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10 free Paramedic practice questions: Advanced Diabetic and Endocrine Emergencies

These are real questions from the same bank the app draws from. Each one is written to the NREMT Paramedic content specifications and kept inside the Paramedic scope of practice. Pick an answer and you get the full rationale, including why the other three options are wrong.

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Question 1 of 10

A 47-year-old patient with type 1 diabetes is confused and combative. A family member says the patient was completely normal 20 minutes ago. The skin is pale, cool, and moist, and breathing is quiet and unlabored. The vital signs are BP 132/84, P 116, R 16, and SpO₂ 98% on room air. Neither glucometer on the truck will power on. Which action best fits this patient?

Show the answer and rationale

Correct answer · Treat for hypoglycemia, since the onset was fast and the skin is moist

When you cannot get a glucose reading on an altered diabetic patient, you treat for hypoglycemia. Neither glucometer on this truck will power on. If the patient is actually high, a dose of sugar changes very little, because a high sugar has been building for hours or days. If the patient is actually low, holding the sugar lets the low cause permanent brain injury while you wait. This patient also looks hypoglycemic. The family member says the patient was completely normal 20 minutes ago. The skin is pale, cool, and moist, and the breathing is quiet and unlabored. Hyperglycemia comes with warm, dry skin and deep breathing. Neither of those findings is here.

Why the others are wrong

Treat as a postictal state and transport without glucose correction: A postictal patient can be confused and combative, and an unwitnessed seizure is always possible. A postictal state clears slowly on its own. Hypoglycemia can cause a seizure too. Skipping the sugar is the one move that can turn a fixable problem into a permanent one.

Treat for hyperglycemia with fluid, since the skin findings fit either: Fluid is the treatment for a hyperglycemic emergency. This patient went from normal to combative in 20 minutes, with pale, cool, moist skin. Those findings fit hypoglycemia. A hyperglycemic crisis does not develop in 20 minutes while a family member watches.

Withhold sugar until a reading confirms which problem this is: Getting a number before you treat is the right habit on most calls. On this call there is no number to get, because neither glucometer works. Waiting through a real hypoglycemia can cause permanent brain injury. Giving sugar to a patient who turns out to be high costs close to nothing.

Question 2 of 10

A 35-year-old patient with type 1 diabetes is drowsy, will not follow commands, and cannot be kept awake long enough to swallow, though the gag reflex is intact. An intravenous line is already established. The vital signs are BP 126/78, P 110, R 16, and SpO₂ 97% on room air. The blood glucose level reads 31 mg/dL. Which route best fits this patient?

Show the answer and rationale

Correct answer · Intravenous dextrose, since the line is in and swallowing is unsafe

This patient is hypoglycemic with a glucose of 31 and cannot swallow safely. The sugar you give depends on what the patient can do and what access you have. Oral glucose is for a patient who can protect the airway and swallow on command. Dextrose is for a patient who cannot swallow, when you have IV access. Glucagon is for a patient who cannot swallow and has no access. This patient cannot stay awake long enough to swallow, so oral glucose is out. The IV line is already in, so you never get to glucagon. Give dextrose through the line. Dextrose works within a minute or two. Glucagon takes ten to twenty minutes even when it works.

Why the others are wrong

Intramuscular glucagon, since the patient cannot swallow: Glucagon is the right route when the patient cannot swallow and you have no access. Here the IV is already in. Choosing glucagon would trade a drug that works in a minute or two for one that takes ten to twenty.

Glucose gel under the tongue, since it is absorbed without swallowing: Glucose gel under the tongue sounds like a way around swallowing. The gel absorbs poorly through the lining of the mouth. Some of the gel can also end up in the airway and be aspirated. None of that risk is needed with a line already in place.

Oral glucose gel, since the gag reflex is intact: An intact gag reflex is a good sign, and it makes oral glucose look possible. Protecting the airway and swallowing on command are two different abilities. A patient who cannot stay awake long enough to swallow cannot take anything by mouth safely.

Question 3 of 10

A 41-year-old patient with type 1 diabetes is unresponsive with a blood glucose level of 26 mg/dL. The only access obtained is a 24 gauge catheter in the back of the hand, which flushes sluggishly and is tender at the site. The vital signs are BP 118/72, P 104, R 14, and SpO₂ 97% on room air. Which concern most shapes the choice of dextrose concentration here?

Show the answer and rationale

Correct answer · Fifty percent dextrose damages tissue badly if it leaks out

The IV is the problem here. The only access is a 24 gauge catheter in the back of the hand, and the catheter flushes sluggishly and is tender at the site. Those are signs the vein is damaged and the line may be failing. Fifty percent dextrose is a thick, hypertonic solution that injures small veins. A leak out of the vein into the tissue is called extravasation. If fifty percent dextrose leaks out of the vein, the dextrose causes serious damage to the tissue around the site. A line that is already failing is likely to leak. Give ten percent dextrose instead, 100 to 250 mL, titrated to mental status. You can also get a better line before you push anything this concentrated.

Why the others are wrong

Fifty percent dextrose is too slow to act through a small catheter: A slow line is a real worry, and a thick solution does move slowly through a small catheter. Dextrose works fast once it reaches the circulation. The danger with fifty percent dextrose through this line is leaking into the tissue, not a delay.

Ten percent dextrose requires a central line to run safely: Fifty percent dextrose is the concentration that can call for a central line, because it injures small veins. Ten percent dextrose is much gentler on a peripheral vein, even a weak one like this. Ten percent dextrose does not need a central line.

Ten percent dextrose cannot raise a glucose level this low: A glucose of 26 is very low, and a weaker solution can sound like too little. Ten percent dextrose corrects hypoglycemia. The weaker solution takes more volume to deliver the same sugar, so you give 100 to 250 mL, titrated to mental status.

Question 4 of 10

A paramedic is called for a newborn delivered at home about 20 minutes ago to a mother whose pregnancy was complicated by diabetes. The newborn has been dried and covered, feels warm, and is breathing well, but is jittery with poor tone and a weak cry. The blood glucose level reads 38 mg/dL. Why is this newborn at particularly high risk for a low blood glucose level?

Show the answer and rationale

Correct answer · The newborn's own insulin ran high against a maternal glucose supply now cut off

This newborn has hypoglycemia. The glucose is 38 mg/dL, and in a newborn a glucose below roughly 45 mg/dL is hypoglycemia. The mother's pregnancy was complicated by diabetes. During the pregnancy, the newborn got a glucose supply from the mother that ran higher than normal. The newborn's own pancreas answered that supply by making more insulin. Delivery cut the glucose supply off at once. The newborn's insulin did not stop at the same time. Now the newborn is making insulin for glucose that is no longer coming, and the glucose falls. That's why a newborn of a diabetic mother is at the top of the risk list. Preterm, small, cold, and stressed newborns are on the list too, because their glycogen runs out fast. The signs are not specific, and this newborn shows them: jitteriness, poor tone, and a weak cry. Correct the glucose with 10% dextrose, not the stronger concentrations used for older children and adults.

Why the others are wrong

The newborn's kidneys spill glucose into the urine until feeding is established: Glucose spilling into the urine is a real way to lose glucose. Spilling glucose is the mechanism behind ketoacidosis with a normal glucose in an adult on certain diabetes medications. A healthy newborn's kidneys do not do that, and nothing in this question points to it.

The mother's insulin crossed the placenta and is still circulating in the newborn: Insulin really is the cause of this low glucose. The insulin is the newborn's own, not the mother's. The newborn's pancreas made extra insulin in response to the mother's high glucose before delivery. The newborn's insulin keeps working now that the supply is cut off.

The newborn burned through its glycogen making heat during and after the delivery: Burning glycogen to make heat is a real mechanism, and it puts cold newborns on the same risk list. This newborn was dried, covered, and feels warm, so this newborn is not burning glycogen for heat. The risk here comes from the mother's diabetes.

Question 5 of 10

A 57-year-old patient with type 1 diabetes was found unresponsive with a blood glucose level of 29 mg/dL. After intravenous dextrose the repeat reading is 118 mg/dL. Ten minutes later the patient is still unresponsive with no change in the examination and no movement to pain. The vital signs are BP 130/78, P 96, R 14, and SpO₂ 97% on room air. Which action best fits this patient?

Show the answer and rationale

Correct answer · Widen the differential and look for a second cause of the coma

The low glucose was not the whole problem, so look for a second cause of the coma. The glucose was 29, you gave dextrose, and the repeat reading is 118. Ten minutes later the patient is still unresponsive, with no movement to pain. When a treatment fixes the number and the patient does not change, your first impression was incomplete. The low glucose may not be the cause at all. Go back through the other causes of coma: a head bleed, a postictal state, an overdose, hypoxia, sepsis, or a stroke. Repeating a treatment that is not working uses up the minutes when you could still find the real problem.

Why the others are wrong

Give intramuscular glucagon to hold the glucose level up: Glucagon can help keep a glucose from dropping again, especially with long acting diabetes drugs on board. This glucose is already normal at 118. Glucagon does nothing for the reason this patient is still unresponsive.

Assume a slow awakening and hold further assessment until arrival: Some patients do wake slowly after a long time with a low glucose. Deciding that ahead of time and holding further assessment means any second cause goes unfound for the whole transport.

Give a second dose of dextrose and recheck in ten minutes: A second dose makes sense when the first dose was too small. The repeat reading of 118 shows the first dose worked. A second dose raises a number that is already normal and does nothing for the coma.

Question 6 of 10

A 70-year-old patient with type 2 diabetes has been declining for two weeks with constant urination. The skin is cool and mottled, the radial pulse is weak, capillary refill is four seconds, and the patient answers only to a loud voice. The vital signs are BP 76/44, P 132, R 24, and SpO₂ 93% on room air. The blood glucose level reads 764 mg/dL. How should this shock state be described?

Show the answer and rationale

Correct answer · Decompensated hypovolemic shock from the osmotic fluid loss

This patient is in decompensated hypovolemic shock. You describe any shock with two questions, in order: which category, then which stage. The category is hypovolemic. A glucose of 764 makes the kidneys pour out water, which is called osmotic diuresis. Two weeks of constant urination has drained this patient's volume the same way bleeding or vomiting would. The stage is decompensated. The blood pressure is 76/44, the radial pulse is weak, and the patient answers only to a loud voice. Compensated means the body is still holding the blood pressure up. Here the compensation has failed. Shock has only two stages, compensated and decompensated. Both stages apply to all four categories of shock.

Why the others are wrong

Compensated hypovolemic shock, since the heart rate is holding output: A fast heart rate is the main sign of compensation, and a rate of 132 shows the body is trying. Compensated shock means the blood pressure is still being held up. At 76/44 with a weak radial pulse and a falling mental status, compensation has already failed.

Decompensated distributive shock from an underlying infection: Infection is a common trigger for a hyperglycemic crisis, so distributive shock is worth thinking about. The decompensated stage in option B is right, but the category is not. This patient lost volume through the kidneys. Distributive shock is blood vessels dilating and leaking. The cool, mottled skin also argues against distributive shock.

Irreversible shock, since the pressure and mentation are both falling: Irreversible shock is a term from older materials. Shock is staged as compensated or decompensated only. There is no irreversible stage to assign.

Question 7 of 10

A 22-year-old patient with a suspected diabetic ketoacidosis has been receiving isotonic crystalloid for 25 minutes. On scene the EtCO₂ was 14 mmHg with deep respirations at a rate of 34. It now reads 29 mmHg, the rate has fallen to 20, and the patient is harder to rouse than on scene. The vital signs are BP 96/56, P 124, R 20, and SpO₂ 96% on room air. What does this change indicate?

Show the answer and rationale

Correct answer · The respiratory compensation is failing as the patient tires

This patient is getting tired, and the breathing can no longer keep up with the acid. On scene, the EtCO₂ was 14 mmHg with deep breathing at 34 a minute. Now the EtCO₂ is 29, the rate is 20, and the patient is harder to rouse than on scene. In diabetic ketoacidosis, deep, fast breathing blows off carbon dioxide to hold the pH up. This patient can no longer move that much air. The carbon dioxide is climbing because the compensation is failing, not because the acid is gone. Fluid for 25 minutes does not reverse a ketoacidosis. Read the EtCO₂ together with the respiratory rate and the mental status. An EtCO₂ rising toward normal in a patient who is getting harder to rouse means the patient is tiring. Support the ventilations, and match the minute volume this patient was making on their own.

Why the others are wrong

The glucose has fallen enough to slow the breathing down: The glucose does come down with fluid. The acid drives this breathing, not the glucose. A falling glucose would not slow the breathing while the mental status gets worse.

The acidosis is resolving as the fluid takes effect: An EtCO₂ moving back toward normal looks like improvement, and fluid is the right treatment for ketoacidosis. Fluid does not clear a ketoacidosis in 25 minutes. A patient whose acidosis was clearing would be waking up, not getting harder to rouse.

The reading has drifted because the cannula has shifted: A shifted cannula can change the EtCO₂ reading, and equipment is always worth checking. A drifting sensor would not also drop the respiratory rate from 34 to 20 or make the patient harder to rouse.

Question 8 of 10

An 81-year-old patient is found obtunded three days after a hospital discharge for pneumonia. The skin is dry and scaly, and the respirations are slow and shallow. The vital signs are BP 104/62, P 46, R 8, SpO₂ 91% on room air, and T 94°F. The EtCO₂ is 62 mmHg. What is most likely causing this presentation?

Show the answer and rationale

Correct answer · Myxedema coma

This patient is in myxedema coma. Myxedema coma is hypothyroidism, an underactive thyroid, at its worst. Everything in this patient has slowed down and cooled off. The temperature is 94°F, the pulse is 46, and the respirations are 8 and shallow. The skin is dry and scaly, and the patient is obtunded. Myxedema coma usually shows up in an older patient after surgery, an infection, or a sedative. This patient was just discharged after pneumonia. The slow, shallow breathing is what kills these patients. Carbon dioxide builds up, and that's why the EtCO₂ is 62. Support the ventilations, rewarm passively, check a blood glucose level, and handle the patient gently.

Why the others are wrong

Thyroid storm: the same gland going the other direction, with too much thyroid hormone. Thyroid storm runs hot, fast, and agitated, with a high temperature and a very fast heart rate. This patient's temperature is 94°F and the pulse is 46.

Adrenal crisis: belongs on the list for any patient who is weak and getting worse after an illness. Adrenal crisis causes a low blood pressure that does not come up with fluid or pressors. This patient's pressure is 104/62. Adrenal crisis also does not cause a low temperature with a rising carbon dioxide.

Septic shock: Sepsis is a fair thought after a recent pneumonia, and a septic patient can have a low temperature. Septic patients are usually tachycardic and hypotensive. This patient has a pulse of 46 and a pressure of 104/62. The dry scaly skin and the slow, shallow breathing point to the thyroid.

Question 9 of 10

A 68-year-old patient with a history of hypothyroidism is found lethargic at home during a cold spell. The skin is cool and dry, and the face appears puffy. The pupils are 4 mm and reactive. The patient responds only to a loud voice with slow, mumbled speech. The vital signs are BP 96/58, P 46, R 8, SpO₂ 91% on room air, and T 93°F. The blood glucose level is 88 mg/dL. What condition should the paramedic most strongly suspect?

Show the answer and rationale

Correct answer · Myxedema coma

This patient is in myxedema coma, which is severe, untreated hypothyroidism. Thyroid hormone sets how fast the body runs. Without enough thyroid hormone, everything slows down at once. The temperature is 93°F, the pulse is 46, and the respirations are 8. The skin is cool and dry, and the face is puffy. The patient only responds to a loud voice. None of those findings proves myxedema coma by itself. Together, in a patient with known hypothyroidism, they add up to myxedema coma. In the field, the slow breathing is what kills these patients, not the thyroid level. That's why the breathing is the first thing you support.

Why the others are wrong

Opioid overdose: An opioid overdose does not explain the low temperature, the slow pulse, and the puffy face all together. Those findings tie back to this patient's known hypothyroidism, not to an opioid.

Thyroid storm: the opposite problem, too much thyroid hormone. Thyroid storm speeds the body up, with fever, a fast heart rate, and agitation. This patient has a temperature of 93°F, a pulse of 46, and respirations of 8.

Adrenal crisis: does not usually cause this mix of a low temperature, puffy dry skin, and slowing of everything. That mix comes from severe untreated hypothyroidism, not from a lack of adrenal hormones.

Question 10 of 10

An 8-month-old infant (8 kilograms) has vomited for 2 days and is now limp and difficult to arouse. The skin is pale and cool. The vital signs are P 172, R 46, and SpO₂ 97% on room air. The blood glucose level is 26 mg/dL. Intravenous access has been established. What is the most appropriate way to correct the blood glucose level?

Show the answer and rationale

Correct answer · 10% dextrose at a weight-based dose

This infant is hypoglycemic, and the treatment is 10% dextrose through the IV, dosed by weight. The blood glucose is 26 mg/dL in an 8-month-old who weighs 8 kilograms. The infant is limp and difficult to arouse, and IV access is already in place. Infants store only a small amount of glycogen, and their veins are small. Dextrose at 10% is a weaker solution, so it is easier on a small vein. Dosing by weight still gives the infant the right amount of sugar for the infant's size. A concentrated solution can scar a vein this small and can make the sugar drop again afterward. Dextrose given straight into the IV fixes the low sugar right away instead of waiting on a slower route.

Why the others are wrong

50% dextrose by rapid push: A rapid push of 50% dextrose is right for an adult with low blood sugar and an IV. This patient is an 8-month-old infant who weighs 8 kilograms. Pushing an adult-strength solution through a small vein can scar the vein and make the sugar drop again. The concentration has to come down for an infant, even though the dose per kilogram stays about the same.

Oral glucose gel in the cheek: Oral glucose gel works for a patient who is awake and can swallow and protect the airway. This infant is limp and difficult to arouse. Gel in the cheek of an infant like this can be aspirated instead of absorbed.

Glucagon by the intramuscular route: Glucagon IM is the backup when you cannot get IV access. Glucagon raises the sugar by releasing the glycogen stored in the liver. This infant already has an IV in place. The slower intramuscular route offers nothing over dextrose straight into the vein.

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