medical problems
indicate what they are, how they were managed at home and if that has changed since
hospitalization (known DM for last 15years managed with diet and Glucophage, but
has been on sliding scale insulin since admission)
 Significant events since admission –
(include surgeries & other interventions, patient progress and/or deterioration; current
status )
 Current Medical Management Including Medications and Planned Interventions
(awaiting CT Scan, surgery, dialysis…)
 Data from Nursing Assessment

At this time the candidate should indicate the nursing diagnoses and plan of care that will
be utilized to manage the client during the period of the exam.

You are to develop care plans to manage all of the nursing problems that you identified.
Diagnoses should be arranged in order of priority.

Care Plans can be modified during the course of the shift as the patient’s condition
improves or deteriorates.

Care Plans should be evaluated before being handed in to the Council Examiner at the
end of the exam.

Your patient is to be nursed according to the interventions outlined in the Care Plans
developed.

Nursing Assessment of The Patient

Use a body systems approach to perform a thorough assessment

System Assessment Points

CNS: Orientation, check GCS on patients with impaired conscious
level/seizures/CVA/ head injury; communication difficulties; Fall Score;
dizziness
CVS: Measure pulse & B/P; edema; assess for DVT; note cyanosis; capillary
refill; note position and patency of IVI; TEDs; Lab results
Respiratory: Check respiratory rate, rhythm and depth; SpO2; assess use of accessory
muscles; note cough –is it productive or dry; assess need for suctioning; O2
therapy;
GI: Type of diet; NGT; bowel habits like - constipation, diarrhea; BMI,
vomitus, appetite; dentition; continence; problems with digestion; ostomy;
skin turgor; I&O Charting

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GU: Does the patient void urine on urge, are they incontinent of urine; urine
output ; signs of UTI; catheter in situ; catheter care, urinalysis
Integumentary: Check pressure areas; does the patient have any rashes, bruises, wounds; is
the skin warm or cool to touch;
MSS: Is the patient able to ambulate independently or do they need assistance; are
they on bedrest or are they immobile; can they perform ROM exercises; do
they have all limbs and digits; any joint contractures, check 4 Ps

Common Nursing Diagnoses for Category 3 Patients

Breathing: impaired gas exchange, ineffective breathing pattern, risk for aspiration

Nutrition: Imbalanced nutrition: less than body requirements, Impaired swallowing, Risk for
unstable blood glucose level,

Hydration: Risk for electrolyte imbalance, Risk for imbalanced fluid volume, Deficient fluid
volume, Risk for deficient fluid volume, Excess fluid volume,

Gastrointestinal function: Constipation, Risk for constipation, Diarrhoea, Dysfunctional

gastrointestinal motility, Risk for dysfunctional gastrointestinal motility, Bowel incontinence

Activity/exercise: Risk for disuse syndrome, Impaired bed mobility, impaired physical
mobility

Cardiovascular/pulmonary responses: Activity intolerance, Decreased cardiac output, Risk

for unstable blood pressure, Risk for decreased cardiac tissue perfusion, Risk for ineffective
cerebral tissue perfusion, Ineffective peripheral tissue perfusion,

Self-care: Bathing self-care deficit, Dressing self-care deficit, Feeding self-care deficit,
Toileting self-care deficit

Cognition: Acute confusion, Risk for acute confusion, Deficient knowledge, impaired
memory

Communication: Impaired verbal communication

Self-concept: Hopelessness, Risk for compromised human dignity, Anxiety

Self-esteem: Situational low self-esteem

Body image: Disturbed body image

Coping responses: Ineffective coping, Death anxiety, Fear, Grieving, Complicated grieving,
Powerlessness, Chronic sorrow, Stress overload

Infection: Risk for infection Risk for surgical site infection

Physical injury: Ineffective airway clearance, Risk for aspiration, Risk for bleeding, Risk for
falls, Risk for injury, Risk for pressure ulcer, Risk for shock Impaired skin integrity, Risk for

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impaired skin integrity, Delayed surgical recovery, Impaired tissue integrity, Risk for venous
thromboembolism

Thermoregulation: Hyperthermia Hypothermia

Physical comfort: Impaired comfort, Nausea, Acute pain, chronic pain

Category III Patient: Most Common Conditions

 MI- NSTEMI, STEMI ACS CCF

 IHD Unstable Angina,

 CVA Cerebral Haemorrhage,

 Head Injury Craniotomy, Burr Holes,

 Spinal Cord Injury Laminectomy,

 Acute/Chronic Renal Failure

 Diabetic Ketoacidosis DVT Pneumonia,

 Bowel Resection Intestinal Obstruction GI bleed,

 Cancer (palliative care) AIDS related complex

 Major Burns

iii) Administration of Medication

Students are expected to administer medications by at least two (2) routes during the
course of the examination.

These routes include: Oral, Sc, IM and IV

Students should be familiar with the class of medication, its mechanism of action, the
therapeutic and side effects.

Patient safety and safety of all medications throughout the process is paramount. Any
action or omission on the part of the student that compromises patient safety, including
failure to adhere to the rights and checks of drug administration, will result in the exam
being stopped.

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 In addition students must be aware of the procedure for taking over DDA drugs, including
the registers to be maintained. They must be familiar with the ward/institutional policies
regarding broken ampoules of DDA/ Controlled Drugs, regulations governing the storage
of DDA/ Controlled drugs.

Students must be familiar with the contents of the Crash Cart especially the frontline
drugs that are stored in the top drawer of the cart. They must also be aware of which
medications are Stock/Proprietary on the ward.

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