CDCES Clinical Procedures and Protocols 2 — Questions and Answers
Question 1: Which site is preferred for continuous glucose monitor (CGM) sensor insertion in adults?
- Deltoid muscle
- Abdomen or upper arm (Correct answer)
- Inner thigh
- Calf
Correct answer: Abdomen or upper arm
The abdomen and upper arm are FDA-approved and preferred CGM insertion sites for most adult devices due to consistent interstitial glucose readings.
Approved CGM sensor sites vary by device, but the abdomen and upper arm are the most widely studied and FDA-cleared locations in adults. These areas provide consistent subcutaneous tissue depth and reliable interstitial glucose measurements. The CDCES must educate patients on rotation within approved sites to prevent lipohypertrophy and sensor inaccuracy.
Question 2: Before performing a finger-stick blood glucose check, which step is most important for accurate results?
- Wipe the first drop of blood away
- Squeeze the finger firmly from base to tip
- Clean the site with alcohol and let it fully dry (Correct answer)
- Use the dominant hand only
Correct answer: Clean the site with alcohol and let it fully dry
Alcohol residue on the finger can dilute the blood sample and cause falsely low readings; the site must fully dry before lancing.
If alcohol is still wet on the fingertip when the lancet is used, it mixes with the blood sample and can falsely lower the glucose reading. Allowing the site to fully air-dry (or wiping with a clean dry gauze) eliminates this error. Additionally, warming the hand improves blood flow. The CDCES reinforces proper technique to prevent erroneous values that could lead to incorrect insulin dosing.
Question 3: A patient reports that their insulin pump infusion set site has become red, swollen, and tender. What is the priority action?
- Apply topical corticosteroid cream to the site
- Remove the infusion set and rotate to a new site (Correct answer)
- Continue using the site but increase basal rate
- Cover the site with a sterile dressing
Correct answer: Remove the infusion set and rotate to a new site
Signs of infusion site infection or occlusion require immediate removal of the set and rotation to a new site to restore insulin delivery and prevent worsening infection.
Redness, swelling, and tenderness at an infusion site indicate a local reaction, possible infection, or site occlusion. Continued use risks abscess formation and poor insulin absorption leading to hyperglycemia or DKA. The CDCES teaches patients to remove and discard the infusion set immediately, inspect the site, and choose a new location at least 2 inches away. Medical evaluation is warranted if infection signs persist.
Question 4: When teaching self-injection technique for insulin, which angle is recommended for a person with very little subcutaneous tissue using a 4 mm pen needle?
- 90 degrees without a skin fold (Correct answer)
- 45 degrees without a skin fold
- 90 degrees with a lifted skin fold
- 30 degrees with a skin fold
Correct answer: 90 degrees without a skin fold
A 4 mm pen needle is short enough that a 90-degree angle without a skin fold is appropriate even in lean individuals, minimizing intramuscular injection risk.
Pen needles of 4 mm length are considered ultra-short and deposit insulin into subcutaneous tissue at a 90-degree angle without requiring a lifted skin fold in most adults and children. Longer needles (8 mm or more) in thin patients may require a 45-degree angle or skin fold to avoid intramuscular injection, which causes erratic absorption. The CDCES must be current on needle length guidelines from organizations like FITTER.
Question 5: Which protocol best describes the sick-day rules for patients with type 1 diabetes on insulin?
- Stop insulin completely to prevent hypoglycemia during illness
- Check blood glucose and ketones more frequently; never skip insulin doses (Correct answer)
- Increase carbohydrate intake to match elevated insulin sensitivity
- Avoid contacting the healthcare team unless glucose exceeds 400 mg/dL
Correct answer: Check blood glucose and ketones more frequently; never skip insulin doses
During illness, counter-regulatory hormones raise blood glucose; patients should increase monitoring frequency, maintain insulin doses, and check for ketones.
Sick-day management for type 1 diabetes includes: checking blood glucose every 2-4 hours, checking urine or blood ketones, maintaining or adjusting (not stopping) insulin doses, staying hydrated with carbohydrate-containing fluids if unable to eat, and contacting the healthcare team if glucose is above 240 mg/dL with ketones or if vomiting prevents fluid intake. The CDCES plays a critical role in pre-emptive sick-day education to prevent DKA hospitalizations.
Question 6: A CDCES is demonstrating how to use a glucagon emergency kit. Which instruction is correct for administering intramuscular glucagon?
- Inject into the forearm for fastest absorption
- Mix the powder and diluent, then inject into the outer thigh, upper arm, or buttock (Correct answer)
- Administer intravenously for severe hypoglycemia only
- Inject into the abdomen like insulin
Correct answer: Mix the powder and diluent, then inject into the outer thigh, upper arm, or buttock
Standard glucagon kits require reconstitution (mixing powder with diluent) and IM injection into a large muscle such as outer thigh, upper arm, or buttock.
Traditional glucagon emergency kits contain a powder vial and a diluent syringe that must be mixed before IM injection. Approved IM sites include the outer thigh, upper arm (deltoid), and buttock (gluteal muscle) -- not the forearm or abdomen. Nasal glucagon (Baqsimi) and autoinjector devices (Gvoke) have simplified administration, but the CDCES must teach whichever product the patient has been prescribed. Proper glucagon training for caregivers is a CDCES core competency.
CDCES Clinical Procedures and Protocols 2
Which site is preferred for continuous glucose monitor (CGM) sensor insertion in adults?