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 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
Infusion set may be left in place too long
Basal rate is too low; increase insulin delivery

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

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

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

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

4. 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

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

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

6. 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
Temperature of the buttocks is lower than other sites
There are fewer blood vessels in the buttocks
Muscle activity in the buttocks decreases absorption

7. 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

8. 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?

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

9. 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?

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

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

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

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

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

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

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

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

Buttocks
Upper arm
Abdomen
Thigh

14. 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
8-mm
6-mm
12-mm

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

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

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

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

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

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

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

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

19. 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
Lipohypertrophy does not affect insulin absorption
Insulin absorption is faster in lipohypertrophic tissue
Insulin absorption is variable and blunted in lipohypertrophic tissue

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

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

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

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

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

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

23. 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?

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

24. 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
8-mm needle without skin lift
12-mm needle with skin lift
4-mm needle with a skin lift

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

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

26. 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 longer lasting
They are less expensive
They cause less bruising because they are sharper

27. 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?

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

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

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

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

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

30. 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?

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

31. 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?

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

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

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

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?

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

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

Half the dose should be drawn when using a U-100 syringe
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

35. 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
The arm has more nerve endings causing pain
Difficulty accessing the correct zone

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

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

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

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

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

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

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

10 seconds
5 seconds
20 seconds
15 seconds

40. Lipohypertrophy is best described as:

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

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