Ordre des infirmières et des infirmiers du Québec (OIIQ) NURSING EXAMINATION IN MONTREAL, QUEBEC, CANADA
PREPARATION GUIDE FOR QUEBEC NURSING EXAMINATION
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Mr. X, age 72, admitted for exploratory laparotomy under general anesthesia. Hx: Hypertension, diabetes, kidney failure and hx of sleep apnea. What assessment finding must you enter to the TNP?
Mr. X post-op, on PCA. Pain: 2/10, RR: 10, SpO2: 94% R/A, BP: 128/72, HR: 78, level of sedation: drowsy. What priority intervention you will do before leaving Mr. X's room?
hydromorphone (Dilaudid) 1mg/tab, 1 tab PO q 3-4 h PRN.
acetaminophen 325 mg/tab, 2 tabs PO 4-6 h PRN.
Last taken acetaminophen is in the morning and states ineffective.
Patient pain now is 5/10 and ask for an analgesics.
What other information must you collect to assess the effectiveness of the acetaminophen Mr. X has taken in the last 8 hours?
The patient refuse to take his prescribed opioid, what recommendation must you give him to help manange his pain better?
What will you reply when Mr. X's ex-wife to ask when he will be discharged?
1. Risk for respiratory depression.
1. Remove the PCA device.
1. How often he has taken the acetaminophen.
2. How many tablets he has taken.
3. When he took the last dose.
4. Pain at the peak action time of the medication.
1. Take the acetaminophen q 4-6 h regularly or before the pain is at more than 4/10.
Rationale: To prevent the pain from peaking or to maintain optimal serum levels.
Any answer that indicate that Mr. X information cannot be disclosed without the patients' agreement.
Mrs. X, age 35, gave birth at 38 weeks gestation to her second baby. She had an extended labor, receive epidural anesthesia and a 3rd-degree perineal tear. When you're doing your initial assessment UF is at 1/0 and has deviated to the right. The patient complaints of "severe cramping" pain in her lower abdomen and perineal pain and her first void was 100 ml.
Based on your assessment, what is her problem?
What are the possible causes of her problem?
You intervene on the patient's problem. Identify two signs that your intervention was effective?
The patient perineum has moderate edema and complains of pain at the area 4/10. You administer two pain medications but the patient would like to know if there are other non-pharmacological ways she could relieve her pain and take fewer analgesics. What will be your response?
What is the difference between cold and lukewarm sitz bath?
Mrs. X has anemia. The MD prescribed iron supplement. What recommendation you tell her to improve the absorption of her iron supplement?
What priority problem you will add to the patient's TNP?
PRIORITY PROBLEM OR NEED
1. Vaginal delivery at 38 weeks.
2. 3rd-degree perineal tear.
Distended bladder or urinary retention.
2.Receive epidural anesthesia
3.3rd degree perineal tear or perineal pain
4. Extra: Difficult delivery.
1. UF: 0/0 or at the umbilicus or below the umbilicus.
2. UF: no longer deviated to the right or is midline.
3. No evidence of distended bladder to the right.
1. Apply ice to the perineum.
2. Take cold sitz baths or perineal showers during the first 24 hours.
3. Take lukewarm sitz baths or perineal showers after the first 24 hours.
4. Contract the buttocks and pelvic floor muscles before sitting down, then release them when she is sitting down.
1. Cold sitz bath or ice decrease inflammation on the first 24 hours while lukewarm sitz bath stimulates blood flow and promote tissue healing.
1. Take iron supplement at least 1 hour before meals or between meals.
2. Take iron supplement 1 to 2 hours after meals.
3. Take iron supplement at mealtimes with water or juice.
4. Wait 1 hour before consuming dairy products or tea and coffee or foods containing wheat or oxalate.
5. Take iron supplement with vitamin C.
A primipara patient gave birth vaginally without anesthesia to a healthy 3.4 kg boy.
The patient asks "Apart from the fact that it doesn't hurt, how will I know if my baby has latched on properly", what will be your response?
What is the importance of latching properly apart from helping the baby to suck effectively?
Apart from the fact that the baby is gaining weight and the baby should be nursed on demand, what will you tell the patient about two other signs that will indicate that her baby is getting enough milk?
Why does a breastfed baby can feed more frequently than a formula-fed baby?
The patient is reluctant to have her newborn vaccinated. She is concern about the dangers of vaccination. She states that vaccines can cause autism and breastfeeding can protect her baby. What information you will tell the patient for her to have an informed decision about whether or not to have her baby vaccinated.
The patient heard a lot about Sudden Infant Death Syndrome (SIDS) and the baby should always be placed on its back to sleep to prevent this problem. Give four recommendations on how to prevent Sudden Infant Death Syndrome.
The patient told you that her sister's newborn had developed jaundice. She then asks you how can she tell that her newborn develops jaundice apart from having the skin turning into yellow.
What is your advice to her sister with a newborn who developed a physiological jaundice?
1. The baby takes in a large part of the areola.
2. The baby opens its mouth very wide.
3. The baby's chin touches the breast and its nose remains clear.
4. The baby's lips are flanged outwards.
5. There are no smacking sounds during nursing.
6. The baby doesn't have dimples or its cheeks are not hallow when it nurses or its cheeks are rounded when it nurses.
1. To prevent or minimize injuries, such as cracked nipples.
2. Allows the baby to compress the mother's milk sinuses effectively.
1. Wet at least 1 diaper a day up to the 5th day, then at least 6 diapers a day.
2. Has at least 2 to 4 substantial very soft and seedy stools a day.
3. The integumentary system is well hydrated: skin and mouth.
4. Nurses at least 8-12 times in a 24-hour period.
5. Is vigorous during waking periods.
1. Breast milk is easier for a newborn to digest than commercial infant formula.
1. The vaccine can have side-effect but, in most cases, they are benign and short-lived.
2. Vaccination offers protection against diseases that could have severe complications.
3. Many studies have shown that there is no connection between vaccination and autism.
4. Breastfeeding does not protect against the diseases targeted by vaccination.
1. Have the baby sleep on a firm, flat surface.
2. Continue breastfeeding.
3. Do not use pillows, comforters, stuffed toys and bumper pads in the baby's bed.
4. Do not allow the baby to sleep in the same bed as its parents or with its brothers and sisters.
5. Have the baby sleep in its own bed in the parents' bedroom.
6. Provide a smoke-free environment.
1. Yellowish color of the sclera.
2. Increased drowsiness or periods of sleep.
3. Decreased numbers of feeds.
1. Expose her newborn to daylight.
2. Breastfeed her baby more often.
A 2-year-old female patient transferred to the Emergency Room to your unit due to bronchospasm which happened to be the 3rd time for the same type of problem. The child presents with moderate xiphoid, subcostal and lower intercostal retractions and an occasional dry cough. On auscultation, wheezing is present. O2 sat is 92% on R/A. The mother states the child has difficulty sleeping and that she has been tired than usual over the past few days.
What other signs and symptoms you must assess about her respiratory condition?
Question 2: child weight 12kg
Prednisolone (Pediapred) 12 mg qd
Salbutamol (Ventolin HFA) 2 mg in 3 ml of NS via nebulizer
Fluticasone (Flovent HFA) 125 mcg/puff, 2 puffs bid via spacer + mask
02 via nasal prongs at 1.5 L/min
Treatment was started in the Emergency Room. The patient mother asks you that her child breathing has improved, but is restless and doesn't want to go to sleep.
What is the explanation of the change in the child's behaviour?
The mother is worried about the medication side effects and thinks that her child is taking too many medications.
What will you tell the mother of the child to alleviate her fear?
The mother asks you why it is important to continue the Flovent even if my daughter is feeling much better?
Should inhaled corticosteroids be tapered at the end of the prescribed treatment yes or no, why?
The child mother is worried about the possible effects of the inhaler medication on her child's growth, what will you tell her?
1. Audible breath sounds
2. Suprasternal or supraclavicular retractions
3. Use of accessory muscles of the neck or abdomen for breathing.
4. Nasal flaring
5. Peripheral cyanosis
6. Altered LOC
7. Inability to say 2 or 3 words without becoming short of breath.
9. Obstruction of nasal passage by nasal secretion or discharge from nasal passages.
1. Side effect of the medication: salbutamol (Ventolin HFA)
1. Reassure the mother that the side effects are only temporary.
2. Tell her that the dose prescribed is based on the child's weight.
1. The mechanism of action of inhaled corticosteroids is slow and gradual.
2. Even if there are no signs, there is still inflammation in the respiratory tract. It is, therefore important to respect the recommended length of treatment.
3. Corticosteroids therapy must be completed, i.e., administered as prescribed, to reduce any residual inflammation and thereby prevent further upper respiratory tract infections from causing a more severe episode of bronchospasm.
No, since the systemic effects are minimal.
1. Inhalers had little systemic absorption, little risk of slowing down growth.
2. Prescribed dose is low
A female 4 y/o patient is hospitalized for fever of unknown etiology and humerus fracture. During physical examination v/s are normal, multiple bruises noted with different shape, size, and color. You notice that the patient avoid eye contact and is withdrawn. Her mother states "The child trip over a toy and fall" while the father explains that her child is clumsy and she fall off her bike.
What is the care priority in this situation of probable child abuse?
What is a possible charge to the nurse if suspected abuse is not reported?
Write up a progress note regarding the situation. Include four items of information that you consider essential.
Enter one nursing directive to the TNP:
Priority problem or need
Probable physical abuse
1. Report possibility of abuse to the unit head (head nurse), assistant head nurse, doctor or social worker.
2. Report the situation to Child Protection Service (CPS).
Important information on the progress notes must include:
1. The patient and child behavior, described objectively, without any judgment or interpretation.
2. Any exchanges between the nurse, the child or the parents, recorded objectively and verbatim.
3. Any objective signs and the observation made during the child's examination.
1. Monitor signs of violence or abuse.
2. Observe the difference in the child's behaviour when the parents are there and when they are gone.
Mr. X age 50 hospitalized due to relapse of ulcerative colitis.
Intake: IV-400 ml, PO-200 ml
Output: Urine-400 ml, Stool-6 liquid, blood tinged, Vomit-0
-Dextrose 5% + NaCl 0.45% 1000 ml + 20 mEq KCl IV at 100 ml/h
-Electrolytes and hb ht qd
-Low residue diet
-Hydromorphone (Dilaudid) 1 mg/ml, 2 ml SC q 3-4 h PRN
-Methylprednisolone (Solu-medrol) 40 mg/ml, 1.5 ml IV q 6h
What priority intervention must you carry out following your analysis of Mr. X's fluid balance?
Enter one nursing directive to the TNP:
Priority problem or need
Relapse of ulcerative colitis
What should be monitored on the patient's stool?
What explanation will you give to Mr. X why methylprednisolone 4mg tablets should be taken in the morning?
The patient states that during ostomy care, the smell is disgusting a reason why he doesn't want to participate. Give 3 recommendations to prevent offensive odors.
Identify foods that help to combat odor?
Identify foods that increase odor or flatulence?
Enter one nursing directive on the TNP:
Priority problem or need:
Refusal to perform ostomy care
1. Adjust the infusion flow rate to 100 ml/h.
1. Notify nurse if signs of dehydration.
2. Appearance or color
1. So that it coincides with the body's natural rhythm of cortisol secretion.
1. Change the appliance every 5-7 days or PRN if it leaks.
2. Empty the bag when 1/3 full.
3. Use a bag with a filter.
4. Avoid foods that produce a foul odor or gas.
5. Use products that reduce odor (M9).
8. Carbonated beverages
10. Sparling wine
1. Nurse to explore psychological aspects of wearing an ostomy appliance (body image, self-esteem,and sexuality) during ostomy care.
A 24 y/o male patient is admitted to your unit due to pneumothorax and has a chest tube on continuous suction. During your assessment, the patient told you: "I drink two beers a day and 1 case every weekend with my friends. It relaxes me at the end of the day and helps me sleep but I wake up 3 to 4 times a night." But when her mother visited she told you that her son drinks a lot more alcohol than he says and has done so regularly since he was 15.
What information will you give the patient about the effect of alcohol consumption on the quality of his sleep?
Apart from relaxation, what priority recommendation you must give to your patient to improve his sleep?
Enter one nursing directive to the TNP:
Priority problem or need
Risk of withdrawal
Identify S/S of alcohol withdrawal?
Approximately how many hours the symptoms of alcohol withdrawal usually develops after the patient stop or reduce his alcohol intake?
Three days after admission the patient has not shown nay signs of withdrawal. Write up a progress note.
The nursing assistant informs you that the patient has no appetite; his trays are untouched.
Weight on admission:52 kg
Weight 3 months ago: 63 kg
Height: 1.80 m
Albumin: 28g/L (normal range: 35 to 50 g/L)
Based on this information, what new assessment finding you will enter in the TNP?
What other health care professional must you involve in the patient's care after your findings?
Identify the vitamins needed to metabolize alcohol?
What are the signs that indicate malnutrition in the patient's case?
Alcohol interferes with sleep quality because it shortens the phases of deep sleep and increases periods of wakefulness.
Reduce alcohol intake or stop drinking alcohol.
Notify nurse if signs and symptoms of alcohol withdrawal (dir. to orderly's work plan)
1. Tremor or trembling
2. Disorientation or confusion
3. Irritability or aggression or anxiety
4. Insomnia or nightmares
5. Psychomotor agitation
7. Eats little or nothing
8. Nausea, vomiting, and diarrhea
1. 4-12 hours
Date and time: No signs of withdrawal in the past 3 days.
sign and title
1. Malnutrition or nutritional deficiency
1. Dietitian or nutritionist
1. Vitamin B
2. Vitamin C
1. Weight loss (more than 17% in the past 3 months)
2. Body mass index of 16
3. Albumin level is low
A 42 y/o male underwent right hemicolectomy 3 days ago rings the bell complaining of 7/10 abdominal pain. He feels bloated, nauseous, and says he belches frequently. His abdomen is distended and has not had a bowel movement since his surgery. Percussion reveals tympany and v/s are all stable.
What do you suspect the patient's problem?
What must you carry out to complete your abdominal assessment?
What is the normal frequency of bowel sounds per minute?
Where should you auscultate on the illustration below?
What is the late sign of ileus that the patient manifest?
Abdominal assessment is done in this manner Inspection, Auscultation, Percussion, and Palpation. What is the main reason why palpation is done last?
Should the patient resume oral diet, yes or no?
In the evening, the patient refuses to get up because he says he has intestinal gas and feels uncomfortable. What will you tell the patient to encourage him to mobilize?
The patient has an infusion of NaCl 0.45% with dextrose 5%, 1000 ml + 20 mEq running at 30ml/h. The doctor ordered ceftriaxone 750mg IV in 30 minutes. On hand, a 1000 mg vial to be diluted with 9.8 ml of sterile water, after the dilution the vial has a total of 10 ml to be mix with 100 ml infusion fluid. Your drip factor on the tubing is 15gtts/min.
1. What volume will draw from the vial to obtain the prescribed dose?
2. What flow rate (drops per minute) will you set the infusion at the respect the administration time?
Apart from checking the medical prescription, medication, dose, route and time against the medication record and patient identity. Identify two additional verifications you must carry out before you start to administer the medication?
1. What are the signs of infiltration?
2. What are the signs of phlebitis?
1. Paralytic ileus or absence of peristalsis
1. Auscultate to check for the presence or absence of bowel sounds
2. Palpate the abdomen to check for rigidity or pain
3. Assess if the patient is able to expel intestinal gas
1. 4-34 irregular bowel sounds per minute
1. Absence of bowel sounds
1. It will alter peristalsis and is painful
1. No, until peristalsis return
1. Mobilization will help expel the intestinal gas and relieve his discomfort.
1. 7.5 ml
750 mg x 10ml = 7.5 ml
2. 54 drops/minute or 50 drops/minute
Flow rate = 108 ml x 15 drops = 54 drops/minute or 50 drops/minute
30 mins ml
1. Check for allergy to ceftriaxone
2. Check the needle insertion site (infiltration or phlebitis)
-Pain or burning
-Localized redness or swelling
-Vein is hard and cord like
You found your 75 y/o male patient lying on the floor who underwent transurethral resection of the prostate (TURP) yesterday. You note that the bed is at the lowest position and that all 4 side rails are up. The patient is delirious. Physical exam and v/s are all normal. You put him back to bed.
What priority action you must take immediately to prevent your patient from having another fall?
Identify one administrative intervention you must carry out?
What should you include when writing a progress note regarding this incident?
At night the patient is very agitated and delirious, he tries to pull out his urinary catheter and IV line. You decide to put a wrist restraint since all the measures done to him are ineffective.
In the morning the patient is sleeping quietly and her daughter just arrived to stay with the patient. The daughter states "I'm worried seeing my father this way, he has always been lucid". Patient's v/s are all normal.
Will you remove the restraint? Yes or No
Give two reasons to explain your decision?
How often should you assess the behaviour of the patient who is on restraint?
Restraint should be use as last resort because it interferes what right?
1. Lower the bed rails or lower one of the bed rails (leg area)
2. Write up an incident/accident report
1. Describing all the detail of the fall
2. The patient's condition
3. Any intervention carried out to reduce or prevent consequences
1. The patient is calm
2. A member of his family is present and can watch him closely
1. At least every hour
1. Right to freedom
This morning a 70 y/o male patient underwent right nephrectomy, who is currently on hydromorphone (Dilaudid) 1mg/ml, 1 ml SC administered in the right arm for pain. During your evening shift, the patient woke up, incoherent and having visual hallucinations. He is unable to follow simple instructions, agitated and disoriented to 2 spheres (time and place). His v/s are all normal.
After assessing the patient's mental status:
Enter one priority problem or need and one nursing directive in the TNP.
Apart from fall, what will be the effect of raising all bed rails to the patient in this scenario (according to Ministere de la Sante et des Service sociaux )?
What factors likely contributes to the patient's altered mental status?
You received a report that the patient is very drowsy and that his face is pale. When you check the patient, you notice that his extremities are cold and his diaphoretic. You attempted to wake him up but remains stupor. V/s are: BP 85/65, P 124/min., reg., R 32/min., irreg. and shallow, SpO2 95% R/A. Urine output last hour is 15ml pink urine.
What else must you check to complete your assessment?
Is the patient urine color normal? Yes or no.
Identify two priority interventions to carry out before calling the doctor?
The next day the patient condition has improved and was started on a light diet with oral liquids restricted to 1.5 L/day.
Previous intake and output record is; intake 4000 ml, output 820 ml. Concerned about the patient's hx of left-sided heart failure, you are afraid that he will develop circulatory overload.
What signs and symptoms you will ask the nursing assistant to report to you concerning the risk of circulatory overload?
1. Signs of postoperative delirium
-Nurse to assess higher mental functions or mental status q 4h
-Notify nurse if patient will become agitated or if signs of deterioration of mental status (dir. to PAB work plan)
1. Risk of fall
-Keep one or both bed rails lowered at all times (dir. to orderly's work plan)
1. Agitation 2. Delirium 3. Fear
1. Side effects of opioid analgesics
2. Side effects of anesthetic products
3. Hospitalization or unfamiliar environment
4. Postoperative situation
1. Check for bleeding at the surgical site or in the patient's bed
1. Yes pink urine is common after this type of surgery
1. Administer oxygen as per collective order
2. Cover the patient to maintain body heat
1. Paroxysmal nocturnal dyspnea or SOB or orthopnea
4. Decreased O2 saturation
6. Audible adventitious breath sounds
You're a nurse in a senior's residence working with a 70 y/o patient who just arrive one week ago due to mobility problems and loss of autonomy. Medical hx: Heart failure. Patient's current medications are; Digoxin, ramipril, furosemide, pravastatin and ASA. V/S: BP-110/70, P-60, R-18.
Will you give the patient's Digoxin? Yes or No. Why?
A few days later, the patient states that she felt a little short of breath than usual especially when lying down. Her V/S: BP-95/55, P-112, R-22, SPO2-95% on R/A.
Identify other signs that would indicate a deterioration of the patient's condition?
This morning the patient complains of fatigue, dizziness, muscle weakness and altered color perception.
-Na: 135 mmol/L (normal 135-145 mmol/L)
-K: 3.4 mmol/L (normal 3.5-5.0 mmol/L)
-Cl: 99 mmol/L (normal 100-106 mmol/L)
-Digoxemia: 2.6 mmol/L (normal range: 1.0-2.6 mmol/L)
Will you give the patient's digoxin?
Explain your decision?
A week later, the patient suddenly collapsed in her chair while holding her chest. She is unconscious, no pulse, and doesn't respond to stimuli. You called 911, placed her on a firm surface and ask for an automated external defibrillator.
Identify the first 3 priority interventions you must carry out in a chronological order?
Yes, V/S are stable (Pulse is 60/min)
1. Leg edema
2. Distended jugular veins
3. Pink, frothy sputum
4. Presence of crackles on auscultation
5. Slow capillary refill: >2 or 3 sec.
No, the patient is showing signs and symptoms of digoxin toxicity
1. Start chest compression
2. Open the patient's airway
3. Give rescue breaths
An 83 y/o female patient who's been living in a nursing home for a few months, the patient has a poor appetite. Today, she went out to for an activity, despite the hot weather. When she returns home, she feels nauseous, dizzy, tired, and weak. Additional assessments noted that the patient is incoherent, dyspneic, and her lips are cracked. V/S: BP 90/60, P 102, R 24, T 37.6 .
Based on your assessment, what is the patient's problem?
What other signs must you check to complete your assessment regarding the patient's problem?
Three days later, the patient's daughter comes to visit. She is worried that her mother doesn't recognize her. You learned that the patient didn't participate in this afternoon activity and ate very little. She stayed in her room , saying she felt very tired. Assessment reveals a dry and unproductive cough. V/S: BP 130/80, P 108/min, R 24/min, rectal T 37.8 C
What health problem could explain the change in the patient's condition?
What are the signs and symptoms that confirm your answer in question number 3?
The following month your home care is offering flu vaccine. When offered the patient, she states "I don't want the vaccine, I don't see any point since it made me sick before."
1. Decreased skin turgor over the forehead or sternum.
2. Dry mouth or absence of saliva.
3. Thickened tongue or longitudinal grooves on the tongue.
4. Disoriented in all 3 spheres: time, person and place.
1. The presence of an infectious process or respiratory infection.
1. Increased in rectal temperature.
2. Increased heart rate.
3. Increased respiratory rate.
1. Benefits of the vaccine.
2. Risks associated with the vaccine.
3. Dangers of the flu virus for older adults.