FIT Injection Technique Practice Exam: Canada Guidelines

The efficacy of insulin therapy is only as good as the technique used to deliver it. The Forum for Injection Technique (FIT) Canada Recommendations emphasize that correct injection technique is just as critical as the type and dose of insulin prescribed. Poor technique can lead to unexplained hypoglycemia, glycemic variability, and long-term complications.

This practice exam tests your ability to apply the “Golden Rules” of injection, manage injection site complications like lipohypertrophy, and select the appropriate delivery devices for patients of all body types.

Key Concepts Covered in This Exam:

Needle Selection: Understanding the evidence supporting the use of 4 mm pen needles as the safest and most effective option for all adults and children, regardless of BMI, to avoid intramuscular (IM) injections.
Lipohypertrophy (LH): Mastering the detection and management of “lumpy” injection sites, acknowledging that injecting into LH can reduce insulin absorption by up to 25% and cause erratic glucose levels.
Structured Rotation: Applying correct rotation principles—spacing injections at least 1 cm (approx. width of a finger) apart and utilizing divided zones—to preserve tissue health.
Single Use: Reinforcing the strict recommendation that needles and syringes are single-use devices and must be discarded immediately to prevent tip deformation, infection, and lipohypertrophy.
Psychological Barriers: Addressing patient fears and anxiety regarding injections to improve adherence and comfort.

1. Case: A healthcare professional is teaching a parent how to inject insulin into their anxious 7-year-old child. What strategy would be most appropriate to reduce needle anxiety?

Use distraction therapy such as watching a favourite TV show
Perform the injection quickly without warning
Bribe the child with candy after each injection
Have multiple family members hold the child still

2. How often should all components of an insulin infusion set (insulin, reservoir, and tubing) be changed?

Every 10 days
Every 2-3 days
Every 5-7 days
Daily

3. A patient on insulin pump therapy develops unexplained hyperglycemia with ketones. After correcting with injection, what troubleshooting steps should be taken?

Assess the infusion set, tubing, and insulin reservoir
Disconnect the pump for 24 hours
Continue using the same infusion set and monitor
Increase basal rate and bolus more frequently

4. What is the strongest correlating factor in the development of lipohypertrophy according to research?

Injecting cold insulin
Using longer needles
Using insulin analogs
Lack of injection site rotation

5. What is the recommended distance between injection sites when rotating within an anatomical area?

At least 5 cm apart
At least 1-2 cm apart
At least 3-4 cm apart
At least 0.5 cm apart

6. Why might non-posted (contoured) pen needle designs be preferred over conventional posted-hub designs?

They may reduce the impact of unintended user pressure and reduce inadvertent IM injections
They are less expensive
They are longer lasting
They cause less bruising because they are sharper

7. Case: An adolescent with type 1 diabetes has poor glycemic control and admits to sometimes skipping insulin doses due to peer pressure. What is the recommended approach?

Increase insulin doses to compensate
Switch to oral medications
Discontinue diabetes management temporarily
Have parents become more involved in insulin administration

8. Case: A diabetes educator is developing a teaching plan for injection technique. According to the guidelines, what is the most critical educational priority?

Techniques to avoid intramuscular injection
Encouraging reuse of needles to reduce cost
Teaching patients to inject through clothing for convenience
Teaching patients to use the longest available needle

9. What effect does massaging the injection site immediately before or after injection have on insulin?

It has no effect on absorption
It reduces the risk of lipohypertrophy
It decreases absorption and prolongs insulin action
It increases absorption rate

10. According to FIT Canada, how should concentrated insulins (U-200, U-300, U-500) be handled regarding syringes?

Regular U-100 syringes may be used with dose adjustment
No pen-to-syringe transfer should occur as it could result in overdose
Half the dose should be drawn when using a U-100 syringe
Concentrated insulin may be drawn from the pen into any syringe

11. Why is the arm NOT recommended as a preferred self-injection site?

The arm is too vascular for safe injection
Insulin absorption is too slow in the arm
Difficulty accessing the correct zone
The arm has more nerve endings causing pain

12. Case: A child aged 5 requires insulin injections. What is the recommended needle length and technique?

12-mm needle with skin lift
4-mm needle with a skin lift
4-mm needle at 45-degree angle without skin lift
8-mm needle without skin lift

13. A patient asks why they should not reuse pen needles. What is the most appropriate response based on FIT recommendations?

Needle reuse only affects injection comfort
Reusing needles is acceptable if the needle is not bent
Reusing needles may increase risk of lipohypertrophy
Needles may be reused up to 5 times safely

14. A patient using an 8-mm needle asks about the correct injection technique. What is the appropriate instruction?

Inject at a 90-degree angle without a skin lift
Inject at a 90-degree angle into a skin lift
Inject at a 45-degree angle without a skin lift
The angle does not matter with 8-mm needles

15. In an institutional setting, what specific safety measure regarding injection devices is emphasized by FIT Canada?

Safety engineered devices should be used
Standard needles may be used if carefully handled
Insulin pens may be shared between patients if the needle is changed
Needles may be recapped if done carefully

16. What should be done if pen needles are left attached to the pen between injections?

This is acceptable practice
The needle may become sharper
Air or contaminants may enter the cartridge, affecting dose accuracy
This only affects the needle, not the insulin

17. A patient with type 2 diabetes expresses psychological resistance to starting insulin therapy. According to FIT recommendations, what is the most appropriate approach?

Delay insulin initiation until the patient is ready
Insist on immediate insulin initiation regardless of concerns
Prescribe anxiolytic medication before discussing insulin
Explore the patient’s anxieties and address concerns

18. Case: A patient using a GLP-1 receptor agonist pen asks if they need to prime the pen before each injection. What is the correct guidance?

Only prime prior to the first dose
Prime once weekly
Never prime GLP-1 receptor agonist pens
Yes, prime before every injection like insulin pens

19. Case: A patient with diabetes is switching from injecting into a lipohypertrophic site to a healthy site. What counseling should be provided?

Increase the insulin dose due to better absorption
Reduce insulin dose initially
Stop insulin therapy temporarily
Maintain the same insulin dose

20. What is the average skin thickness (epidermis and dermis) regardless of age, BMI, gender, or race?

Approximately 4.0 mm
Approximately 0.5 mm
Approximately 6.0 mm
Approximately 2.0 mm

21. Case: A patient using an insulin pump develops recurrent unexplained hyperglycemia and increased skin irritation at infusion sites. What is the likely issue and solution?

Use longer tubing to reduce irritation
Switch to injection therapy immediately
Basal rate is too low; increase insulin delivery
Infusion set may be left in place too long

22. What is the recommended storage temperature for unopened insulin vials and cartridges?

Any temperature below 30°C
Refrigeration temperature (2 to 8°C)
Room temperature only
Freezer temperature (-18°C)

23. Case: A patient reports unexplained hypoglycemic episodes despite consistent insulin dosing. Upon examination, you discover lipohypertrophic tissue at their usual injection site. What is the most likely explanation?

The patient requires a higher insulin dose
Insulin absorption is faster in lipohypertrophic tissue
Insulin absorption is variable and blunted in lipohypertrophic tissue
Lipohypertrophy does not affect insulin absorption

24. Case: A 4-month-old infant is diagnosed with neonatal diabetes requiring insulin therapy. What is the most appropriate infusion site consideration?

Infants cannot use insulin infusion therapy
Abdomen only due to consistent absorption
The arm is the preferred site in infants
The buttocks may be more suitable than the abdomen

25. Case: An elderly patient with cognitive impairment requires insulin therapy. What is the preferred delivery device according to FIT recommendations?

Reusable insulin pens
Disposable prefilled pens or memory pens with safety features
Vial and syringe for better dose accuracy
Insulin pump therapy

26. Case: A 55-year-old person with obesity (BMI 38 kg/m²) is initiating insulin therapy. They ask if they need a longer needle due to their body size. What is the most appropriate response?

A 4-mm needle is suitable regardless of BMI
Recommend a 12-mm needle
Only syringes should be used in patients with severe obesity
An 8-mm needle with a skin lift is required

27. When using cloudy insulin (NPH or premixed), what is the recommended technique for re-suspension?

Roll 5 times only
No mixing required
Shake vigorously 20 times
Gently roll 10 times, then tip 10 times

28. Case: A patient taking >50 units of regular or NPH insulin per injection asks about splitting the dose. What is the clinical rationale for this recommendation?

Splitting doses only reduces injection site pain
Larger doses have a longer, flatter action profile
Splitting is only necessary with insulin analogs
There is no benefit to splitting doses

29. What percentage of individuals with lipohypertrophy has been observed in international trials?

10-20%
80-90%
49-64%
25-35%

30. Case: An insulin pump user develops a “pump bump” (localized bump at insertion point) with redness. What is the most likely cause and recommended action?

Insulin allergy; switch to a different insulin brand
Movement of the infusion line transferred to the cannula; anchor tubing with tape and consider using antiseptic/barrier products
Insulin allergy; switch to a different insulin brand
Normal tissue response; continue using the same site

31. Case: A woman in her third trimester of pregnancy asks where she should inject her insulin. What is the most appropriate recommendation?

Upper arm exclusively
Lateral sides of the abdomen
Central abdomen only
Buttocks only

32. A healthcare professional asks about the proper technique for palpating injection sites to detect lipohypertrophy. What is the correct technique?

Use a pinch test at random locations
Palpate in a circular, sweeping motion using the fingertips
Visual inspection only is sufficient
Press firmly with the palm of the hand

33. Case: A clinical team is debating whether to use alcohol swabs before insulin injections in a community setting. Based on FIT guidelines, what is the correct recommendation?

Disinfection is generally not required
Alcohol swabs should only be used in hospital settings
Disinfection is never required under any circumstances
Alcohol swabs are mandatory before every injection

34. According to FIT Canada, what is the recommended pen needle length suitable for all people with diabetes, regardless of BMI?

4-mm, 5-mm, or 6-mm
12-mm
8-mm
6-mm

35. Research shows that after avoiding lipohypertrophic sites for 3-6 months, what outcome may be observed?

Lesions will become harder and more defined
Lesions may decrease by up to 50% in diameter
No change in lesion size
Lesions will spread to other areas

36. What is the minimum duration a patient should count after depressing the insulin pen injection dose knob before withdrawing the needle?

5 seconds
10 seconds
15 seconds
20 seconds

37. According to FIT Canada, which injection area offers the most consistent absorption of regular and NPH insulin?

Abdomen
Buttocks
Thigh
Upper arm

38. Case: A lean male patient (BMI 22 kg/m²) reports injecting into his thigh using a 6-mm needle at 90 degrees. He frequently experiences rapid-onset hypoglycemia. What is the most likely cause?

Inadvertent intramuscular injection
Injecting into lipohypertrophy
Insufficient insulin dose
Using the wrong insulin type

39. Case: A patient asks why injection into the buttocks results in slower insulin absorption. What is the scientific explanation?

There are fewer blood vessels in the buttocks
Temperature of the buttocks is lower than other sites
Muscle activity in the buttocks decreases absorption
The buttocks have the thickest subcutaneous layer of the injection areas

40. Lipohypertrophy is best described as:

An allergic reaction to insulin
A depression of the skin at injection sites
Skin discoloration at injection sites
Thickened or rubbery lesions under the skin from repeated injection

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