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NCLEX endocrine and diabetes practice questions

20 free NCLEX-style endocrine questions: insulin peaks, hypoglycemia, DKA versus HHS, thyroid and adrenal crises and the water hormones, each with the answer and rationale.

Tap an answer to check it, or open "Show the answer and rationale" under each question. Every client is fictional. For exam practice only, not medical advice.

Question 1 of 20

A client with type 2 diabetes who takes glipizide every morning and acarbose with each meal is shaky and sweaty before lunch. The fingerstick reading is 61 mg/dL, and the client is alert and able to swallow. Which should the nurse give?

  1. Glucose tablets with 15 g of carbohydrate
  2. Glucagon 1 mg intramuscularly
  3. 4 oz (120 mL) of orange juice
  4. 1 tablespoon of table sugar dissolved in water
Show the answer and rationale

Answer: A

Acarbose blocks the intestinal enzymes that break down sucrose, so its label says sucrose is unsuitable for rapid correction of a low and that oral glucose (dextrose), whose absorption acarbose does not block, should be used instead. Juice is the usual choice for most clients, which makes it the runner-up, but part of its sugar is sucrose, so its effect is less reliable here. Table sugar is pure sucrose, and glucagon is for a client who cannot safely swallow. The reading is rechecked in 15 minutes.

📚 Learn it: Insulin Peaks: When the Client Will Crash

Question 2 of 20

A client admitted 2 days ago with hyperosmolar hyperglycemic state is receiving IV fluids and an insulin infusion. Which finding requires immediate follow-up?

  1. Measured sodium of 147 mEq/L, up from 142 mEq/L as the glucose fell
  2. Glucose of 236 mg/dL with dextrose added to the IV fluid
  3. Urine output of 45 mL/hr in a client who weighs 70 kg
  4. New swelling, warmth, and tenderness of the left calf since yesterday
Show the answer and rationale

Answer: D

HHS is a prothrombotic state: severe dehydration and high osmolality thicken the blood, and bed rest adds to the risk, which is why prophylactic anticoagulation is part of the plan. New swelling and tenderness of one calf suggests deep vein thrombosis and is reported for an ultrasound before a clot reaches the lungs. The rising sodium is the tempting choice, but as glucose falls, water moves back into cells and the measured sodium rises; a gradual fall in osmolality is what matters. A glucose of 236 mg/dL with dextrose running is on target, and 45 mL/hr is above 0.5 mL/kg/hr for 70 kg.

📚 Learn it: DKA Versus HHS: Ketones, Fluids and the Potassium Trap

Question 3 of 20

A client with months of fatigue, weight loss, darkening skin, and dizziness on standing is found to have both primary adrenal insufficiency and hypothyroidism. The blood pressure is 96/60 mm Hg. The provider prescribes oral hydrocortisone and levothyroxine. Which plan should the nurse follow?

  1. Hold the hydrocortisone until the thyroid level returns to normal
  2. Give hydrocortisone only on the days the client feels dizzy
  3. Give the hydrocortisone first, then add the levothyroxine
  4. Give the levothyroxine first and add hydrocortisone if the blood pressure stays low
Show the answer and rationale

Answer: C

Thyroid hormone speeds the metabolism and clearance of cortisol, so starting levothyroxine in a client whose adrenal glands cannot respond can set off an adrenal crisis with circulatory collapse. Cortisol is replaced first, or at the same time in an emergency, and thyroid hormone follows. Starting levothyroxine and adding hydrocortisone only if the pressure stays low is the tempting runner-up, but it waits for the crisis the plan should prevent. Waiting for a normal thyroid level leaves the adrenal insufficiency untreated, and replacement in primary adrenal insufficiency is daily and lifelong, not taken only on days with symptoms.

📚 Learn it: Thyroid, Adrenal and the Water Hormones

Question 4 of 20

A client with type 2 diabetes admitted 2 days ago with pneumonia is eating most of each meal. Home metformin is on hold, and the only insulin prescribed is insulin lispro by sliding scale before meals. Glucose readings have ranged from 232 to 314 mg/dL. Which change in the insulin plan should the nurse anticipate?

  1. Holding the lispro until the pneumonia has been treated
  2. A higher-dose sliding scale with glucose checks every 2 hours
  3. Scheduled basal insulin plus mealtime and correction doses
  4. A bedtime correction dose added to the current sliding scale
Show the answer and rationale

Answer: C

A sliding scale alone treats high glucose only after it happens and gives no background or meal coverage, and the ADA Standards of Care strongly discourage its sole use in the hospital; for a client who is eating, the preferred regimen has basal, prandial and correction components. A steeper scale or an added bedtime dose sounds like tighter control, which makes them the runners-up, but both are still reactive sliding-scale insulin, and holding the lispro would leave readings above 300 mg/dL untreated.

📚 Learn it: Insulin Peaks: When the Client Will Crash

Question 5 of 20

A client with type 2 diabetes and decreased sensation in both feet is reviewing foot care with the nurse. Which statement by the client indicates a need for further teaching?

  1. 'I'll test the water with my elbow before I wash my feet.'
  2. 'I'll wear clean, dry socks to bed if my feet feel cold at night.'
  3. 'I'll rub lotion on the tops and soles of my feet but not between my toes.'
  4. 'I'll soak my feet in warm water for 20 minutes every evening.'
Show the answer and rationale

Answer: D

Soaking strips the skin's natural oils and leaves it dry and prone to cracks that let infection in, so the feet are washed daily in lukewarm water and dried well rather than soaked; a client with neuropathy also may not feel water that is hot enough to burn. Testing the water with an elbow can sound like advice for bathing a baby, but it is correct, because the elbow still senses heat that numb feet cannot. Lotion goes on the feet but not between the toes, where moisture invites fungal infection, and socks at bedtime warm cold feet safely without a heating pad or hot water bottle.

📚 Learn it: DKA Versus HHS: Ketones, Fluids and the Potassium Trap

Question 6 of 20

A client with central diabetes insipidus started desmopressin nasal spray 1 week ago. The client calls the clinic to report a headache and nausea and says, 'I'm still drinking about 4 liters of water a day like before, just to be safe.' The client's weight is up 2.5 kg (5.5 lb) since the last visit. Which action should the nurse take?

  1. Limit water to 1 liter a day and keep using the spray as prescribed
  2. Keep drinking 4 liters a day, since the spray can cause dehydration
  3. Hold the next dose and come in today for a serum sodium level
  4. Take acetaminophen and call back if the headache lasts
Show the answer and rationale

Answer: C

Desmopressin replaces the missing antidiuretic hormone, so the kidneys now hold water. Drinking the large volumes needed before treatment dilutes the blood, and headache, nausea, and a 2.5 kg gain point to water retention with hyponatremia, which can progress to seizures, so the client holds the next dose and has the sodium checked today. Limiting water while continuing the spray is the runner-up: drinking only to thirst is the right teaching, but it leaves a possibly dangerous sodium unchecked. Desmopressin does not cause dehydration, and acetaminophen treats only the symptom.

📚 Learn it: Thyroid, Adrenal and the Water Hormones

Question 7 of 20

At 2100 a client has prescriptions for insulin glargine 18 units and a correction dose of insulin lispro 3 units for a glucose of 214 mg/dL. A nursing student says, 'I'll draw up the lispro first and then the glargine so the client only needs one injection.' Which response by the nurse is best?

  1. 'That's right, because the clear insulin is always drawn up first.'
  2. 'Draw up the glargine first so the long-acting insulin goes in last.'
  3. 'Mixing is fine as long as you inject it within 5 minutes of drawing it up.'
  4. 'Glargine is never mixed with other insulins, so give two shots.'
Show the answer and rationale

Answer: D

The glargine label says not to dilute or mix it with any other insulin or solution, so the two doses are given as separate injections. Agreeing with the student is the runner-up because it echoes a familiar rule, but drawing clear before cloudy applies to mixing regular insulin with cloudy NPH; glargine is itself a clear, colorless solution, which is part of why it gets mixed by mistake. Reversing the order does not make mixing acceptable, and neither does injecting quickly.

📚 Learn it: Insulin Peaks: When the Client Will Crash

Question 8 of 20

A client with DKA who weighs 165 lb has a prescription for a regular insulin infusion at 0.1 units/kg/hr. The pharmacy supplies regular insulin 100 units in 250 mL of 0.9% sodium chloride. At what rate should the nurse set the infusion pump? Round to the nearest tenth.

  1. 3.0 mL/hr
  2. 7.5 mL/hr
  3. 18.8 mL/hr
  4. 41.3 mL/hr
Show the answer and rationale

Answer: C

Convert the weight first: 165 lb ÷ 2.2 = 75 kg, and 75 kg × 0.1 units/kg/hr = 7.5 units/hr. The bag holds 100 units in 250 mL, or 0.4 units/mL, so 7.5 units/hr ÷ 0.4 units/mL = 18.75, rounded to 18.8 mL/hr. Setting 7.5 mL/hr is the common slip of treating units/hr as mL/hr, which works only for a 1 unit/mL bag. 41.3 mL/hr comes from skipping the pound-to-kilogram step (16.5 units/hr ÷ 0.4), and 3.0 mL/hr comes from multiplying by the concentration instead of dividing.

📚 Learn it: DKA Versus HHS: Ketones, Fluids and the Potassium Trap

Question 9 of 20

An 81-year-old client is admitted with myxedema coma after a fall at home. The client is drowsy, with a temperature of 94.6°F (34.8°C), a respiratory rate of 10 breaths/min, and a PaCO2 of 58 mm Hg, and grimaces when the bruised hip is moved. Which prescription should the nurse question?

  1. Levothyroxine IV instead of the usual oral tablet
  2. Morphine IV every 2 hours as needed for pain
  3. Dextrose 5% in 0.9% sodium chloride at 75 mL/hr
  4. Warm blankets for slow, passive rewarming
Show the answer and rationale

Answer: B

Myxedema coma blunts the drive to breathe in response to carbon dioxide, and this client is already hypoventilating with a PaCO2 of 58 mm Hg, so an opioid that further depresses breathing could cause respiratory arrest; the nurse asks for a safer pain plan. The change to IV levothyroxine is the runner-up because it departs from the client's home routine, but IV is the right route for an obtunded client who cannot swallow safely. Dextrose in saline treats the low glucose and low sodium this crisis often brings, and passive rewarming avoids the vasodilation and shock that active external heat can cause.

📚 Learn it: Thyroid, Adrenal and the Water Hormones

Question 10 of 20

A nurse reviews insulin prescriptions for four clients who are scheduled for procedures tomorrow morning and will be NPO after midnight. Which prescription should the nurse question?

  1. Type 2 diabetes: give insulin glargine 16 units tonight instead of the usual 20 units
  2. Type 2 diabetes: hold the breakfast dose of insulin lispro while NPO
  3. Type 2 diabetes: check glucose every 4 hours while NPO and give correction lispro by scale
  4. Type 1 diabetes: hold tonight's insulin glargine because of the NPO status
Show the answer and rationale

Answer: D

A client with type 1 diabetes makes no insulin, so basal insulin is still needed while fasting, and omitting it can lead to diabetic ketoacidosis. The reduced glargine dose is the runner-up because a dose cut can look like an error, but the ADA suggests giving 75% to 80% of a long-acting basal dose (or half of an NPH dose) before surgery so the fasting client does not go low, and 16 of 20 units is 80%. Mealtime lispro covers food, so it is held while NPO, and glucose checks at least every 2 to 4 hours with correction insulin are the standard plan.

📚 Learn it: Insulin Peaks: When the Client Will Crash

Practice 10 more Endocrine & diabetes questions free →

A timed or tutor-mode set in the app, scored by area, with every miss saved for review. Free, no sign-up needed.

Question 11 of 20

A client with untreated hypothyroidism is brought to the emergency department difficult to arouse, with a temperature of 94.1°F (34.5°C), a heart rate of 46 beats/min, a blood pressure of 86/50 mm Hg, and shallow respirations of 8 breaths/min. Which action should the nurse take first?

  1. Give the prescribed IV levothyroxine dose
  2. Infuse 0.9% sodium chloride for the hypotension
  3. Cover the client with blankets to rewarm slowly
  4. Prepare to support the client's breathing
Show the answer and rationale

Answer: D

Myxedema coma depresses the drive to breathe, and a respiratory rate of 8 with a decreased level of consciousness means the airway and ventilation must be supported first, often with intubation. IV levothyroxine is the definitive treatment and is given IV rather than by mouth to an obtunded client, which makes it tempting, but its effects take hours to days while hypoventilation threatens life now. Isotonic saline for the hypotension comes after breathing and is preferred over hypotonic fluid because hyponatremia often accompanies this crisis, and gradual rewarming with blankets is right, because aggressive external heat dilates peripheral vessels and can cause cardiovascular collapse, but it does not come before breathing.

📚 Learn it: Thyroid, Adrenal and the Water Hormones

Question 12 of 20

A client with hypothyroidism has a new prescription for levothyroxine and also takes a calcium carbonate supplement. Which statement by the client indicates understanding of the teaching?

  1. 'I can stop the levothyroxine once my energy level is back to normal.'
  2. 'I'll take the calcium an hour after my levothyroxine each morning.'
  3. 'I'll take levothyroxine with breakfast so it won't upset my stomach.'
  4. 'I'll take levothyroxine with water before breakfast and calcium at dinner.'
Show the answer and rationale

Answer: D

Levothyroxine is absorbed best on an empty stomach with water 30 to 60 minutes before breakfast, and calcium, iron and antacids bind it, so they are taken at least 4 hours apart, such as at dinner. Taking the calcium an hour later sounds careful, but it is still too close to block that binding. Taking levothyroxine with breakfast lowers its absorption, and hypothyroidism needs lifelong replacement even after symptoms improve.

📚 Learn it: Thyroid, Adrenal and the Water Hormones

Question 13 of 20

A nurse is reviewing sick-day rules with a client who has Addison's disease and takes hydrocortisone daily. Which statement by the client indicates understanding?

  1. 'If I have a fever, I'll take the extra dose I was taught and call my provider.'
  2. 'If my face gets round or I gain weight, I'll stop the hydrocortisone.'
  3. 'When I'm well again, I'll taper the extra dose off over a few weeks.'
  4. 'If I'm vomiting, I'll double my next tablet once I can keep it down.'
Show the answer and rationale

Answer: A

The adrenal glands cannot raise cortisol during physical stress, so clients increase the glucocorticoid dose during fever or illness as instructed, contact the provider, and keep injectable hydrocortisone for emergencies. Doubling the next tablet after vomiting sounds like the same sick-day rule, but vomiting prevents absorption of oral doses, so it calls for the emergency injection and urgent care. After a short illness the client returns to the usual dose as instructed rather than tapering over weeks, and replacement is lifelong and taken every day, because stopping it, even for side effects, can trigger an Addisonian crisis.

📚 Learn it: Thyroid, Adrenal and the Water Hormones

Question 14 of 20

A client who started methimazole for Graves' disease 6 weeks ago calls the clinic to report a sore throat and a temperature of 101.4°F (38.6°C). Which instruction should the nurse give?

  1. 'Take acetaminophen for the fever and call back if it lasts 3 days.'
  2. 'Keep taking it, because stopping it suddenly can bring on thyroid storm.'
  3. 'Hold your next dose and come in today for a blood count.'
  4. 'Keep taking it and come in today so we can do a throat culture.'
Show the answer and rationale

Answer: C

Methimazole can cause agranulocytosis, most often in the first months of therapy, and fever with a sore throat is the classic warning sign, so the client holds the drug and is seen the same day for a complete blood count with differential. Coming in today for a throat culture sounds thorough, but it keeps the client on the drug and misses the white cell count that matters. Treating the fever at home delays care for a possibly life-threatening infection, and a short hold while the count is checked is safer than taking more of the drug that may be causing the problem.

📚 Learn it: Thyroid, Adrenal and the Water Hormones

Question 15 of 20

A nurse reviews the diabetes medications prescribed for an 83-year-old client with chronic kidney disease and an eGFR of 28 mL/min/1.73 m². Which prescription should the nurse clarify with the provider?

  1. Glucagon 1 mg IM as needed for severe hypoglycemia
  2. Glyburide 5 mg by mouth every morning
  3. Linagliptin 5 mg by mouth once daily
  4. Insulin glargine 8 units subcutaneously at bedtime
Show the answer and rationale

Answer: B

Glyburide is a long-acting sulfonylurea with active metabolites that the kidneys clear, so in an older adult with an eGFR of 28 it can cause severe, prolonged hypoglycemia, and it is on the Beers list of drugs older adults should avoid. Linagliptin, a DPP-4 inhibitor, is cleared mainly through the bile and needs no dose change for kidney disease, and a modest dose of basal insulin with glucagon on hand for emergencies is a reasonable plan.

📚 Learn it: Insulin Peaks: When the Client Will Crash

Question 16 of 20

A nurse reviews the morning laboratory results for four clients. Which result should the nurse act on first?

  1. White blood cell count of 13,000/mm³ in a client on day 2 of antibiotics
  2. Creatinine of 4.1 mg/dL in a client with known stage 4 chronic kidney disease
  3. INR of 2.4 in a client taking warfarin for chronic atrial fibrillation
  4. Potassium of 3.1 mEq/L in a client with DKA receiving an insulin infusion
Show the answer and rationale

Answer: D

Insulin drives potassium into the cells, so a potassium of 3.1 mEq/L in a client receiving an insulin infusion for diabetic ketoacidosis can keep falling and cause life-threatening dysrhythmias; the nurse notifies the provider at once because current guidelines call for holding the insulin and replacing potassium until the level is at least 3.5 mEq/L. A creatinine of 4.1 mg/dL is expected in stage 4 kidney disease, and an INR of 2.4 is within the usual target of 2 to 3 for atrial fibrillation. A mildly elevated white blood cell count on day 2 of antibiotics is expected while the infection resolves.

📚 Learn it: DKA Versus HHS: Ketones, Fluids and the Potassium Trap

Question 17 of 20

A client with episodes of pounding headaches, sweating, and palpitations has a blood pressure of 228/128 mm Hg and elevated plasma metanephrines and is scheduled for adrenalectomy in 2 weeks. No medications have been started yet. Which item in the plan of care should the nurse question?

  1. A high-sodium diet with generous fluid intake
  2. No deep palpation of the abdomen during assessments
  3. Propranolol by mouth starting today for the palpitations
  4. Phenoxybenzamine by mouth, titrated to the blood pressure
Show the answer and rationale

Answer: C

In pheochromocytoma the tumor floods the body with catecholamines, and a beta blocker started before alpha blockade leaves the alpha receptors unopposed, so the vessels constrict further and a hypertensive crisis can follow; a beta blocker is added only after several days of alpha blockade, and only if tachycardia persists. An alpha blocker such as phenoxybenzamine is started first and titrated, and a high-sodium diet with generous fluids counters the volume contraction and orthostatic hypotension it causes. Deep palpation of the abdomen is avoided because pressing on the tumor can release a surge of catecholamines.

📚 Learn it: Thyroid, Adrenal and the Water Hormones

Question 18 of 20

An 84-year-old client who takes glipizide every morning ate little breakfast and became sweaty and confused, with a glucose of 54 mg/dL. Fifteen minutes after 4 oz of juice, the glucose is 98 mg/dL. Which action should the nurse take next?

  1. Give a snack with protein and carbohydrate and keep checking the glucose
  2. Give glucagon intramuscularly to prevent another low glucose
  3. Let the client rest quietly and recheck the glucose before the evening meal
  4. Resume the routine glucose checks before each meal and at bedtime
Show the answer and rationale

Answer: A

Glipizide keeps stimulating insulin release for many hours, so hypoglycemia can return once the juice is used up; the nurse follows the fast carbohydrate with a snack containing protein and complex carbohydrate and continues frequent glucose checks. Routine before-meal checks or a recheck at dinner can miss a recurrence, and glucagon is for a client who cannot swallow, not a preventive measure.

📚 Learn it: Insulin Peaks: When the Client Will Crash

Question 19 of 20

A client's diabetic ketoacidosis has resolved: pH 7.36, bicarbonate 20 mEq/L, and beta-hydroxybutyrate 0.4 mmol/L. The client is eating breakfast, and the provider prescribes subcutaneous basal insulin and discontinuation of the IV insulin infusion. Which action should the nurse take?

  1. Give the subcutaneous insulin before stopping the infusion
  2. Stop the infusion now and give the subcutaneous dose at bedtime
  3. Stop the infusion and wait until the glucose exceeds 250 mg/dL
  4. Continue the infusion until the urine tests negative for ketones
Show the answer and rationale

Answer: A

IV regular insulin wears off within minutes of being stopped, so the subcutaneous basal dose is given first and the infusion keeps running for the overlap period the protocol sets; stopping the drip before the long-acting insulin is working lets the glucose and ketones climb again. Waiting for hyperglycemia or delaying the dose until bedtime creates the same dangerous gap. Urine ketones can stay positive after the acidosis has resolved, so they are not used to decide when to stop the infusion.

📚 Learn it: DKA Versus HHS: Ketones, Fluids and the Potassium Trap

Question 20 of 20

A client who has taken prednisone 20 mg daily for 8 months for rheumatoid arthritis has been NPO for 2 days after bowel surgery, and the prednisone was not continued after surgery. The client is now weak and nauseated, with a blood pressure of 82/48 mm Hg and a glucose of 64 mg/dL. Which prescription should the nurse anticipate?

  1. IV ondansetron and a faster maintenance IV rate
  2. Oral prednisone 20 mg once the client tolerates liquids
  3. IV hydrocortisone with an isotonic fluid bolus
  4. A norepinephrine infusion titrated to the mean arterial pressure
Show the answer and rationale

Answer: C

Months of daily prednisone suppress the adrenal glands, so stopping it abruptly during the stress of surgery can cause adrenal crisis, with weakness, nausea, hypotension and hypoglycemia; treatment is IV hydrocortisone with isotonic fluid, plus dextrose for the low glucose. Waiting until the client can take oral prednisone delays a life-saving drug, and a vasopressor or an antiemetic treats the numbers without replacing the missing cortisol.

📚 Learn it: Thyroid, Adrenal and the Water Hormones

Practice 10 more Endocrine & diabetes questions free →

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