NCLEX Endocrine Emergencies questions
The PrepScore bank has 78 Endocrine Emergencies questions, each with a rationale and two tags: the Client Needs category from the test plan and the clinical judgment step it tests. In this topic the items lean on Take action and Recognize cues, which is worth knowing before you practise it. Three worked samples are below, answers behind a reveal.
DKA, HHS, thyroid storm, Addisonian crisis, SIADH and DI — recognize the cluster, treat the cause, watch the labs.
Three worked questions
Q1. A 22-year-old female with type 1 diabetes presents to the ED with BG 380, Kussmaul respirations, fruity breath, and confusion. She admits she stopped her insulin 3 days ago because she was vomiting. Vitals: BP 96/58, HR 122, RR 28, T 37.8, K 5.4, pH 7.18, anion gap 22. Which intervention is the PRIORITY?
- A. Initiate IV normal saline 15–20 mL/kg bolus over 1 hour, then start IV regular insulin infusion at 0.1 units/kg/hr, monitor K every 2 hours
- B. Administer subcutaneous regular insulin 10 units now to begin lowering the blood glucose before fluid resuscitation begins for this DKA
- C. Encourage oral fluids (Gatorade) and monitor for the next hour before initiating any IV fluid or insulin therapy for the symptom management
- D. Give 50% dextrose 25 mL IV push immediately to address the hyperglycemia-related confusion present in this acute symptomatic patient
Show answer and rationale
Answer: Initiate IV normal saline 15–20 mL/kg bolus over 1 hour, then start IV regular insulin infusion at 0.1 units/kg/hr, monitor K every 2 hours
DKA bundle: IV crystalloid first (volume + electrolyte distribution), THEN IV insulin infusion (subQ insulin is too slow), K monitoring (insulin drives K into cells — can drop dangerously even from 'normal' starting K). SubQ insulin alone, oral fluids, and D50 each represent fundamental errors.
Q2. A 68-year-old male with small-cell lung cancer is admitted with serum Na 118, confusion, and new seizure activity. Workup confirms SIADH with high urine osmolality + low serum osmolality + euvolemic exam. He is currently seizing. Which intervention is MOST APPROPRIATE?
- A. Hypertonic 3% saline 100 mL IV bolus, fluid restrict, monitor Na closely to correct < 10 mEq/L in first 24 h (avoid central pontine myelinolysis)
- B. Rapid 0.9% normal saline infusion at 250 mL/hr to address the volume deficit driving the hyponatremia in this patient acutely
- C. D5W infusion at 100 mL/hr to provide free water and address the seizure activity through metabolic correction over the next several hours
- D. Furosemide 40 mg IV plus oral KCl supplementation as the primary management approach for the symptomatic hyponatremia
Show answer and rationale
Answer: Hypertonic 3% saline 100 mL IV bolus, fluid restrict, monitor Na closely to correct < 10 mEq/L in first 24 h (avoid central pontine myelinolysis)
Symptomatic severe hyponatremia (seizures, AMS) requires hypertonic 3% saline + fluid restriction + careful correction limit (< 10 mEq/L in first 24 hours to avoid osmotic demyelination). 0.9% saline and D5W each worsen hyponatremia; furosemide is for hypervolemic hyponatremia, not euvolemic SIADH.
Q3. A 52-year-old female with newly diagnosed adrenal insufficiency is being discharged with prescribed hydrocortisone replacement (15 mg morning + 5 mg afternoon). The discharge nurse is providing teaching about ongoing management. Which teaching point is the MOST IMPORTANT?
- A. Increase the hydrocortisone dose 2–3× during illness/stress (sick-day rules) and carry an emergency injectable hydrocortisone for crisis use
- B. Stop the hydrocortisone whenever you feel well so the medication does not accumulate during periods of good health
- C. Reduce the dose by half if you skip a meal to avoid the GI side effects associated with hydrocortisone taken on an empty stomach
- D. Take the medication only on weekdays so your adrenal glands can recover function over the weekend without exogenous suppression
Show answer and rationale
Answer: Increase the hydrocortisone dose 2–3× during illness/stress (sick-day rules) and carry an emergency injectable hydrocortisone for crisis use
Adrenal insufficiency teaching focuses on the sick-day rules: 2–3× dose during illness/stress (febrile illness, surgery, trauma, vomiting), plus carrying emergency injectable hydrocortisone for crisis use. Stopping when well, reducing for skipped meals, and weekend-only dosing each represent fundamental misunderstandings that precipitate Addisonian crisis.
The rules that decide these questions
From the pack's rule cards — the reasoning shortcuts a wrong answer usually means you were missing.
In DKA the FIRST move is isotonic fluid (0.9% NS), not insulin. Check K+ before starting insulin — if K+ < 3.3, HOLD insulin and replete K+ first (insulin drives K+ into cells). Add K+ to maintenance once it falls into 3.3–5.2. Switch to D5 ½NS when glucose reaches ~200 to prevent rapid drop and cerebral edema.
The rule of 15 (15 g oral carbs, recheck in 15 min) is for an awake, swallow-safe patient. In an obtunded patient, push IV D50. For sulfonylurea-induced hypoglycemia, a single D50 isn't enough — start a D10 infusion to bridge the long drug half-life and prevent rebound.
HHS has 8–10 L of fluid deficit and minimal ketosis. Treatment is volume-led: aggressive 0.9% NS first, then slow insulin (0.05–0.1 unit/kg/hr) only after the first liter and K+ check. Aim to drop glucose 50–75 mg/dL/hr — faster causes cerebral edema. Correct Na+ slowly (≤ 10 mEq/L per 24 h).
Order matters. Iodine given before thionamide can paradoxically increase hormone release. The sequence: (1) beta blocker for adrenergic symptoms, (2) thionamide (PTU preferred in storm) to block synthesis, (3) iodine ≥ 1 hour later to block release, (4) glucocorticoid to block T4→T3 conversion. Use acetaminophen, not aspirin (aspirin displaces T4 → worsens storm).
Concurrent adrenal insufficiency is common — give IV hydrocortisone BEFORE IV levothyroxine to prevent triggering adrenal crisis. Rewarm passively/slowly: rapid external rewarming causes peripheral vasodilation and cardiovascular collapse. Correct hyponatremia and hypoglycemia carefully.
Suspected adrenal crisis (hypotension + hypoNa + hyperK + hypoglycemia + appropriate history) is a clinical diagnosis. Draw cortisol + ACTH, then immediately give IV hydrocortisone 100 mg + 0.9% NS with D5. Lab workup proceeds in parallel; treatment does not wait. Never stop chronic steroids abruptly.
Practise the whole pack, tagged and explained
Every item carries its Client Needs category and clinical judgment step, so a wrong answer names the step that failed.
Frequently asked questions
How many Endocrine Emergencies questions does the bank have?
78 multiple-choice items, plus 10 unfolding cases in the Endocrine Emergencies pack, each with a rationale.
Are the samples real bank items?
Yes — the three questions above are drawn from the live bank, with their real rationales and tags.
Which clinical judgment steps does this topic train?
Most items in this topic test Take action and Recognize cues, though every step appears.
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