Take This Test on Insulin: You May Be Smarter Than a Doctor!

This article was originally published in Diabetes Health in April, 2008.

| Dec 17, 2008

Take this test on insulin and see if you can get a higher score than hospital doctors and nurses.

When you first heard about the game show “Are You Smarter Than a 5th Grader?” maybe you thought, “Of course an adult will be able to answer a first-grade science question, or a second-grade geography question.”

Then you watched the show.

“Which of the Great Lakes lies farthest east?” Um… Erie? “In the Northern Hemisphere, the summer solstice occurs in which month?” Let’s see…August is the hottest month, so…

It’s not so easy when you’re 5, 10, or 20 years past elementary school.

Now imagine you’re a doctor working in a hospital. You are not an endocrinologist. You learned a little about diabetes in medical school. Over the years, you’ve had opportunities to take continuing education courses on diabetes and workshops on new insulins sponsored by the manufacturers. But there were always other courses about diseases you see more often.

A patient who uses insulin is admitted. It’s your responsibility to give the medication orders. Will you make the right decisions?

Researchers at Johns Hopkins University in Baltimore gave an anonymous survey about insulin to 377 doctors and nurses from four teaching hospitals in the Baltimore area. The goal of the researchers was to identify topics for educational programs.

Those surveyed included internal medicine faculty members, house staff, nurses, interns, and second- and third-year residents. Specialty faculty included those in cardiology, geriatric medicine, gastroenterology, pulmonary, and nephrology.

The doctors and nurses were given about 10 minutes to complete the survey. They could not ask others for help or check books.

Some of the questions are quite technical, but you might like to take a stab at the test before you read the answers and see how the doctors and nurses did.

Department of Medicine Insulin Use Knowledge Assessment

1. Humulin is:

Rapid-acting insulin

Intermediate-acting insulin

Long-acting insulin

An insulin brand name

2. 75/25 is:

75% NPH, 25% lente

75% protamine, 25% glargine

75% protamine, 25% regular

75% protamine, 25% lispro

3. 70/30 is:

70% NPH, 30% regular

70% NPH, 30% glargine

70% protamine, 30% lispro

70% glargine, 30% aspart

4. Glargine is:



Basal insulin

Rapid-acting insulin

5. In general, a rapid-acting insulin:

Peaks within 6 to 8 hours

Peaks within 2 to 4 hours

Peaks within 1 hour

Has no peak

6. In general NPH insulin:

Peaks within 4 to 10 hours

Peaks within 12 to 24 hours

Peaks within 2 to 4 hours

Has no peak

7. Which of the following cannot be physically mixed in the same syringe with other types of insulin?





8.Which of the following is a cloudy, rather than a clear, solution?





9. Commercially available insulin pumps:

Need to be surgically inserted

Use NPH insulin

Use rapid-acting insulin

Provide basal insulin only

10. The American Diabetes Association definition of hypoglycemia is a blood level less than:

50 mg/dl

70 mg/dl

80 mg/dl

100 mg/dl

11. In order to avoid complications, when a type 1 patient is NPO (“nothing by mouth,” that is, not eating or drinking):

Discontinue all insulin

Continue basal insulin

Continue only sliding scale insulin

Continue only rapid-acting insulin

12. Sliding scale insulin is best used:

a. To meet basal insulin requirements

b. To cover carbohydrates eaten in meals

c. As a supplement to scheduled insulin to correct hyperglycemia

d. As a guide for making changes to scheduled insulin doses

a & b

b & c

c & d

All of the above

13. A typical daily insulin requirement for an adult with type 1 diabetes:

0.2-0.4 units/kg

0.5-0.7 units/kg

0.8-1.0 units/kg

1.2-1.4 units/kg

14. What percentage of the daily insulin requirement does basal insulin generally account for?





15. Diabetic ketoacidosis (DKA) can develop in:

Type 1 diabetes only

Type 2 diabetes only

Both type 1 and type 2

None of the above

16. In DKA, when converting from a continuous insulin infusion to subcutaneous insulin, start subcutaneous insulin approximately:

2 hours before stopping the infusion

At the same time as stopping the infusion

1 hour after stopping the infusion

4 hours after stopping the infusion

Answers and Results

We’ll list the groups that did the best and the worst on each question.

1. Humulin is an insulin brand name.

Answered correctly by 65 percent of specialty faculty but only 21 percent of interns. Many test-takers answered that it is a rapid-acting insulin, perhaps confusing Humulin with Humalog.

2. 75/25 is 75% protamine/25% lispro.

This question stumped the most people. It was answered correctly by only 22 percent of third-year residents and 3 percent of specialty faculty.

3. 70/30 insulin has been around a long time, and most test-takers (88-95 percent in each group) knew that it is 70% NPH/30% regular.

4. Almost all of the third-year residents (97 percent) but only a third of the nurses with 6-10 years experience knew that glargine is a basal insulin.

5. In general, a rapid-acting insulin peaks within 1 hour.

What a difference a year makes: 49 percent of interns (first-year residents) and 74 percent of second-year residents got this right.

6. In general, NPH insulin peaks within 4-10 hours.

Answered correctly by 64 percent of the interns, and 82 percent of second-year residents.

7. Most third-year residents (88 percent) but only 48 percent of specialty faculty knew that glargine cannot be mixed with other insulins.

8. Almost all of the nurses (97-99 percent) knew that NPH is cloudy. Only 25 percent of specialty faculty knew this.

9. Commercially available insulin pumps use rapid-acting insulin.

Only 32 percent of nurses with less than 5 years experience but 63 percent of third-year residents knew this.

10. The ADA definition of hypoglycemia is a blood glucose less than 70 mg/dl.

Specialty faculty finally stepped up: 48 percent got it right, versus 34 percent of nurses with more than 10 years experience.

11. If you’re NPO, hope that a third-year resident is writing your insulin orders: 81 percent of them knew to continue basal insulin, but only 12 percent of nurses with more than 10 years experience knew this.

    The researchers write: “Recognition that patients with type 1 diabetes require basal insulin at all times is crucial because stopping insulin can result in DKA and death. Nevertheless, 25 percent of all house staff and the majority of faculty and nurses answered this question incorrectly.”

12. Sliding-scale insulin is best used as a supplement to scheduled insulin to correct hyperglycemia and as a guide for making changes to scheduled insulin doses.

Answered correctly by 53 percent of third-year residents, but fewer than 20 percent of the nurses.

13. A typical daily insulin requirement for an adult with type 1 diabetes is 0.5-0.7 units/kg.

Answered correctly by 71 percent of second-year residents, and 24 percent of nurses with more than 10 years experience.

14. Basal insulin generally accounts for 40-50% of the daily insulin requirement.

Answered correctly by 60 percent of first-year residents, and 14 percent of nurses with 6-10 years experience.

15. Most of the test-takers knew that DKA can develop in both type 1 and type 2 diabetes; 97 percent of third-year residents, 71 percent of nurses with more than 10 years experience, and even 80 percent of the specialty faculty got this right.

16. In DKA, start insulin shots about 2 hours before stopping the insulin infusion.

Most third-year residents (93 percent) but only 32 percent of nurses with less than 5 years experience knew this.

Peek, Copy, and Save

In their quest to win a million dollars, contestants on the Fox game show can “peek” and “copy” from the bright fifth-graders in the show’s “class.” The Baltimore researchers note that in a real world situation, doctors would be able to ask colleagues if they weren’t sure of what to do. But there’s the rub. One of the questions in the survey was, “How comfortable do you feel medically managing patients with diabetes?” The researchers report: “[G]iven that most respondents self-reported feeling very or somewhat comfortable in diabetes management, we may reasonably expect that many would not seek additional information when confronted in the clinical setting with diabetes management issues addressed by our questionnaire.”

On the TV show, a contestant who answers incorrectly can once – and only once – be  “saved” if his or her chosen fifth-grader has the correct answer. Does this happen in hospitals? Yes. If a doctor give orders for an inappropriate dose of insulin, the nurse can say, “Are you sure this is the right dose?” But this study shows that not all nurses know the appropriate doses.

What should you do if you are in the hospital? Rachel L. Derr, MD, a senior fellow in endocrinology and metabolism at the Johns Hopkins School of Medicine, and Annabelle Rodriguez, MD, director of the Diabetes Management Service at Johns Hopkins Bayview Medical Center, offer this advice:

  • If you have type 1 diabetes, you are not eating, you’re not being given insulin shots, and you’re on IV fluids, ask whether the IV fluids contain insulin. Remember, you need some insulin even when you’re not eating. (People with type 2 diabetes may be making enough insulin of their own to avoid DKA.)
  • Every time you are being given insulin, ask, “What dose are you giving me?” If it sounds wrong, say, “That doesn’t sound right. Can I speak to the doctor?”
  • You can always ask for a consultation from an endocrinologist or the inpatient diabetes team. Many hospitals in the United States are now establishing such teams to increase patient safety.
  • It’s hard to speak up and question doctors and nurses. But you know your body and your typical insulin doses better than anyone at that hospital. It may fall to you to make the save. And the stakes are higher than a million dollars.

Marie McCarren is the author of Guide to Insulin & Type 2 Diabetes and A Field Guide to Type 2 Diabetes. The answers are “Lake Ontario” and “June.”

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Categories: Blood Glucose, Diabetes, Diabetes, Hospital Care, Insulin, Insulin Pumps, Low Blood Sugar, Professional Issues, Syringes, Type 1 Issues, Type 2 Issues

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Posted by cgentry@dirtware.net on 26 March 2008

Lets hope there is a RN/CDE or Endocrinologist available in every hospital.

Posted by Anonymous on 27 March 2008

I'm a nurse and greatly appreciated this article. Thank you.

Posted by Anonymous on 28 March 2008

As a diabetes educator this is very 'eye opening' and can be used as a great teaching tool for our staff!!

Posted by Anonymous on 28 March 2008

Let's not forget the Registered Dietitian, Certified Diabetes Educator (RD, CDE). I scored 100% on the test.

Posted by Anonymous on 29 March 2008

You did not mention how regular attendings did on the test. I have been out of my residency now for almost 30 years. I have not worked in the hospital for over 10 years since the advent of Hospitalists, (that I was against at first but now I am thankful for). I am planning to take my boards again for the 5th time this year and hopefully my last time. I missed "two". Hypoglycemia, I placed at 50, and I thought sliding scale was for all the above. I am happy to say that I got the others correct, though I did guess at some, It was an educated guess...as I have not used or prescribed any of the newer insulins or the pumps. I am a Family Physician, I ask my Endocriologist friends to help me with the insulin dependant diabetics.

Posted by Anonymous on 29 March 2008

The questions were helpful to all with diabetes. Most important questions which were not asked, were how a diabetic patient in a hospital for surgery should act. 1) insulin is given with IV.2) Usually the patient should ask the nurse how many grams of carbohydrate will be given so that patient can get his right type of insulin on the sliding scale. 3) The surgery should be planned between monday-tuesday so that the endocrinologist is available for the pre & post surgery consultations/complications.

Posted by Anonymous on 31 March 2008

What about when you get an attitude because you know your or your child's diabetes better then the staff? Many professionals can't handle someone telling them how to do their job, especially under an stressful situation like the ER.

Posted by Anonymous on 31 March 2008

As an RN staff development educator in an urban medical center I intend to use this information as a teaching tool as well. Nicely done.

Posted by Xerelda on 5 April 2008

This article also shows the importance of educating your family members about your diabetic needs in case you are too sick to oversee them yourself while in the hospital. I was in the ER recently and had a nurse who wanted to send me home with a blood sugar of 50. My gastroparesis was acting up too. I wonder now if she thought 50 was a normal blood sugar. This is scary.

Posted by Sweet-Survivor on 7 April 2008

I am among the world's oldest living Juvenile diabetics--47 years. I was a pioneer in coping strategies, diets and nutrtion & TV cook shows--and at 21 started a new educational specialty as a Juvenile Management Specialist. Reading the QUIZ about insulins was fantastic! I did pretty darn good, too, but recently in two diffenrent hospitals for 30-year ulcerated toe--I was divested of my own insulin, they refused to give me any insulin "until I got high enough" then the nursing director said she couldn't make that decision! Horrors! Yikes! The same thing happened with a team family doctor who was so obnoxious he signed himself off my case--leaving me without INSULIN at all. The ER said my BG was 77--so I don't get any insulin. Gggrrr. . .I left to save my own life--once again. So much for "surviving". Hmpf.

Posted by James on 9 April 2008

I would like to add a few comments. I have lived as a T1 diabetic for between 56-57 years now. The section on how much insulin is required based on a persons weight isn't necessarily correct. My weight now is 150 lbs., or 68.03 kg if you wish. In January of last year my weight was 204.

Based on the calculation given my insulin requirement is 34.019 units. I am on a low carb diet (30 grams daily, 6-12-12)) and my insulin requirements are 7 Units Lantus(basal) in a.m. before breakfast, and 4 units Novolog; prior to lunch 2-3 units Novolog and at dinner 2-3 uits Novolog.
I was introduced to the low carb way of managing my diabetes in July of last year, and will never change from this way due to the excellent results I've had.

Prior to following this way of control, I was and had been hypoglycemic-unaware for many many years. Within a month or so of this way of eating I gradually began to partialy reverse the unawareness. I'm sure it'd be difficult for anyone without this condition to know how good it feels to be able to get a little dizzy when the BG get too low. It's great to be able to get a little dizzy when needed. My A1c is now 5.6...best it's ever been. Before it was 6.2-6.8.

I do think the medical professionals need to learn to 'think outside the box' of what they learned while in school, and become aware of the possibilities available when treating patients if they are willing to learn, and their ptients receptive.

My endo had said last July I'd never sitck with it, nor would anyone, and did all she could to discourage me. I'm still doing it and know of about 8000-9000 others who do, and will continue. In contrast to my endo, fortunately, the cardiologist she referred me to last Nov. for the Cardiolite Stess Test feels every diabetic should be on a low-carb plan.


Posted by SGANPMSBS on 12 April 2008

This was excellent, it is a great tool to use for nursing education. Has anyone taken the CDE recently like in 2007. please let me know, I am taking it in May, no matter what I study it is not enough I think.

Posted by Anonymous on 17 April 2008

I really did good on the test being a type 1 I only missed three, but I will have to agree about the insulin to weight ratio really depends on your carb intake as I have also adjusted my insulin due to going on a lower carb diet. I was also a victim of DKA 9 years ago and didn't realize I still needed to take my insulin even though I could not hold down even water being severely sick.I was in ICU for 72 hours with an initial blood sugar of 1486 which was done in the lab because all of the meters just said HIGH check KETONES. I thank GOD I had a good team of doctors who worked on me around the clock to get my blood sugar stabilized. I really think that this type of tests should be given out to alot of doctors nationwide to increase their knowledge.

Posted by kdommer on 19 April 2008

I have been in the hospital for knee surgeries and have been asked by the nursing staff "Can I see your pump, I've never seen one before?" I always choose to treat my diabetes on my own when in the hospital because it has been clear that the staff does not have enough knowledge. Whatever can to done to improve on this would be appreciated by all.

Posted by Anonymous on 1 May 2008

I am NIDDM for the last 12 years and on metformin and dianil. On getting blood test, i was surprised about B12,calcium and testerone levels low. As I am not satisfied with the above medications, I started 70/30 insulin(on my own) about year back along with testocaps and b12 syrup, surprisingly my health well developed and sugar levels are under control. Presently no problem. Here i am unable to uderstand why doctors prescribe metformin when it lowers insulin production,testerone,B12 etc and i felt there are more disadvantages than advantages in taking metformin for a long period,,,,, Metformin reduces insulin resistance may be helpful for woman with high level of serum insulin,testerone and or suffering with PCOD than for diabetic particularly male patients. Here i would be very happy if some one give me some more suggestions.

Posted by Anonymous on 8 May 2008

As of late, we have learned that glargine can be mixed with fast acting as long as the shot is administered immediately. Most people will have similar effects to delivering them in two shots.

Posted by Anonymous on 24 May 2008

can anyone tell me the effects of lantus and water weight? i have gained ten pounds in three months on lantus and i now have difficulty walking due to swelling in my feet and legs!

Posted by Anonymous on 23 June 2008

this is a sure print out!!! take this test to the docs you are interviewing when trying to select a new one to care for you! make them take it so you can check their competence! at best, if they don't get it 100%, they will learn something and you'll have done a great service to the future diabetics that visit this doc!

Posted by Anonymous on 9 June 2009

I think it's a crime that they won't make pork insulin in this country, because the DNA insulin is causing so much unnecessary harm to many people with diabetes. Only those people who don't have diabetes or diabetics who have never been on pork or beef insulin for the treatment of diabetes think DNA insulin is a dependable option.

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