Diabetic Ketoacidosis (DKA) Practice Questions

25 multiple-choice questions on Diabetic ketoacidosis (DKA) for paramedic and EMT students, from Chapter 24 (Endocrine Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. The underlying cause of diabetic ketoacidosis is:

   1. A. Too much insulin
   2. B. A severe lack of insulin
   3. C. Too much glucagon alone
   4. D. Excess dietary fat intake
   Show answer

   Answer: B. A severe lack of insulin

   Without insulin, cells cannot use glucose, so the body burns fat and produces ketoacids. Glucose and ketones both climb.

2. The three defining features of DKA are:

   1. A. Hyperglycemia, ketosis, alkalosis
   2. B. Hypoglycemia, sweating, tremor
   3. C. Hyperosmolality, coma, no ketones
   4. D. Hyperglycemia, ketosis, acidosis
   Show answer

   Answer: D. Hyperglycemia, ketosis, acidosis

   Under the 2024 consensus, DKA is defined by hyperglycemia (glucose 200 mg/dL or higher, or known diabetes), ketosis (beta-hydroxybutyrate 3.0 mmol/L or higher), and metabolic acidosis (pH below 7.3 or bicarbonate below 18). Glucose can be only mildly raised, for example with SGLT2 inhibitors or in pregnancy. DKA causes acidosis, not alkalosis, and high osmolality with absent ketones describes HHS.

3. A vomiting type 1 diabetic has a fingerstick blood ketone (beta-hydroxybutyrate) of 3.5 mmol/L. This suggests:

   1. A. Likely DKA
   2. B. Normal ketone levels
   3. C. Hypoglycemia
   4. D. A meter error only
   Show answer

   Answer: A. Likely DKA

   A beta-hydroxybutyrate of 3.0 mmol/L or more meets the ketone criterion for DKA in the 2024 consensus; levels below 0.6 are normal. Point-of-care ketone meters help identify DKA early.

4. A heavy drinker who has vomited for days and not eaten has deep breathing, a normal glucose, and ketones. You should suspect:

   1. A. Diabetic ketoacidosis
   2. B. HHS
   3. C. Alcoholic ketoacidosis
   4. D. A simple hangover from drinking
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   Answer: C. Alcoholic ketoacidosis

   Alcoholic ketoacidosis follows binge drinking with starvation and vomiting; glucose is usually normal or low, unlike classic DKA. Treatment is fluids, dextrose, and thiamine.

5. Which group of patients with DKA has the highest risk of death?

   1. A. Young adults with no other illness
   2. B. Older adults with other illnesses
   3. C. Teens with a first episode
   4. D. Patients with mild ketosis
   Show answer

   Answer: B. Older adults with other illnesses

   DKA mortality is low in young patients in modern care but rises sharply in older adults and those with serious triggers such as sepsis or MI.

6. The fruity breath odor in DKA comes from:

   1. A. Ammonia
   2. B. Acetone
   3. C. Alcohol
   4. D. Glucose
   Show answer

   Answer: B. Acetone

   Acetone is a ketone that is exhaled. Ammonia-like breath suggests liver or kidney failure.

7. A type 2 diabetic feels well with a glucose of 380 mg/dL, normal breathing, normal mental status, and no vomiting. This is best described as:

   1. A. Severe diabetic ketoacidosis
   2. B. Hyperosmolar coma
   3. C. An insulin overdose taken at home
   4. D. Hyperglycemia without a crisis
   Show answer

   Answer: D. Hyperglycemia without a crisis

   High glucose alone, without acidosis, ketosis, dehydration, or altered mental status, is not DKA or HHS. Assess for triggers and advise follow-up per protocol.

8. Insulin is generally not started in the field for DKA mainly because:

   1. A. Insulin worsens the dehydration
   2. B. It worsens the ketosis
   3. C. Potassium must be monitored closely
   4. D. It lasts far too long when given by IV
   Show answer

   Answer: C. Potassium must be monitored closely

   Insulin drives potassium into cells and can cause dangerous hypokalemia if potassium is low at the start, so hospitals check potassium first and use a monitored infusion. Field care focuses on fluids. Insulin stops ketone production rather than worsening it, and IV regular insulin acts only briefly.

9. Urine ketone strips may underestimate DKA because they do not detect:

   1. A. Beta-hydroxybutyrate
   2. B. Acetoacetate
   3. C. Glucose in the urine
   4. D. Protein
   Show answer

   Answer: A. Beta-hydroxybutyrate

   Standard nitroprusside strips detect acetoacetate and acetone but not beta-hydroxybutyrate, the main ketone in DKA. Blood beta-hydroxybutyrate testing is preferred.

10. Why is potassium checked before insulin is started in DKA?

    1. A. Insulin raises potassium levels
    2. B. Potassium blocks insulin
    3. C. Potassium itself causes hypoglycemia
    4. D. Insulin can drop potassium sharply
    Show answer

    Answer: D. Insulin can drop potassium sharply

    Insulin moves potassium into cells. If potassium is already low, insulin can cause life-threatening arrhythmias.

11. Abdominal pain in an adult with DKA that persists after the acidosis is corrected suggests:

    1. A. Another cause, e.g., pancreatitis
    2. B. Normal recovery from DKA
    3. C. Too much IV fluid given
    4. D. Low blood sugar caused by insulin
    Show answer

    Answer: A. Another cause, e.g., pancreatitis

    DKA-related abdominal pain usually improves as acidosis resolves. Persistent pain should prompt a search for a trigger or alternate diagnosis, such as pancreatitis, appendicitis, or bowel ischemia.

12. An older diabetic with DKA should have a 12-lead ECG mainly because:

    1. A. DKA always causes heart block
    2. B. MI can trigger DKA; K+ affects ECG
    3. C. It confirms the diagnosis of DKA
    4. D. It replaces the need for a glucose check
    Show answer

    Answer: B. MI can trigger DKA; K+ affects ECG

    Myocardial infarction is a recognized trigger for DKA, and potassium shifts in DKA can produce peaked T waves or dysrhythmias, so an ECG helps find both.

13. A child with new-onset diabetes often presents with:

    1. A. Weight gain and hypoglycemia
    2. B. Weight gain with frequent urination
    3. C. Weight loss, thirst, and DKA
    4. D. Low thirst and dark urine
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    Answer: C. Weight loss, thirst, and DKA

    Many children are first diagnosed in DKA after weeks of thirst, frequent urination, and weight loss. Weight is lost, not gained, and thirst is increased with large volumes of pale urine.

14. The most feared complication of DKA treatment in children is:

    1. A. Bilateral kidney stones
    2. B. Pneumothorax
    3. C. Cerebral edema
    4. D. Hypertension
    Show answer

    Answer: C. Cerebral edema

    Rapid fluid shifts can cause brain swelling. Pediatric fluids are given cautiously per protocol. Watch for headache, bradycardia, and declining mental status.

15. A DKA patient with pneumonia has a normal temperature. This should be interpreted as:

    1. A. Proof that there is no infection
    2. B. Not ruling out infection
    3. C. A sign the DKA is resolving
    4. D. A reason to withhold fluids
    Show answer

    Answer: B. Not ruling out infection

    Patients in DKA are often normothermic or even hypothermic despite infection, partly from vasodilation. Infection is the most common trigger, so lack of fever does not exclude it.

16. A DKA patient's deep, rapid breathing slows and becomes shallow while his mental status worsens. This most likely means he is:

    1. A. Tiring, worsening his acidosis
    2. B. Recovering from the DKA
    3. C. Becoming hypoglycemic
    4. D. Having a panic attack from fear
    Show answer

    Answer: A. Tiring, worsening his acidosis

    Kussmaul breathing compensates for metabolic acidosis. Respiratory fatigue lets CO2 rise, causing rapid worsening of pH, and is a sign of impending collapse. Prepare to support ventilation at a matching rate.

17. In DKA, sodium bicarbonate is generally:

    1. A. Given to every patient in the field
    2. B. Given before any IV fluids
    3. C. Used mainly to lower the glucose
    4. D. Reserved for a pH below about 7.0
    Show answer

    Answer: D. Reserved for a pH below about 7.0

    The 2024 consensus advises bicarbonate only for severe acidosis (pH below 7.0), because it can worsen hypokalemia and has not improved outcomes. Fluids and insulin correct the acidosis in most patients.

18. Cancer immunotherapy drugs (checkpoint inhibitors) can cause:

    1. A. Lasting low blood sugar
    2. B. Kidney stones
    3. C. New type 1 diabetes and DKA
    4. D. Thyroid cancer in the neck area
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    Answer: C. New type 1 diabetes and DKA

    Immune checkpoint inhibitors can trigger autoimmune destruction of beta cells, causing new insulin-dependent diabetes that often presents as DKA. Check glucose in any immunotherapy patient who is vomiting or unwell.

19. DKA in a toddler is often missed at first because:

    1. A. Ketones do not form in children this young
    2. B. It is mistaken for a viral illness
    3. C. Toddlers do not vomit with DKA
    4. D. Children rarely get DKA at all
    Show answer

    Answer: B. It is mistaken for a viral illness

    Vomiting, rapid breathing, and lethargy in a young child can be mistaken for gastroenteritis or pneumonia, delaying diagnosis. A glucose check in any ill child with these signs can identify DKA. Toddlers make ketones and often vomit in DKA, and DKA is a common way type 1 diabetes first appears in children.

20. Mental status changes in DKA are caused by:

    1. A. Acidosis and dehydration
    2. B. Low glucose in the brain
    3. C. An excess of insulin
    4. D. Severe hyperthermia
    Show answer

    Answer: A. Acidosis and dehydration

    Severe acidosis and fluid loss affect brain function. Unresponsiveness signals severe DKA.

21. A DKA patient's ETCO2 is likely to be:

    1. A. High
    2. B. Normal
    3. C. Absent
    4. D. Low
    Show answer

    Answer: D. Low

    Hyperventilation blows off CO2. A low ETCO2 can be an early clue to metabolic acidosis.

22. Some patients have features of both DKA and HHS at the same time. This means:

    1. A. The two can overlap
    2. B. One test excludes the other
    3. C. Only children get the mixed form
    4. D. Neither needs fluids
    Show answer

    Answer: A. The two can overlap

    Many adults present with mixed DKA-HHS, with significant ketoacidosis and very high osmolality. Recognizing overlap matters because both need careful fluids and monitoring.

23. Many people cannot smell the fruity acetone odor of DKA. This means:

    1. A. The odor is present in every case
    2. B. The patient must have HHS
    3. C. Ketones are not present
    4. D. No odor does not exclude DKA
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    Answer: D. No odor does not exclude DKA

    The ability to smell acetone varies widely, so an absent odor should not lower suspicion. Breathing pattern, glucose, and ketone testing are more reliable.

24. Which patient should be transported for possible DKA?

    1. A. A type 2 diabetic with a normal glucose
    2. B. A vomiting type 1 diabetic
    3. C. A non-diabetic with a head cold
    4. D. A diabetic who just ate lunch
    Show answer

    Answer: B. A vomiting type 1 diabetic

    Vomiting prevents oral intake and can cause DKA to develop quickly.

25. After 1 L of saline, an adult DKA patient's heart rate is still 130 and her mucous membranes are dry. This most likely reflects:

    1. A. Fluid overload from the bolus
    2. B. Normal recovery from DKA
    3. C. An ongoing large fluid deficit
    4. D. A reaction to the saline solution itself
    Show answer

    Answer: C. An ongoing large fluid deficit

    Adults in DKA often have a fluid deficit of 6 liters or more, so one liter rarely corrects tachycardia. Continue fluids per protocol while watching lung sounds and mental status.