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

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

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

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

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

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

4. 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?

Normal tissue response; continue using the same site
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

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

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

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

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

7. 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
Concentrated insulin may be drawn from the pen into any syringe
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

8. 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?

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

9. 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
Alcohol swabs are mandatory before every injection
Disinfection is never required under any circumstances

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

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

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

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

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

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

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

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

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

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

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

16. Lipohypertrophy is best described as:

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

17. 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?

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

18. 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?

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

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

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

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

Upper arm
Thigh
Buttocks
Abdomen

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

5 seconds
15 seconds
20 seconds
10 seconds

22. 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 use the longest available needle
Teaching patients to inject through clothing for convenience

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

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

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

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

25. 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?

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

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

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

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

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

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?

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

29. 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?

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

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

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

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

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

32. 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?

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

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

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

34. 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
Needles may be reused up to 5 times safely
Reusing needles may increase risk of lipohypertrophy

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

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

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

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

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

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

38. 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?

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

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

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

40. 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

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