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Pharmacological and Parenteral Therapies

NCLEX Insulin and Diabetes Medication Practice Questions

Quick answer

Insulin and oral diabetes drugs show up in almost every NCLEX-RN form, usually as part of the pharmacology and safety items. Expect two to four questions per exam on insulin timing, mixing, hypoglycemia treatment, and side effects of the newer agents.

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Diabetes questions are rarely about memorizing onset and peak tables. The exam wants to know if you can keep a client safe when the tray is late, the pump is off, or the blood sugar reads 52 mg/dL and the client is slurring words. Most items test one decision: what do you do first, and what should you never do. The trap that catches a lot of students is reaching for a "treat it fast" answer that is actually unsafe, like giving juice to a client who cannot swallow, or holding insulin for a client who is sick and not eating. Read the stem for level of consciousness and for what the client can actually take by mouth before you pick an option.

Practice questions

1

A client with type 1 diabetes is prescribed insulin lispro 6 units subcutaneously before breakfast. The breakfast trays usually arrive at 0800. When should the nurse give the dose?

  1. AAt 0700, one hour before the tray arrives
  2. BAt 0745 to 0755, with the tray in sight
  3. CAt 0830, after the client finishes eating
  4. DAt 0600 with the morning vital signs
Show answer

Answer: B

Lispro is a rapid-acting insulin that starts working within 10 to 15 minutes, so it is given no more than 15 minutes before the meal, ideally when the food is actually on the unit. Giving it too early with no food available can drop the blood sugar before the client eats.

Why the others are wrong

Option A leaves a gap of up to an hour with active insulin and no carbohydrate. Option C misses the glucose rise from the meal, since lispro is meant to cover the food as it is absorbed. Option D is two hours before food and is the most dangerous timing of the four.

2

The nurse is preparing a dose of 10 units of regular insulin and 20 units of NPH insulin in one syringe. Which sequence is correct?

  1. ADraw up the NPH first, then the regular insulin
  2. BInject air into the regular vial, then the NPH vial, draw up NPH, then regular
  3. CInject air into the NPH vial, then the regular vial, draw up regular, then NPH
  4. DDraw each insulin into a separate syringe and inject them at different sites
Show answer

Answer: C

Air goes into the cloudy (NPH) vial first, then the clear (regular) vial, and the clear regular insulin is drawn up before the cloudy NPH. The phrase to remember is "clear before cloudy." This keeps the regular vial free of NPH, which would otherwise change its action.

Why the others are wrong

Option A reverses the draw-up order and contaminates the regular vial with NPH. Option B gets the air step backwards and the draw-up order backwards. Option D is not wrong for safety, but it is not the correct technique for a prescribed mixed dose and gives the client an extra injection.

3

A client on insulin glargine at bedtime asks the nurse to mix it with the lispro dose "so I only need one shot." Which response by the nurse is correct?

  1. A"I can mix them as long as I draw up the glargine first."
  2. B"Glargine cannot be mixed with any other insulin, so it needs its own syringe."
  3. C"They can be mixed if we give the injection within five minutes."
  4. D"Glargine can be mixed with lispro but not with NPH."
Show answer

Answer: B

Glargine is a long-acting insulin with an acidic pH. Mixing it with another insulin changes how both are absorbed, so it is always given alone in its own syringe, usually at the same time each day.

Why the others are wrong

Option A describes a mixing order that does not apply because glargine is never mixed. Option C invents a time rule that does not make the mixture safe. Option D is wrong because glargine is not compatible with lispro or NPH.

4

A client with diabetes is awake, sweaty, shaky, and anxious. The fingerstick glucose is 58 mg/dL. Which action should the nurse take first?

  1. AGive 4 ounces of orange juice and recheck the glucose in 15 minutes
  2. BGive 1 mg of glucagon intramuscularly
  3. CGive the scheduled lispro dose with a snack
  4. DCall the provider and wait for orders
Show answer

Answer: A

An alert client who can swallow gets 15 grams of fast-acting carbohydrate (4 ounces of juice or regular soda, or 4 glucose tablets), then a recheck in 15 minutes. Repeat if the glucose is still under 70 mg/dL. This is the "rule of 15."

Why the others are wrong

Option B is reserved for a client who cannot swallow safely; this client is awake. Option C gives insulin during hypoglycemia and makes it worse. Option D delays treatment of a problem the nurse can and should fix immediately.

5

The nurse finds a client with type 1 diabetes unresponsive in bed. Skin is cool and damp and the fingerstick glucose reads 34 mg/dL. Which action is correct?

  1. APlace glucose gel inside the cheek and monitor
  2. BGive glucagon 1 mg subcutaneously or intramuscularly and turn the client on the side
  3. CGive 8 ounces of juice slowly through a straw
  4. DGive regular insulin 2 units and recheck in 15 minutes
Show answer

Answer: B

An unconscious client cannot protect the airway, so nothing goes by mouth. Glucagon (IM or subcutaneous, or IV dextrose if access is available) is the treatment. Turning the client on the side matters because glucagon often causes vomiting as the client wakes.

Why the others are wrong

Option A and option C both put something in the mouth of a client who cannot swallow and risk aspiration. Option D adds insulin to a client who already has far too little glucose.

6

A client with type 1 diabetes calls the clinic with vomiting and a fever and says, "I have not eaten since last night so I skipped my insulin." Which instruction should the nurse give?

  1. A"That is correct, hold your insulin until you can eat normally."
  2. B"Keep taking your insulin, check your glucose every 3 to 4 hours, and sip fluids."
  3. C"Double your long-acting dose to cover the illness."
  4. D"Check your urine for ketones only if your glucose goes over 400 mg/dL."
Show answer

Answer: B

Illness raises counter-regulatory hormones, so blood sugar often climbs even when the client is not eating. Sick-day rules are to keep taking the basal insulin, check glucose every 3 to 4 hours, check urine ketones when glucose is above 240 mg/dL, drink fluids, and call if vomiting continues or ketones are moderate to large.

Why the others are wrong

Option A is the mistake that sends type 1 clients into DKA. Option C changes a dose without an order and risks hypoglycemia. Option D sets the ketone threshold too high; ketones should be checked at 240 mg/dL and above.

7

An older adult who lives alone is started on glipizide. Which teaching point is the highest priority?

  1. A"Take it with your evening snack to avoid stomach upset."
  2. B"Carry a fast sugar source with you, because this drug can drop your blood sugar."
  3. C"Expect some weight loss in the first month."
  4. D"Avoid dairy for two hours after each dose."
Show answer

Answer: B

Sulfonylureas like glipizide and glyburide push the pancreas to release insulin whether or not the client has eaten, so hypoglycemia is the main danger. Older adults, people who skip meals, and anyone with kidney problems are at higher risk, so they must know how to treat a low.

Why the others are wrong

Option A gives the wrong timing; glipizide is taken about 30 minutes before breakfast. Option C is backwards, since sulfonylureas tend to cause weight gain. Option D has no basis; there is no dairy restriction with this drug.

8

A client with type 2 diabetes was started on semaglutide (a GLP-1 agonist) two weeks ago. Which client report would the nurse expect and should address with teaching?

  1. ANausea and feeling full after small meals
  2. BFrequent urinary tract infections
  3. CSwelling of both ankles
  4. DHand tremors that worsen with activity
Show answer

Answer: A

GLP-1 agonists slow gastric emptying and reduce appetite, so nausea, early fullness, and sometimes vomiting or diarrhea are the common early effects. Teaching includes smaller meals, stopping eating when full, and reporting severe or persistent abdominal pain, which can signal pancreatitis.

Why the others are wrong

Option B is a known problem with SGLT2 inhibitors, not GLP-1 agonists. Option C is linked to thiazolidinediones like pioglitazone, which cause fluid retention. Option D is not an expected effect of this drug class.

9

A client taking empagliflozin (an SGLT2 inhibitor) is being discharged. Which statement shows the teaching was understood?

  1. A"I should drink plenty of water and tell my doctor if I get itching or discharge in the genital area."
  2. B"This medicine can cause my blood sugar to go very low, so I will eat every two hours."
  3. C"I need to avoid all exercise while on this medicine."
  4. D"I should cut my fluids to keep from urinating so often."
Show answer

Answer: A

SGLT2 inhibitors make the kidneys dump glucose into the urine. Sugar in the urine feeds yeast and bacteria, so genital yeast infections and urinary tract infections are common. The extra urine output can also cause dehydration and low blood pressure, so fluids should go up, not down.

Why the others are wrong

Option B overstates the risk; on their own, SGLT2 inhibitors rarely cause hypoglycemia. Option C is not a restriction with this class. Option D increases the risk of dehydration and acute kidney injury.

10

The nurse assesses a client on long-term insulin and finds a firm, rubbery, raised area on the right side of the abdomen where the client "always gives the shot because it doesn't hurt there." Which action is correct?

  1. AContinue using that site, since reduced pain shows good technique
  2. BTeach the client to rotate within one body area and keep injections at least 1 inch apart, and to avoid the lumpy area
  3. CMassage the area firmly after each injection to break up the tissue
  4. DTell the client to switch to the thigh for all future doses
Show answer

Answer: B

The area is lipohypertrophy, a buildup of fatty tissue from repeated injections in the same spot. Insulin absorbed from that tissue is unpredictable, which leads to swings in blood sugar. Rotate sites within the same region (the abdomen, for consistent absorption) about 1 inch apart and leave the thickened area alone until it resolves.

Why the others are wrong

Option A ignores erratic absorption; the area does not hurt because the tissue is damaged. Option C does not fix the problem and massage after injection changes absorption. Option D moves the client to a region with slower absorption and does not teach rotation, so the same problem will repeat.

Quick tips

  • Rapid-acting insulin (lispro, aspart, glulisine) goes in 15 minutes before food or with the first bite. If the tray is not there, do not give it yet.
  • Mixing order: air into NPH, air into regular, draw regular, then draw NPH. Clear before cloudy. Glargine and detemir are never mixed with anything.
  • For hypoglycemia under 70 mg/dL: 15 grams of fast carbohydrate if the client can swallow, recheck in 15 minutes, repeat if needed. Unresponsive client means glucagon or IV dextrose, nothing by mouth.
  • Beta blockers (metoprolol, propranolol) hide the shaky, racing-heart warning signs of a low. Sweating is usually still present, so teach these clients to check glucose rather than trust how they feel.
  • Match the side effect to the class: sulfonylureas cause lows and weight gain, GLP-1 agonists cause nausea and early fullness, SGLT2 inhibitors cause genital infections and dehydration, pioglitazone causes fluid retention.

Related topics

FAQ

How many insulin questions are on the NCLEX?

There is no fixed number, but insulin and diabetes drugs are one of the most common pharmacology themes. Most test takers see two to four items that involve insulin timing, mixing, hypoglycemia, or a newer oral or injectable agent. Expect them to be mixed in with safety and prioritization questions rather than labeled as pharmacology.

Do I need to memorize onset, peak, and duration for every insulin?

Know the four groups: rapid (15 minute onset, 1 hour peak), short or regular (30 minute onset, 2 to 3 hour peak), intermediate NPH (peak 4 to 12 hours), and long-acting glargine or detemir (no real peak). The exam uses peaks to ask when a client is most likely to go low, so link each peak time to a time of day.

What if a client on a beta blocker has a low blood sugar?

Treat it the same way, with 15 grams of carbohydrate or glucagon if unresponsive. The difference is in recognizing it. Beta blockers blunt the tremor and fast pulse, so the client may only notice sweating, hunger, confusion, or headache. Teach these clients to check glucose on a schedule instead of waiting for symptoms.

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