In-Hospital Diabetes Practice Exam: Diabetes Chapter 16

Hyperglycemia in hospitalized patients—whether they have a history of diabetes or not—is a common and serious condition associated with increased morbidity, infection rates, and mortality. This exam tests your ability to apply the 2018 Clinical Practice Guidelines to the acute care setting, focusing on the shift away from “sliding scale” monotherapy toward proactive, physiologic insulin regimens.

Key Concepts Covered in This Exam:

Glycemic Targets: Differentiating targets for critically ill versus non-critically ill patients (e.g., maintaining preprandial glucose between 5.0–8.0 mmol/L for most non-critically ill patients).
Insulin Protocols: Understanding why scheduled basal-bolus-correction regimens are preferred over correction-only (sliding scale) insulin to prevent “glycemic rollercoasters”.
Perioperative Care: Managing glycemic control before, during, and after surgery to minimize infection risk and improve wound healing.
Safety & Monitoring: Identifying the correct frequency for blood glucose monitoring (e.g., every 1–2 hours for IV insulin) and strategies to prevent inpatient hypoglycemia.
Transition of Care: Reviewing best practices for discharge planning to ensure safe transitions back to community settings.

1. Case: A patient in the ICU is being transitioned from intravenous insulin to subcutaneous insulin. When should subcutaneous rapid-acting insulin be administered relative to discontinuing the IV insulin?

3 to 4 hours after IV insulin discontinuation
1 to 2 hours before IV insulin discontinuation
At the same time as IV insulin discontinuation
6 hours after IV insulin discontinuation

2. Case: A patient with type 2 diabetes is started on high-dose prednisone for an acute COPD exacerbation. What monitoring is recommended?

Weekly A1C measurements
No glucose monitoring is needed
Check fasting glucose only
Glycemic monitoring for 48 hours after initiation of steroids

3. Case: A diabetes educator is developing discharge instructions for a patient with diabetes. What essential information should be included?

Instructions to reduce the dose of all diabetes medications 1 week post-discharge
Only the medication list
Appointment with endocrinology only
Timing and frequency of home glucose monitoring, hypoglycemia management, reconciled medication list, and contact information for ongoing diabetes care

4. Case: A hospital wants to implement an inpatient diabetes self-management program. According to the guidelines, what should be considered for patients using CSII (insulin pump) therapy?

CSII is contraindicated in all hospital settings
CSII can be safely continued under certain circumstances with documented policies, assessment of self-management skills, and patient consent
No special considerations are needed for CSII patients
All patients on CSII should automatically switch to subcutaneous injections

5. Case: A patient with type 2 diabetes is being managed by a glycemic management team during hospitalization. What outcomes have been associated with timely consultation of such teams?

Higher rates of hypoglycemia
Increased length of hospital stay
No measurable impact on outcomes
Improved quality of care, reduced length of stay, and lower costs

6. In insulin-naive hospitalized patients, what is the typical starting dose of insulin per kilogram of body weight per day?

0.1 to 0.2 units/kg/day
0.2 to 0.3 units/kg/day
0.6 to 0.8 units/kg/day
0.4 to 0.5 units/kg/day

7. Case: A patient with type 1 diabetes is admitted to hospital and wants to continue using their insulin pump (CSII). What assessment should be performed to determine suitability?

No assessment is needed if the patient requests to continue
Only assess the patient’s blood glucose levels
Automatically discontinue pump therapy for all hospital admissions
Assessment of pump-specific self-management skills including basal rate adjustment, bolus administration, and infusion set insertion

8. Case: A hospitalized patient with diabetes is receiving continuous enteral feeding. How should their insulin be managed?

Only use long-acting insulin once daily
Use correction insulin only
Approximately 50% basal insulin and 50% bolus insulin divided to match feed times
Discontinue all insulin during enteral feeding

9. What interventions at the time of discharge have been associated with post-discharge reduction in A1C?

Arranging continuation of care, telephone follow-up, and communication with primary providers
Providing only medication names without dosing instructions
Stopping all diabetes medications at discharge
Discharging patients without any diabetes education

10. What blood glucose level should trigger modification of antihyperglycemic therapy in hospitalized patients?

≤3.0 mmol/L
≤3.9 mmol/L
≤3.5 mmol/L
. ≤4.5 mmol/

11. Case: A patient with poorly controlled type 2 diabetes is undergoing cataract surgery with moderate to severe nonproliferative diabetic retinopathy. What perioperative consideration is important?

Surgery should be cancelled until A1C is below 7%
Glycemic control has no impact on cataract surgery outcomes
Rapid institution of glucose control must be carefully considered due to possible increased risk of postoperative progression of retinopathy and maculopathy
Rapid institution of glucose control is always beneficial

12. What is the definition of in-hospital hyperglycemia according to Diabetes Canada guidelines?

Any glucose value >7.8 mmol/L
Any glucose value >7.0 mmol/L
Any glucose value >6.1 mmol/L
Any glucose value >10.0 mmol/L

13. Case: A patient’s parenteral nutrition is unexpectedly interrupted. What should be done to prevent hypoglycemia?

Start oral feeding immediately
Immediately give additional insulin
Nothing, hypoglycemia risk is low
Intravenous dextrose may be required depending on the last dose and type of insulin administered

14. When comparing insulin glargine vs. detemir as basal insulin in a basal-bolus program in hospitalized patients, what was found?

No difference in blood glucose levels or rates of hypoglycemia
Neither insulin should be used in hospitalized patients
Detemir resulted in significantly less hypoglycemia
Glargine resulted in significantly better glycemic control

15. What blood glucose range should be maintained for critically ill hospitalized people with diabetes?

8.0 to 12.0 mmol/L
4.0 to 6.0 mmol/L
6.0 to 10.0 mmol/L
4.5 to 8.0 mmol/L

16. What percentage of patients admitted to a community teaching hospital were found to have hyperglycemia?

48%
38%
28%
18%

17. What is a key factor that increases the risk of hypoglycemia in hospitalized patients?

Increasing corticosteroid dose
Starting parenteral nutrition
Sudden reduction in oral intake or discontinuation of parenteral/enteral nutrition
Increasing oral intake

18. Case: A patient with diabetes undergoing CABG surgery needs glycemic management. What method has been shown to prevent postoperative infections?

Oral antihyperglycemic agents
Correction subcutaneous insulin only
No glycemic management is needed during CABG
Continuous intravenous insulin infusion

19. Case: A clinical team is debating whether to use intravenous insulin for a patient post-acute stroke. Based on the evidence, what is the most appropriate conclusion?

IV insulin is always superior to subcutaneous insulin post-stroke
Evidence suggests there is no benefit to IV insulin over subcutaneous insulin post-acute stroke
IV insulin should never be used post-stroke
Only oral agents should be used post-stroke

20. Case: A 55-year-old person with type 2 diabetes is admitted for elective hip replacement surgery. The person is currently well-controlled on metformin and gliclazide. What is the most appropriate perioperative management?

Stop metformin 48 hours before surgery and continue gliclazide
Only use correction insulin if blood glucose exceeds 15 mmol/L
Continue all oral agents throughout the perioperative period
Consider discontinuing oral agents and initiating a basal-bolus insulin regimen

21. A diabetes educator is reviewing why correction-only (supplemental) insulin should be discouraged. What is the primary reason?

It only treats hyperglycemia after it has occurred and is associated with higher rates of hyperglycemia
It is not effective in hospitalized patients
It causes more hypoglycemia than basal-bolus regimens
It is more expensive than basal-bolus regimens

22. What percentage of the total daily insulin dose should be given as basal insulin when transitioning from IV to subcutaneous insulin in surgical patients?

90% to 100%
20% to 30%
60% to 80%
40% to 50%

23. Case: A diabetes educator is explaining to hospital staff why insulin is considered a high-alert medication. What approach should be used to reduce insulin administration errors?

Allow nurses to determine insulin doses independently
Avoid using insulin in the hospital setting
Verbal orders for insulin should be encouraged
A systems approach with pre-printed, approved, unambiguous standard orders and/or computerized order entry

24. A hospitalized person with type 2 diabetes requires more than 2 units of intravenous insulin per hour to maintain glycemic control. What does this suggest about the patient’s insulin needs?

The patient likely requires scheduled subcutaneous insulin therapy
The patient has insulin resistance and should be treated with oral agents
The patient should be discharged on diet therapy alone
The IV insulin rate should be reduced immediately

25. According to the guidelines, what is the preferred method for achieving glycemic control in hospitalized people with diabetes who are eating?

Scheduled basal, bolus, and correction (supplemental) insulin
Oral antihyperglycemic agents only
Correction (supplemental) insulin only
Sliding scale insulin only

26. What is the prevalence of corticosteroid-induced hyperglycemia among people without a previous history of diabetes?

60% to 80%
20% to 50%
10% to 15%
5% to 10%

27. What is the recommended intraoperative blood glucose target range for patients undergoing coronary artery bypass grafting (CABG)?

7.0 to 12.0 mmol/L
4.0 to 7.0 mmol/L
6.0 to 10.0 mmol/L
5.5 to 11.1 mmol/L

28. When intermediate- or long-acting insulin is used during the transition from IV to subcutaneous insulin, how long before IV discontinuation should it be administered?

1 hour prior
At the same time
2 to 3 hours prior
6 hours prior

29. What A1C threshold has been found to be highly specific for the diagnosis of dysglycemia in hospitalized patients

>6.0%
>6.5%
>5.5%
>7.0%

30. What type of insulin is preferred as the subcutaneous bolus and correction insulin in the hospital setting?

NPH insulin
Long-acting insulin analogues
Regular insulin
Rapid-acting insulin analogues

31. Case: A 68-year-old patient with newly discovered hyperglycemia during hospitalization has an A1C of 6.2%. What follow-up is recommended?

Repeat screening 6 to 8 weeks post-hospital discharge
Start insulin therapy immediately
Diagnose diabetes and refer to endocrinology
No follow-up needed as A1C is normal

32. Why should capillary blood glucose (CBG) point-of-care testing be interpreted with caution in critically ill patients?

Critically ill patients cannot provide finger-prick samples
CBG meters are not accurate at high glucose levels
CBG testing is contraindicated in the ICU
Poor perfusion indices may yield conflicting capillary, arterial, and whole blood glucose values

33. Case: A clinical team is evaluating the evidence for perioperative glycemic targets for minor and moderate surgeries. What is a reasonable target based on the guidelines?

10.0 to 15.0 mmol/L
4.0 to 6.0 mmol/L
No glycemic targets are needed for minor surgeries
5.0 to 10.0 mmol/L

34. A patient survey found that hospitalized patients with diabetes were more likely to be satisfied with their care under what circumstances?

When they were managed with oral agents only
When they had confidence that the team was knowledgeable about diabetes, presented a consistent message, and acknowledged them in their diabetes care
When they had no interaction with the healthcare team
When insulin was avoided entirely

35. How often should blood glucose be monitored for people on continuous intravenous insulin or those who are critically ill?

Every 2 to 4 hours
Every 4 to 6 hours
Every 1 to 2 hours
Every 30 minutes

36. How often should bedside blood glucose monitoring be performed in people who are NPO (nothing by mouth)?

Every 4 to 6 hours
Once daily
Every 1 to 2 hours
Every 8 to 12 hours

37. What are the recommended preprandial blood glucose targets for noncritically ill hospitalized people with diabetes?

4.0 to 6.0 mmol/L
8.0 to 12.0 mmol/L
5.0 to 8.0 mmol/L
6.0 to 10.0 mmol/L

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