Diabetes and Endocrine Nursing Questions for the Prometric Exam 2026: 20 MCQs with Answers on Insulin Types and Administration, Hypoglycaemia, DKA and HHS, Sick-day Rules, Foot Care, Gestational Diabetes, Ramadan Fasting, Thyroid, Adrenal and Pituitary Disorders

The Gulf has among the highest diabetes prevalence in the world, with roughly one in five adults affected in several states, so diabetes and endocrine nursing is weighted more heavily on Gulf papers than on NCLEX: expect 10 to 15 questions across the medical-surgical, pharmacology and maternal domains. The exam tests the safety rules (insulin, hypoglycaemia, DKA), patient education, and recognition of the endocrine emergencies. This set covers what recurs. Physicians sit a separate paper (endocrinology specialist questions).

Insulin

Question 1

A patient receives rapid-acting insulin aspart at 07:30 with breakfast. When is hypoglycaemia most likely, and what must the nurse ensure?

1. At midnight; give a bedtime snack
2. Within about 1 to 3 hours of the injection (onset 10 to 20 minutes, peak 1 to 3 hours, duration 3 to 5 hours); the nurse ensures the meal is actually eaten within 15 minutes of the dose, delays the dose if the meal is delayed, and knows that long-acting insulins (glargine, detemir, degludec) have no pronounced peak while NPH peaks at 4 to 12 hours
3. After 12 hours
4. Rapid-acting insulin never causes hypoglycaemia

Answer: B. Regular (soluble) insulin has onset 30 to 60 minutes and peak 2 to 4 hours, so it is given 30 minutes before meals; insulin is a high-alert medication requiring independent double checks and units written in full.

Question 2

Which insulin administration practice is correct?

1. Inject into the same spot each day for consistent absorption
2. Rotate sites within one anatomical region (abdomen for fastest absorption, then arms, thighs, buttocks), at least 2 to 3 cm from the previous injection, inspect for lipohypertrophy and avoid injecting into it, use a new 4 to 6 mm pen needle each time at 90 degrees without pinching in most adults, hold for 10 seconds, never share pens between patients, and store unopened insulin in the refrigerator with in-use pens at room temperature for up to about 28 days
3. Massage the site after injection
4. Inject into the thigh before exercise

Answer: B. Lipohypertrophy causes erratic absorption and unexplained glucose swings; injecting into an exercising limb accelerates absorption and hypoglycaemia.

Question 3

When mixing regular and NPH insulin in one syringe, the nurse should:

1. Draw up NPH first, then regular
2. Inject air into the NPH vial first, then into the regular vial, draw up the regular (clear) insulin first, then the NPH (cloudy), and administer within 15 minutes; glargine and detemir are never mixed with any other insulin
3. Shake the mixture vigorously
4. Mix glargine with regular insulin

Answer: B. "Clear before cloudy" prevents contamination of the short-acting vial with protamine; premixed insulins are rolled gently, not shaken.

Hypoglycaemia

Question 4

A conscious patient on insulin is sweating, trembling and confused with a glucose of 3.1 mmol/L. The nurse should:

1. Give the scheduled insulin and a meal
2. Give 15 to 20 g of fast-acting carbohydrate (glucose tablets, 150 to 200 mL of fruit juice or regular soft drink, or glucose gel), recheck glucose after 15 minutes and repeat if still below 4 mmol/L, then give a longer-acting carbohydrate snack or the meal once above 4, document the episode and review the cause and insulin dose with the prescriber
3. Give chocolate or milk as first choice
4. Wait for the next scheduled meal

Answer: B. Fat slows glucose absorption, so chocolate is not first line; hypoglycaemia unawareness develops after recurrent episodes and in long-standing disease.

Question 5

An unconscious patient with type 1 diabetes has a glucose of 1.8 mmol/L and no intravenous access. The nurse should:

1. Put glucose gel in the mouth
2. Protect the airway and position on the side, give glucagon 1 mg intramuscularly (or intranasal glucagon), call for help, establish intravenous access for 10% or 20% dextrose if there is no response within 10 to 15 minutes, recheck glucose, and give carbohydrate once able to swallow because glucagon's effect is short and it depletes glycogen stores
3. Give insulin to stabilise the patient
4. Wait for the patient to wake

Answer: B. Nothing is given by mouth to an unconscious patient; glucagon is less effective in malnourished patients, after alcohol and in liver disease.

Hyperglycaemic emergencies

Question 6

A 22-year-old with type 1 diabetes has vomiting, abdominal pain, Kussmaul breathing, glucose 28 mmol/L, ketones 5.2 mmol/L, pH 7.12 and potassium 3.4 mmol/L. The nurse's priorities in the first hour are:

1. An insulin bolus before any fluids
2. Rapid intravenous isotonic fluid resuscitation per protocol, potassium replacement in the fluids once the level is known (and holding insulin until potassium is above 3.3 to 3.5 mmol/L), then a fixed-rate intravenous insulin infusion (about 0.1 units/kg/h), hourly glucose and ketones, two-hourly electrolytes, strict fluid balance, cardiac monitoring, continuing the patient's basal insulin, and adding dextrose to fluids when glucose falls below about 14 mmol/L while insulin continues until ketosis resolves
3. Oral fluids and subcutaneous insulin
4. Bicarbonate infusion as first treatment

Answer: B. Potassium falls rapidly once insulin starts; cerebral oedema is the feared complication in young patients and presents with headache, falling heart rate and declining consciousness. The precipitant (infection, missed insulin, new diagnosis) is sought and treated.

Question 7

A 78-year-old with type 2 diabetes is brought in drowsy and profoundly dehydrated with a glucose of 48 mmol/L, serum osmolality of 345 mOsm/kg, minimal ketones and a normal pH. The condition and nursing considerations are:

1. DKA; identical management
2. Hyperosmolar hyperglycaemic state, which develops over days, carries a higher mortality than DKA and a high thrombosis risk; cautious fluid replacement guided by osmolality to avoid rapid shifts, lower-dose insulin only once glucose stops falling with fluids alone (or if ketonaemia is present), VTE prophylaxis, pressure area care, frequent neurological observations and careful search for the precipitant such as infection or a new drug
3. Hypoglycaemia
4. Normal for an elderly diabetic

Answer: B. Osmolality is calculated as 2 × sodium + glucose + urea; a fall of more than 3 to 8 mOsm/kg/h risks cerebral oedema and central pontine myelinolysis.

Question 8

Which sick-day advice should the nurse give a patient with type 1 diabetes who has gastroenteritis?

1. Stop insulin while not eating
2. Never stop basal insulin; check glucose every 2 to 4 hours and ketones when glucose is above 14 mmol/L or when unwell, take extra rapid-acting insulin for raised glucose and ketones per the sick-day plan, maintain fluids with sugar-free drinks (or sugary drinks if unable to eat), and seek urgent help for persistent vomiting, ketones above 1.5 mmol/L that do not fall, drowsiness or abdominal pain; patients with type 2 diabetes hold metformin and SGLT2 inhibitors while dehydrated or vomiting
3. Double all insulin doses automatically
4. Take oral agents instead of insulin

Answer: B. Illness raises counter-regulatory hormones and insulin needs even without eating; stopping insulin is the commonest cause of DKA.

Oral agents, targets and complications

Question 9

Which teaching is correct for a patient started on metformin?

1. It causes hypoglycaemia frequently when used alone
2. Take with or after meals to reduce gastrointestinal upset (which usually settles), it does not cause hypoglycaemia on its own, it is held before and for 48 hours after iodinated contrast and during dehydrating illness or acute kidney injury because of lactic acidosis risk, renal function is monitored and the dose adjusted or stopped at low eGFR, and vitamin B12 is checked periodically on long-term use
3. Take on an empty stomach
4. It must be stopped during Ramadan

Answer: B. Sulfonylureas (gliclazide, glimepiride) do cause hypoglycaemia, especially in the elderly and with missed meals; SGLT2 inhibitors cause genital infections, volume depletion and euglycaemic ketoacidosis, so they are held when unwell and before surgery.

Question 10

A patient asks what their HbA1c result means. The nurse explains:

1. It shows today's glucose level
2. It reflects average glucose over the previous two to three months; a general target of about 7% (53 mmol/mol) is individualised, with less stringent targets (7.5 to 8%) for older adults, those with hypoglycaemia risk or limited life expectancy, and tighter targets for some younger patients without hypoglycaemia; it is checked every three to six months, and conditions affecting red cell turnover (anaemia, haemoglobinopathies common in the Gulf) can make it unreliable
3. It should be below 5% in everyone
4. It replaces the need for any glucose monitoring

Answer: B. Continuous glucose monitoring metrics (time in range above 70%) are increasingly used alongside HbA1c, especially in type 1 diabetes.

Question 11

A patient with type 2 diabetes for 15 years has reduced sensation to the 10 g monofilament on both feet, a callus under the first metatarsal head and a small painless ulcer beneath it. The nurse's actions include:

1. Advise walking barefoot at home to toughen the skin
2. Recognise a high-risk neuropathic foot with an active ulcer, assess for infection and ischaemia (pulses, capillary refill, temperature), offload the ulcer, refer urgently to the multidisciplinary foot team or podiatry (within 24 hours for infected or ischaemic ulcers), and reinforce daily foot inspection, never walking barefoot, well-fitting footwear, moisturising but not between the toes, careful nail cutting, avoiding heat sources on the feet and prompt reporting of any wound
3. Apply a hot water bottle to improve circulation
4. Soak the feet daily in hot water

Answer: B. The Gulf has very high amputation rates from diabetic foot disease; annual foot screening and risk stratification are the prevention standards.

Question 12

Which annual screening and prevention measures does the nurse coordinate for a patient with diabetes?

1. HbA1c only
2. Retinal screening (dilated eye examination or retinal photography), urine albumin-to-creatinine ratio and eGFR, foot examination with risk classification, blood pressure and lipid review, HbA1c every three to six months, dental review, vaccination (influenza, pneumococcal, hepatitis B where indicated), smoking cessation, weight and lifestyle counselling, and screening for depression
3. Eye test only if vision changes
4. Kidney tests only after age 60

Answer: B. Diabetic retinopathy is a leading cause of blindness in working-age Gulf adults and is asymptomatic until late; ACE inhibitors or ARBs and SGLT2 inhibitors slow kidney disease.

Special situations

Question 13

A woman at 26 weeks' gestation is diagnosed with gestational diabetes. The nurse's education includes:

1. A severely carbohydrate-restricted diet
2. Self-monitoring of fasting and one-hour post-meal glucose with targets per the local protocol (commonly fasting below 5.3 mmol/L and one-hour post-meal below 7.8), a dietitian-led meal plan with controlled carbohydrate distribution, regular physical activity, metformin or insulin if targets are not met within one to two weeks, fetal growth scans, planning for delivery timing, and a postpartum glucose test at 6 to 12 weeks with lifelong screening because of the high risk of type 2 diabetes
3. No treatment, since it resolves after delivery
4. Oral sulfonylureas as first choice

Answer: B. Gestational diabetes affects up to a quarter of pregnancies in some Gulf populations; neonatal hypoglycaemia is monitored in the baby after birth.

Question 14

A patient with type 2 diabetes on gliclazide and metformin intends to fast during Ramadan. Evidence-based advice includes:

1. Fasting is forbidden for all diabetics
2. A pre-Ramadan risk assessment (very high-risk patients, such as those with recent DKA, severe hypoglycaemia or advanced complications, are advised not to fast), adjusting medication timing and dose (for example taking the sulfonylurea with iftar and reducing or omitting the suhoor dose), continuing metformin with meals, frequent glucose monitoring (which does not break the fast), breaking the fast if glucose falls below 3.9 mmol/L or rises above 16.7, avoiding heavy sugary iftar meals, maintaining hydration between sunset and dawn, and adjusting exercise timing
3. Stop all medication for the month
4. Take all daily medication at suhoor

Answer: B. The IDF-DAR guidelines are the reference; insulin users shift basal doses to the evening and reduce them, and SGLT2 inhibitors are taken with iftar with hydration advice.

Thyroid

Question 15

A patient with untreated Graves' disease develops a temperature of 40 °C, heart rate of 160 with atrial fibrillation, agitation and vomiting after an infection. The nurse recognises and anticipates:

1. Myxoedema coma; levothyroxine
2. Thyroid storm; ICU care with cardiac monitoring, cooling (paracetamol, not aspirin, which displaces thyroid hormone), beta blockers (propranolol) for rate control, antithyroid drugs (propylthiouracil or methimazole) followed at least an hour later by iodine, hydrocortisone, fluids and treatment of the precipitant
3. Sepsis only; antibiotics
4. Anxiety; reassurance

Answer: B. Thyroid storm carries a mortality of about 10%; agranulocytosis is the serious side effect of antithyroid drugs, so patients are told to report fever or sore throat immediately.

Question 16

An elderly woman with untreated hypothyroidism is found hypothermic (34 °C), bradycardic, hypotensive, hyponatraemic and barely conscious. The nurse anticipates:

1. Rapid rewarming with a hot bath and oral levothyroxine
2. Myxoedema coma; ICU care with airway support (hypoventilation and hypercapnia are common), intravenous levothyroxine (with liothyronine in some protocols), intravenous hydrocortisone until adrenal insufficiency is excluded, passive rewarming (active rewarming causes vasodilatation and collapse), cautious fluids, glucose monitoring and treatment of the precipitant; sedatives are avoided
3. Insulin for the low glucose
4. Fluid restriction alone

Answer: B. Hyponatraemia is corrected slowly; mortality remains high even with treatment.

Question 17

Twelve hours after a total thyroidectomy, a patient has tingling around the mouth, a positive Chvostek sign and a hoarse voice. The nurse should:

1. Reassure; these are expected effects of the anaesthetic
2. Check calcium urgently, notify the surgeon, prepare intravenous calcium gluconate for symptomatic hypocalcaemia from parathyroid injury, keep the airway equipment and clip removers at the bedside (laryngospasm and neck haematoma are the airway threats), assess the neck for swelling and the voice for recurrent laryngeal nerve injury, and position semi-upright with the head supported
3. Give oral calcium tomorrow
4. Give a sedative for anxiety

Answer: B. Hypocalcaemia peaks at 24 to 72 hours; bilateral recurrent laryngeal nerve injury causes stridor and airway obstruction.

Adrenal and pituitary

Question 18

A patient on long-term prednisolone for rheumatoid arthritis develops vomiting, hypotension (80/50 mmHg), hyponatraemia, hyperkalaemia and confusion after missing doses during a gastrointestinal illness. The nurse recognises and anticipates:

1. Gastroenteritis only; oral rehydration
2. Adrenal (Addisonian) crisis from steroid withdrawal; immediate intravenous hydrocortisone 100 mg, rapid intravenous isotonic saline, glucose monitoring and correction, treatment of the precipitant, and education on sick-day rules: never stop steroids abruptly, double the dose during illness, carry a steroid emergency card and injectable hydrocortisone, and wear medical identification
3. Insulin for the hyperkalaemia
4. Fluid restriction

Answer: B. Any patient on more than about 5 mg of prednisolone daily for over three weeks is at risk of adrenal suppression; perioperative stress-dose steroids are required.

Question 19

A patient with Cushing's syndrome from long-term steroid use is admitted for surgery. Which nursing considerations apply?

1. No special considerations
2. Fragile skin and easy bruising requiring careful handling and padding, impaired wound healing and infection risk with possibly masked fever, hyperglycaemia needing monitoring, hypertension and fluid retention, osteoporosis and fracture risk with falls precautions, muscle weakness, mood changes and insomnia, gastric protection as prescribed, and stress-dose steroid cover with no abrupt withdrawal
3. Encourage a high-sodium diet
4. Stop steroids on admission

Answer: B. Potassium may be low and glucose high; the moon face, central obesity, striae and proximal weakness are the recognisable features.

Question 20

Two days after pituitary surgery, a patient's urine output rises to 350 mL/h of pale urine with a specific gravity of 1.002, serum sodium of 149 mmol/L and intense thirst. Another patient after head injury has a sodium of 122 mmol/L, concentrated urine and no oedema. The conditions and nursing responses are:

1. Both have diabetes insipidus; fluid restriction for both
2. The first has diabetes insipidus (ADH deficiency): strict intake and output, hourly urine output and specific gravity, daily weight, free access to fluids or intravenous replacement as prescribed, serum sodium monitoring and desmopressin as prescribed, watching for fluid overload once treated; the second has SIADH (excess ADH): fluid restriction (commonly 800 to 1,000 mL/day), seizure precautions and neurological checks, sodium monitoring with slow correction, and hypertonic saline or vaptans only under close supervision for severe symptoms
3. Both have SIADH
4. Neither needs monitoring

Answer: B. Diabetes insipidus produces large volumes of dilute urine with rising sodium; SIADH produces small volumes of concentrated urine with falling sodium. A triphasic response can follow pituitary surgery.

How to practise

• Memorise the insulin profiles and the high-alert rules: double checks, units in full, clear before cloudy, never mix long-acting analogues.
• Learn the emergencies as sequences: hypoglycaemia (15/15 rule, glucagon), DKA (fluids, potassium, then insulin), HHS (cautious fluids), thyroid storm, myxoedema coma, adrenal crisis, DI versus SIADH.
• Know the education points: sick-day rules, foot care, annual screening, gestational diabetes targets and Ramadan adjustments.

Endocrine and metabolic chapters with explanations are in the Registered Nurse bank; related sets are the pharmacology questions, fluid and electrolyte questions, medical-surgical questions and maternal and newborn questions. The physician route for diabetes specialists is in the endocrinologist guide.

Frequently asked questions

How many diabetes and endocrine questions are in the Prometric nursing exam?

About 10 to 15 of 150, spread across the medical-surgical, pharmacology and maternal domains; Gulf papers weight diabetes heavily because of local prevalence.

Which diabetes nursing topics come up most?

Insulin profiles and administration, hypoglycaemia treatment, DKA priorities, sick-day rules, foot care and gestational diabetes.

Are questions on Ramadan and diabetes included?

Yes. Gulf authorities expect nurses to know the IDF-DAR principles for fasting patients.

Which endocrine emergencies do I need to know?

Thyroid storm, myxoedema coma, post-thyroidectomy hypocalcaemia, adrenal crisis, and the difference between diabetes insipidus and SIADH.

Are these real exam questions?

No. They are original practice questions written to the published blueprint. Real exam content is confidential.