Endo Exam 3: STUDENT DKA

Case: A 67-year-old admitted with pneumonia has type 2 diabetes and no A1c in the past 3 months. Who should get an A1c on admission?
A) Only patients with new-onset hyperglycemia
B) All admitted patients with diabetes, or patients with random BG >140 mg/dL, if no A1c from the past 3 months exists
C) Only patients in the ICU
D) Only patients on insulin

B

Case: A patient admitted with a random BG of 195 mg/dL is not on insulin at home. When should insulin be started in the hospital?
A) BG 140 mg/dL or higher
B) BG 180 mg/dL or higher
C) BG 200 mg/dL or higher
D) BG 250 mg/dL or higher

B

Case: A critically ill patient in the ICU. What is the ADA 2026 glucose goal for most patients?
A) 80-140 mg/dL
B) 100-180 mg/dL
C) 140-180 mg/dL
D) 70-110 mg/dL

A. Use 100-180 mg/dL for noncritically ill patients

Case: A noncritically ill patient on the medical floor. What is the ADA 2026 glucose goal, if achievable without significant hypoglycemia?
A) 80-140 mg/dL
B) 100-180 mg/dL
C) 140-180 mg/dL
D) 70-110 mg/dL

B

Case: A patient in hospice with a short life expectancy. Which patient can have a higher glucose goal, up to 250 mg/dL?
A) A healthy 45-year-old on basal insulin
B) A patient in hospice with a short life expectancy
C) A newly admitted patient with BG 150 mg/dL
D) A patient in the ICU on IV insulin

B. Higher goals also apply to advanced CKD, high hypoglycemia risk, and labile glucose

Case: A hospital adopts the NICE-SUGAR trial’s intensive protocol. Which target range was used in the intensive arm?
A) 80-110 mg/dL
B) 140-180 mg/dL
C) 100-180 mg/dL
D) 180-250 mg/dL

A. The conventional arm was 140-180 mg/dL

Case: A hospital reviews the NICE-SUGAR results for intensive control. What did the trial find?
A) Lower mortality
B) Significantly higher mortality, with severe hypoglycemia of 6.8% vs. 0.5% with conventional control
C) No difference in hypoglycemia
D) Shorter hospital stays

B. Length of stay did not differ significantly

Case: A nurse sees a floor patient with a BG of 165 mg/dL. How is inpatient hyperglycemia defined?
A) BG >140 mg/dL
B) BG >200 mg/dL
C) BG >250 mg/dL
D) BG >180 mg/dL only in the ICU

A

Case: A patient with hyperglycemia develops a longer ICU stay and a new infection. Which outcomes are linked to hyperglycemia?
A) Lower infection rates and shorter stays
B) Higher morbidity and mortality, more infections, and longer hospital and ICU stays
C) No association with outcomes
D) Improved wound healing only

B

Case: A patient with sepsis is on dexamethasone and receiving TPN. Which factors cause inpatient hyperglycemia?
A) Nutrition status, organ dysfunction, stress hyperglycemia in critical illness, surgery, and medications
B) Diet alone
C) Insulin use alone
D) Alcohol use alone

A

Case: An NPO patient with no food intake has rising glucose while on TPN. Why do NPO patients still need glucose coverage?
A) NPO patients have no glucose-raising factors
B) Enteral feeds or TPN can raise glucose, and dextrose in TPN is a major cause
C) NPO patients always have low glucose
D) Dextrose lowers glucose

B

Case: A patient is admitted after a hemorrhage with rising glucose. What triggers stress hyperglycemia?
A) Hypoxia, hemorrhage, sepsis, and surgery
B) Hypothermia only
C) Dehydration only
D) A low-carbohydrate diet

A

Case: A patient in septic shock has rising glucose. Which mechanisms drive stress hyperglycemia?
A) Increased cortisol, glucagon, gluconeogenesis, glycogenolysis, and catecholamines, with insulin resistance
B) Decreased cortisol and glucagon
C) Increased insulin sensitivity
D) Decreased gluconeogenesis

A

Case: A patient on a long-term steroid course has rising glucose. Which medications raise glucose?
A) Glucocorticoids, fluoroquinolones, CNIs, beta blockers, and atypical antipsychotics
B) Metformin
C) Insulin
D) Aspirin

A

Case: An asymptomatic patient has a BG of 62 mg/dL. How is hypoglycemia defined, and what is its main concern?
A) BG <70 mg/dL, associated with increased mortality
B) BG <100 mg/dL, with no clinical concern
C) BG <50 mg/dL only
D) BG <90 mg/dL, associated with weight gain

A

Case: A patient with kidney failure has a low BG after a steroid dose was suddenly reduced. What are common inpatient causes of hypoglycemia?
A) Insulin dosing or administration errors, improper prescribing of other glucose-lowering drugs, poor follow-up after a first episode, kidney failure, sudden steroid dose reduction, and reduced oral intake or vomiting
B) Exercise only
C) A high-protein diet only
D) Metformin only

A

Case: A patient is eating meals on the floor. What is the monitoring frequency?
A) Every 4-6 hours
B) Point-of-care BG before meals
C) Once daily
D) Every 30 minutes

B

Case: A patient is not eating and is on the floor. What is the monitoring frequency?
A) Before meals
B) Every 4-6 hours
C) Every 12 hours
D) Only at bedtime

B

Case: A patient is on an IV insulin infusion. How often should BG be checked?
A) Every 4 hours
B) Every 30 minutes to 2 hours
C) Once daily
D) Every 8 hours

B

Case: A hospital has a patient with a BG of 65 mg/dL. What must the hospital have in place?
A) A standardized hypoglycemia protocol, with every episode documented, including the cause and what helped
B) Nothing; treatment is at nurse discretion
C) A glucagon kit only
D) Insulin dose reduction only

A

Case: An asymptomatic, responsive patient who can swallow and is not NPO has a BG of 60 mg/dL. What is the treatment?
A) 50% dextrose 25 g IV push
B) Glucagon 1 mg IM
C) 15-20 g oral carbohydrate (tablet, juice, or gel); slow onset
D) 100 mL IV saline

C

Case: A 67-year-old admitted with pneumonia has type 2 diabetes and no A1c in the past 3 months. Who should get an A1c on admission?
A) Only patients with new-onset hyperglycemia
B) Only patients in the ICU
C) Only patients on insulin
D) All admitted patients with diabetes, or patients with random BG >140 mg/dL, if no A1c from the past 3 months exists

D

Case: A patient admitted with a random BG of 195 mg/dL is not on insulin at home. When should insulin be started in the hospital?
A) BG 180 mg/dL or higher
B) BG 140 mg/dL or higher
C) BG 200 mg/dL or higher
D) BG 250 mg/dL or higher

A

Case: A critically ill patient in the ICU. What is the ADA 2026 glucose goal for most patients?
A) 100-180 mg/dL
B) 140-180 mg/dL
C) 80-140 mg/dL
D) 70-110 mg/dL

C

Case: A noncritically ill patient on the medical floor. What is the ADA 2026 glucose goal, if achievable without significant hypoglycemia?
A) 80-140 mg/dL
B) 140-180 mg/dL
C) 70-110 mg/dL
D) 100-180 mg/dL

D

Case: Which patient can have a higher glucose goal, up to 250 mg/dL?
A) A patient in hospice with a short life expectancy
B) A healthy 45-year-old on basal insulin
C) A newly admitted patient with BG 150 mg/dL
D) A patient in the ICU on IV insulin

A

Case: A hospital adopts the NICE-SUGAR trial’s intensive protocol. Which target range was used in the intensive arm?
A) 140-180 mg/dL
B) 80-110 mg/dL
C) 100-180 mg/dL
D) 180-250 mg/dL

B

Case: A hospital reviews the NICE-SUGAR results for intensive control. What did the trial find?
A) Lower mortality
B) No difference in hypoglycemia
C) Shorter hospital stays
D) Significantly higher mortality, with severe hypoglycemia of 6.8% vs. 0.5% with conventional control

D

Case: A nurse sees a floor patient with a BG of 165 mg/dL. How is inpatient hyperglycemia defined?
A) BG >200 mg/dL
B) BG >250 mg/dL
C) BG >140 mg/dL
D) BG >180 mg/dL only in the ICU

C

Case: A patient with hyperglycemia develops a longer ICU stay and a new infection. Which outcomes are linked to hyperglycemia?
A) Higher morbidity and mortality, more infections, and longer hospital and ICU stays
B) Lower infection rates and shorter stays
C) No association with outcomes
D) Improved wound healing only

A

Case: A patient with sepsis is on dexamethasone and receiving TPN. Which factors cause inpatient hyperglycemia?
A) Diet alone
B) Insulin use alone
C) Alcohol use alone
D) Nutrition status, organ dysfunction, stress hyperglycemia in critical illness, surgery, and medications

D

Case: An NPO patient with no food intake has rising glucose while on TPN. Why do NPO patients still need glucose coverage?
A) NPO patients have no glucose-raising factors
B) NPO patients always have low glucose
C) Enteral feeds or TPN can raise glucose, and dextrose in TPN is a major cause
D) Dextrose lowers glucose

C

Case: A patient is admitted after a hemorrhage with rising glucose. What triggers stress hyperglycemia?
A) Hypothermia only
B) Hypoxia, hemorrhage, sepsis, and surgery
C) Dehydration only
D) A low-carbohydrate diet

B

Case: A patient in septic shock has rising glucose. Which mechanisms drive stress hyperglycemia?
A) Decreased cortisol and glucagon
B) Increased insulin sensitivity
C) Decreased gluconeogenesis
D) Increased cortisol, glucagon, gluconeogenesis, glycogenolysis, and catecholamines, with insulin resistance

D

Case: A patient on a long-term steroid course has rising glucose. Which medications raise glucose?
A) Metformin
B) Insulin
C) Glucocorticoids, fluoroquinolones, CNIs, beta blockers, and atypical antipsychotics
D) Aspirin

C

Case: An asymptomatic patient has a BG of 62 mg/dL. How is hypoglycemia defined, and what is its main concern?
A) BG <100 mg/dL, with no clinical concern
B) BG <70 mg/dL, associated with increased mortality
C) BG <50 mg/dL only
D) BG <90 mg/dL, associated with weight gain

B

Case: A patient with kidney failure has a low BG after a steroid dose was suddenly reduced. What are common inpatient causes of hypoglycemia?
A) Exercise only
B) A high-protein diet only
C) Metformin only
D) Insulin dosing or administration errors, improper prescribing of other glucose-lowering drugs, poor follow-up after a first episode, kidney failure, sudden steroid dose reduction, and reduced oral intake or vomiting

D

Case: A patient is eating meals on the floor. What is the monitoring frequency?
A) Point-of-care BG before meals
B) Every 4-6 hours
C) Once daily
D) Every 30 minutes

A

Case: A patient is not eating and is on the floor. What is the monitoring frequency?
A) Before meals
B) Every 12 hours
C) Only at bedtime
D) Every 4-6 hours

D

Case: A patient is on an IV insulin infusion. How often should BG be checked?
A) Every 4 hours
B) Once daily
C) Every 30 minutes to 2 hours
D) Every 8 hours

C

Case: A hospital has a patient with a BG of 65 mg/dL. What must the hospital have in place?
A) Nothing; treatment is at nurse discretion
B) A standardized hypoglycemia protocol, with every episode documented, including the cause and what helped
C) A glucagon kit only
D) Insulin dose reduction only

B

Case: An asymptomatic, responsive patient who is NPO has a BG of 60 mg/dL. What is the treatment?
A) 50% dextrose 50 mL (25 g) IV push
B) 15-20 g oral carbohydrate
C) Glucagon 1 mg IM
D) Oral juice

A

Case: A symptomatic or nonresponsive patient has a BG of 45 mg/dL. What is the preferred treatment?
A) Oral juice
B) Glucagon only
C) Wait 15 minutes and recheck
D) 50% dextrose 50 mL (25 g) IV push, fast onset, preferred route

D

Case: A patient with hypoglycemia has no IV access. What is the treatment option?
A) 50% dextrose IV
B) Glucagon 1 mg IM, an option but not commonly used due to cost and sometimes not stocked
C) Oral glucose only
D) Insulin

B

Case: A hospitalized patient has hyperglycemia. What is the preferred treatment?
A) Metformin
B) Sulfonylurea
C) Insulin
D) SGLT-2 inhibitor

C

Case: A critically ill patient in the ICU needs glucose control. What is the most effective insulin regimen?
A) Continuous IV regular insulin, with fast onset and offset, requiring constant glucose monitoring
B) Sliding scale alone
C) Oral metformin
D) Once-daily glargine

A

Case: A patient on the medical floor needs insulin. What is the preferred regimen?
A) Sliding scale alone
B) Oral glipizide
C) IV insulin drip
D) Scheduled subcutaneous insulin

D

Case: A patient with poor oral intake needs insulin on the floor. When is basal or basal plus correctional bolus preferred?
A) Only in DKA
B) When eating full meals
C) Poor oral intake or NPO status
D) Only for hypoglycemia

C

Case: A floor team plans sliding scale insulin as the only insulin. Is this recommended?
A) Strongly discouraged; it can be used only as correction on top of basal and bolus
B) Yes, as first-line therapy
C) Yes, for all ICU patients
D) Only at discharge

A

Case: A team uses sliding scale insulin for a patient. What must be in place?
A) Nothing
B) Metformin
C) Oral glucose only
D) A hypoglycemia protocol, per ADA 2026

D

Case: An NPO patient outside DKA has a BG of 210 mg/dL. When should continuous IV insulin be used?
A) Only when eating normally
B) Hyperglycemic patients who are NPO or have BG ≥180 mg/dL, or critically ill patients on continuous TPN
C) Only when BG is under 100 mg/dL
D) Only for outpatient use

B

Case: A hospital plans continuous IV insulin for a patient outside DKA. Where is this typically limited?
A) Clinics
B) Outpatient infusion centers
C) Home care
D) ICU or higher-acuity units, due to monitoring and nursing needs

D

Case: A patient is admitted on home oral diabetes medications. Which oral agents should be avoided while inpatient?
A) Insulin glargine
B) Acarbose
C) Metformin, meglitinides, sulfonylureas (especially glyburide and glimepiride), and SGLT-2 inhibitors
D) Acetaminophen

C

Case: A stable inpatient is eating a normal diet and is not in the ICU. When can oral agents be continued?
A) Always
B) Only if the patient is stable, eating a normal diet, and not in the ICU
C) Only in the ICU
D) Only after discharge

B

Case: A patient on prednisone (a short-acting steroid) has hyperglycemia. How is it managed?
A) IV regular insulin drip
B) Metformin alone
C) Stop all insulin
D) NPH insulin given with the steroid, on top of daily basal-bolus or oral agents

D

Case: A patient on dexamethasone (a long-acting steroid) has hyperglycemia. How is it managed?
A) NPH insulin only
B) Sliding scale alone
C) Long-acting insulin
D) Oral sulfonylurea

C

Case: A patient is switched to a higher steroid dose. How should insulin be handled?
A) Stop insulin
B) Increase prandial and correctional insulin
C) Decrease insulin
D) Switch to metformin

B

Case: A critically ill patient needs insulin. Why is continuous IV insulin preferred?
A) Because it is cheaper
B) Because it is easier to give
C) Because it is the fastest route for home use
D) It can achieve specific goals and avoid hypoglycemia, not because it is easier or cheaper

D

Case: A patient is scheduled for elective surgery. What is the A1c goal before surgery?
A) <8%, whenever possible
B) <6.5%
C) <10%
D) <7%

A

Case: A patient is NPO after surgery. What is the BG goal within 4 hours of surgery, and how often should BG be monitored while NPO?
A) 80-110 mg/dL; every hour
B) 140-200 mg/dL; once daily
C) 100-180 mg/dL; every 2-4 hours
D) 70-140 mg/dL; every 12 hours

C

Case: A patient on metformin and an SGLT-2 inhibitor is scheduled for surgery. What happens to each drug?
A) Continue metformin; stop the SGLT-2 inhibitor on the day of surgery
B) Hold both for 1 week
C) Continue both
D) Hold metformin on the day of surgery; stop the SGLT-2 inhibitor 3-4 days before surgery

D

Case: A patient has several home oral agents and is scheduled for a procedure. When should the other oral agents be held?
A) One week before
B) The morning of surgery or procedure
C) Never
D) After surgery

B

Case: A patient on NPH and long-acting insulin is scheduled for surgery. How should home insulin be adjusted?
A) Double the NPH dose
B) Stop all insulin
C) 50% of NPH dose, 75-80% of long-acting analog dose, and adjust pump basal rates
D) Give the full home dose

C

Case: A patient has surgical stress hyperglycemia after a major operation. How long can it last?
A) 1-2 days
B) 30 days
C) Indefinitely
D) 9-21 days after surgery

D

Case: PC is NPO after surgery. What does his chart suggest about his glucose risk?
A) Hyperglycemia risk only
B) Hypoglycemia risk from NPO status, not hyperglycemia
C) No glucose risk
D) DKA risk only

B

Case: PC is acutely ill and NPO after surgery. Which home medications should not be restarted while he is acutely ill?
A) Lantus only
B) Aspirin
C) Metformin and glipizide
D) Atorvastatin

C

Case: PC is on an IV insulin drip in the ICU and is NPO. Why should he stay on the drip instead of switching to SC meal insulin?
A) IV insulin is cheaper
B) SC insulin is contraindicated in all ICU patients
C) He is eating normally
D) He is acutely ill and NPO, so IV insulin continues until stable

D

Case: PC’s glucose is rising in the ICU. What is raising it?
A) Oral metformin
B) IV dexamethasone
C) Hypoglycemia

B

Case: A nurse needs to convert an IV insulin drip to SC insulin. The drip used 30 units over the last 6 hours. What are the conversion steps?
A) Sum units over the last 6 hours, multiply by 4 for total daily dose, take 60-80% of TDD, split 50% basal and 50% bolus, and divide bolus by 3 for meals
B) Multiply the 6-hour total by 2 and give as bolus only
C) Stop the drip and give 100% of the 6-hour total as SC
D) Sum units over 24 hours and give the full amount as basal

A. Here 30 × 4 = 120 units TDD, so 60-80% is 72-96 units.

Case: A team is switching a patient from an IV drip to SC insulin. What is the overlap rule?
A) Stop IV insulin immediately
B) Continue IV insulin for at least 2-4 hours after starting SC insulin
C) Continue IV insulin for 24 hours
D) No overlap is needed

B. This follows the inpatient lecture; see the discrepancy card.

Case: An insulin-naive patient needs SC insulin on the floor. How should therapy start?
A) 1 unit/kg/day
B) 2 units/kg/day
C) 0.3-0.6 units/kg/day
D) 0.1 unit/kg/day

C

Case: An insulin-experienced patient is ready to transition off the hospital regimen. How should they transition?
A) Always switch to metformin
B) Always switch to glargine only
C) Always switch to sliding scale
D) Usually return to their prior home regimen

D