CA Review

Fourth Editon

a ‘Chapter review questions and practice tests for both CLT and CLS
a fe & A reflecting the NCA exam format, NCA job analysis, and
current entry-level practice
B Free CD-ROM with an additional 500 practice questions
a liars
Test-taking strategies and explanation of exam content, format,

WILLIAMS & WILKINS (ta Published in collaboration with the NCA

Pe ys Pron
ee
 NCA Review for the
Clinical Laboratory Sciences
4th Edition
 oS

NCA Review for the

Clinical Laboratory
Sciences 1 ag
Susan J. Beck, PhD, CLS (NCA)
Professor and Director
Division of Laboratory Science
University of North Carolina at Chapel Hill School of Medicine
Chapel Hill, North Carolina

& LA LIPPINCOTT WILLIAMS & WILKINS

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Preface

The NCA Review for the Clinical Laboratory Sciences was developed to assist
candidates preparing for the Clinical Laboratory Scientist (CLS) and Clinical
Laboratory Technician (CLT) certification and re-certification examinations.
This, the fourth edition of the book, reflects changes in the NCA examinations
resulting from a recent national job analysis. NCA regularly conducts job analy-
ses to determine the tasks that are considered important for the CLS and CLT in
the first year of practice. The NCA content outlines are derived from the job
analyses and the items on the NCA examinations are directly linked to the con-
tent outlines. This ensures that NCA examinations are relevant to current entry-
level practice.

As in the previous editions of this book, each chapter consists of sample items,
the correct answers, and explanations of items. Each subject area is divided into
CLT and CLS level questions. Additional review questions covering all the areas
on the CLS and CLT examinations are also provided. Candidates are encouraged
to complete the review sections before answering the review questions. The
questions in the chapters and the review questions are representative of the type
of items that are found on CLS and CLT examinations.

Mastery of the items provided in chapters or review questions in this book does
not ensure that a candidate will pass a certification examination. Careful review
of performance on the items presented in this book should, however, help a can-
didate identify areas of weakness that may be strengthened through additional
study and review. The references at the end of each review section may serve as
a guide for further study.

The NCA provides high-quality, clinically relevant peer-review certification

examinations for laboratory personnel. This book and the NCA certification
examinations are the result of the efforts of clinical laboratory practitioners who
are committed to certification by the profession and for the profession. The
authors hope that this book will help candidates prepare for NCA examinations
and attain the distinguished credentials of Clinical Laboratory Technician or
Clinical Laboratory Scientist.
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Acknowledgments

The National Certification Agency for Medical Laboratory Personnel gratefully

acknowledges the efforts of all the people who have contributed to each edition
of NCA Review for the Clinical Laboratory Sciences. We are particularly
indebted to James L. Bender, editor of the first edition, and Sharon L. Zablotney,
editor of the second edition of this book. NCA also acknowledges the laboratory
professionals who served as contributing authors in previous editions of this
Review Book:

Shauna C. Anderson Mary Ann McLane

Susan J. Beck Sharon M. Miller
Nancy A. Brunzel Frances A. Morgenstern
Suzanne H. Butch Donna L. Oblack
Susan Cockayne Joan E. Polancic
Suzanne W. Conner Joan A. Radtke
Kathryn Doig Bernadette F. Rodak
Rebecca Janine Fithen John P. Seabolt
Margaret J. H. Fuller Linda L. Seefried
Jean D. Holter Catherine Sheehan
M. Kathleen Huck Barbara Snyderman
William B. Hunt Betty Lynn Theriot
Judy C. Jones Linda M. Ubelacker
Marcia A. Kilsby Kathy V. Waller
Rosemary Kuhn Michelle S. Wright
Hal S. Larsen Patricia Etnyre-Zacher
Susan J. Leclair Joyce A. Zook

Each edition of this book has been the result of the hard work of chapter authors
and other contributing authors who wrote questions and explanations. The ded-
ication and expertise of these outstanding clinical laboratory professionals
exemplifies the best in the profession and serves as the foundation for the NCA
peer-review certification process.

vii
 Digitized by the Internet Archive
in 2022 with funding from
Kahle/Austin Foundation

https ://archive.org/details/ncareviewforclinO00OOunse_c/a3
Contributors

Chapter Authors Michelle S. Wright-Kanuth, PhD, CLS

(NCA)
Scott E. Aikey, CLS/CLDir (NCA), CHS Clinical Associate Professor
Lead Tissue Typing Technologist Department of Clinical Laboratory Science
Hospital of the University of Pennsylvania University of Texas Medical Branch at
Philadelphia, Pennsylvania Galveston
Galveston, Texas
Nancy Brunzel, MS, CLS (NCA)
Division of Medical Technology
Department of Lab Med and Pathology
University of Minnesota Contributing Authors
Minneapolis, Minnesota
Kathleen Beach
Kathryn Doig, PhD, CLS (NCA) Supervisor
Associate Professor and Chair University of Virginia Health Systems
Department of Medical Technology Charlottesville, Virginia
Michigan State University College of Human
Medicine Jimmy L. Boyd, CLS (NCA), MS/MHS
East Lansing, Michigan Chief Executive Officer
Research Services Unlimited, Inc.
Susan J. Leclair, PhD, MC, CLS (NCA) Jackson, Mississippi
Professor
Department of Medical Laboratory Science Heather DeVries, CLS(NCA)
University of Massachusetts Dartmouth Senior Medical Technologist
North Dartmouth, Massachusetts Clarian Health Partners
Indiana University Hospital
Connie R. Mahon, CLS (NCA) Thrombosis and Hemostasis Laboratory
Department of Clinical Laboratory Sciences Indianapolis, Indiana
University of Texas Health Science Center
San Antonio, Texas Virginia Emmons, MS, CLS (NCA)
Technical Specialist II
Bernadette F. Rodak, MS, CLSpH (NCA) Laboratory Accreditation Program
Associate Professor College of American Pathologists
Clinical Laboratory Science Northfield, [linois
Indiana University School of Allied Health
Sciences George A. Fritsma, MS, MT (ASCP)
Department of Pathology and Laboratory Diagnostic Service Manager
Medicine, School of Medicine Esoterix Coagulation
Indianapolis, Indiana Aurora, Colorado
Xx Contributors

Brenda N. Galloway, CLSup (NCA), CLSp(H) David L. McGlasson, MS, CLS (NCA)
Phenix Regional Hospital Research Medical Technologist
Phenix City, Alabama 59th Clinical Research Squadron/MSRL
Lackland Air Force Base
San Antonio, Texas
Mary M. Gourley, CLDir (NCA), CLS
Technical Supervisor Mary Ann McLane, PhD, CLS (NCA)
American Red Cross Blood Services Assistant Professor
Pittsburgh, Pennsylvania Department of Medical Technology
University of Delaware
William H. Hunt, MBA, CLS (NCA), CLSp(H) Newark, Delaware
Technical Manager
AutoLab and Central Receiving Terri L. Murphy-Sanchez, BSc, CLS (NCA)
Hospital of the University of Pennsylvania Laboratory Manager
Philadelphia, Pennsylvania Department of Clinical Laboratory Sciences
The University of Texas Health Science Center at
San Antonio
Kimberly Kinney, MT (ASCP) San Antonio, Texas
Technical Coordinator
Clarian Health Partners Stacey Pastore, CLS (NCA)
Indiana University Hospital Tissue Typing Technologist
Thrombosis and Hemostasis Laboratory Hospital of the University of Pennsylvania
Indianapolis, Indiana Philadelphia, Philadelphia
Contents

Preface
Acknowledgments
Introduction

1. Clinical Chemistry

2. Hematology and Hemostasis

3. Immunohematology

4. Microbiology

5. Immunology 143

6. Laboratory Practice

7. Review Tests 183

xi
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 Introduction

The NCA certification examinations for clinical laboratory technicians (CLTs)

and clinical laboratory scientists (CLSs) are designed to assess candidates’ com-
petence as entry-level clinical laboratory practitioners. The NCA offers general-
ist examinations for CLTs and CLSs and categorical examinations at the CLS
level. This review book is designed to help candidates prepare for the CLT- or
CLS-level examinations by (1) explaining the examination content, format, and
scoring method; (2) reviewing some test-taking strategies; and (3) providing
practice items and explanations. A careful review of the material in this book
should help candidates identify areas of weakness that can be strengthened
through additional study.

About NCA

The National Credentialing Agency for Laboratory Personnel (NCA) was estab-
lished in 1977 by members of American Society for Clinical Laboratory Science
(ASCLS) to provide a certification process for laboratory professionals that
would be controlled by laboratory professionals. NCA is governed by a Board
of Directors composed of representatives from NCA’s sponsoring organizations,
ASCLS and the Association of Genetic Technologists (AGT). A member of the
public and the chair of NCA’s Examination Council also serve on the Board of
Directors. NCA’s Examinations are developed by an Examination Council,
which is comprised of leading clinical laboratory educators, practitioners, and
administrators. NCA contracts with a professional testing agency, Applied Mea-
surement Professionals (AMP), to administer the examinations and provide psy-
chometric guidance.
NCA endorses the voluntary certification for laboratory professionals at
entry-level and re-certification of laboratory professionals throughout their
careers. NCA’s re-certification program allows individuals to document contin-
ued competence by re-examination or through the accumulation of continuing
education credits. Additional information on NCA examinations, publications,
and policies is available on NCA’s website: www.nca-info.org.

Examination Content

The NCA examinations are carefully developed in order to assess current entry-
level job competence. Through national job analyses, NCA identifies the tasks
that are most important for laboratory professionals in their first year of practice.
The content outlines are derived from these national job analyses and all items
Xiv Introduction

on the NCA examinations are directly related to tasks in the content outlines.
The NCA content outlines are available on the NCA website.
The CLT- and CLS-content outlines differ in some of the tasks included on
the examinations and in the cognitive level of the items in each section of the
examinations. The three cognitive levels used on the NCA examination are
recall, application, and analysis. Recall refers to the ability to remember previ-
ously learned material. This may involve remembering a simple fact or remem-
bering complex theories. Application involves translating or applying informa-
tion to new situations. This could involve transforming data, explaining
information, or calculating results. Items at the Analysis level involve evaluation
and problem-solving skills and usually require judgments or choices regarding
the appropriate course of action to resolve issues or problems.

Examination Format

The NCA examinations are comprehensive, job-related, objective tests adminis-

tered nationally by computer at AMP Assessment Centers. Before beginning an
examination, a candidate may practice taking a test on the computer. The time
used for the practice test is not counted as part of the examination time. The test
items are in a multiple choice format similar to the examples in this book. The
“stem” of the item will contain a statement or a question; after the stem, four
alternative answers will be presented. The one best answer should be chosen.

Pre-testing items
To keep NCA’s examinations reflective of current practice, new questions must
be continuously developed and introduced in versions of the test. NCA uses
“pre-testing” to collect meaningful statistics about new questions that may be
scored on future examinations. Pre-test items are interspersed throughout the
examination, however, they are not scored as a part of the candidate’s creden-
tialing examination and they do not affect a candidate’s pass/fail status.

Scoring the Examination

After you have completed the examination, you will receive a score report that
includes a raw score, the number of questions correctly answered, and a scaled
score. A scaled score is statistically derived from the raw score. Because differ-
ent test forms may vary slightly in difficulty from one to another, it is desirable
to report examination scores as scaled scores to ensure that all candidates have
demonstrated the same level of competence regardless of which form of the test
they took. NCA uses a scaled score range of 0 to 99 with the passing scaled score
of 75 for each examination.
Each of the scored items contributes equally to the final test score. In other
words, a candidate does not need to obtain a minimum score in each area of the
examination (e.g., microbiology, laboratory practice). Only correct answers con-
tribute to the total score; points are not subtracted for incorrect answers or unan-
swered items.
In determining the passing score for the NCA examination, the NCA seeks to
reflect the minimum skill level required for competent job performance. The
passing score separates the individuals who are minimally competent to practice
—_—_
Introduction XV

from the individuals who are not competent to practice. This method of scoring
is very different from the norm-referenced scoring used in many educational pro-
grams. The criterion-referenced NCA examinations do not compare candidates
with one another but with a predetermined score that reflects minimal compe-
tence. To determine the passing score, the NCA conducts a cut-score study.
Experts in the field are asked to evaluate the questions on the examinations and
to determine the percentage of minimally competent candidates who would be
likely to answer each question correctly. The estimates of eight to ten experts are
averaged for each question. The minimum passing score on an examination is
determined by averaging the probabilities for all the items on the examination.

Important Examination Policies

Arrive on time
Give yourself plenty of time to find the test center, park your car, and check in
with the test supervisors. Arriving with time to spare will help you feel more
relaxed and less rushed when you begin the examination. Anyone who arrives
more than 15 minutes after the scheduled testing time will not be admitted and
must reapply for the examination.

Have the correct forms of identification

Two forms of identification are required, one with a current photograph. Both
forms must be current and include your current name and signature.

What you can bring

A silent, non-programmable calculator may be used during the examination. You
will be provided with scratch paper to use during the examination which must
be returned to the supervisor at the completion of testing.

What you can’t bring

You cannot bring books, papers, dictionaries, other reference materials, or per-
sonal items (purses, briefcases, coats, hats, etc.) into the assessment center. You
should keep all personal items in your automobile. No eating, drinking, or smok-
ing is allowed in the assessment center.

Watch the time

The examination will be timed. The computer will indicate the time remaining
on the screen. If you find this feature distracting, the time feature can be turned
off during the examination.

Test Taking Strategies

Study!
There is no substitute for knowing the subject material. Review and study all the
resources from your educational program. The notes and charts that you pre-
xvi
es
eR Introduction

pared as a student or that you make as you study are particularly helpful because
they reflect your learning style and organizational schemes. After you have stud-
ied a section, use this book to test your knowledge and understanding of the
material. Remember that items in this book are only samples of the subject mat-
ter. Your review must be comprehensive.
Review the content outline. This is an important guide to the content of the
examinations and the amount of coverage given to each area. Make a special
effort to review areas on the content outline that are unfamiliar to you.

Organize your time

Periodically note the time as you work through the examination so that you give
yourself sufficient time for each part.

Stay calm
Do not let frustration over any one item or section influence your performance
on the rest of the examination. Do not panic if you are stumped by an item. It is
possible that items will be difficult for you or will contain unfamiliar or
unknown information. Everyone misses some questions on a national certifica-
tion examination. If you stay calm, you will be more confident as you continue
to work through the exam. Remember that all items are equally weighted, so it
is in your best interest to proceed to an easier question if you are having diffi-
culty.

Answer all the questions

There is no penalty for guessing so be sure to answer each question.

Should you change your answers?

You can go back and review your answers at any time during the testing period.
In general, it is better not to change an answer, because your first impression is
usually best. However, if you find that you misread a question the first time or,
if you recall some information after working through the examination, you may
improve your score by changing the answer to an item.

Improving your performance on

multiple-choice questions

Most candidates have answered thousands of multiple choice questions by the

time they take the NCA examination and are comfortable with this format. Many
candidates like multiple-choice questions because the correct answer is provided
and they always have a 25% chance of guessing the right answer. Other candi-
dates have difficulty with multiple choice questions because they read too much
into the question or because they read too quickly and miss a key word or num-
ber. The multiple choice items used on the NCA examinations have been care-
fully written and reviewed. In answering the questions, remember that they are
straightforward and are not intended to “trick” the candidate but to assess the
candidate’s knowledge in a particular area.
 Introduction xvii

Performance on multiple-choice items cam be improved by following a few

guidelines.
Read the stem carefully. After reading the stem, think of the correct answer
before you look at the alternatives. Some people cover the alternatives while
reading the stem to force themselves to think of the answer. After deciding on
the right answer, read the alternatives. If you are correct, your answer should
be one of the choices.
In some cases, you may not be sure of the right answer immediately after read-
ing the stem. In this case, read each alternative. Cross out any alternatives that
are obviously incorrect. Select the best answer from the plausible alternatives.
If you have no idea what the correct answer is, make a guess and go on to the
next question. Remember that you have a 25% chance of guessing correctly
and that there is no penalty for guessing incorrectly.
Do not spend too much time on any one question. If you are having difficulty
with an item, make a guess and proceed to the next item. The more items you
answer, the better your chances of achieving a passing score.

Summary

Study the material that you have been given in your educational program. Use
the content outline as a study guide and this book to test your performance.
Review all the material in the candidate handbook regarding test administration
so that there will be no surprises on the day of the examination. Stay calm and
pace yourself as you work through the examination.
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 Clinical Chemistry Clini
Chem

Chapter Author Nancy Brunzel

CLT Review Questions

1. The turbid appearance of lipemic serum is due to an elevated level of

A. cholesterol
B. HDL
C. phospholipid
D. triglycerides

The answer is D. Lipemia is due to the presence of large fat-containing micelles.

Both chylomicrons and VLDL particles have large enough diameters to scatter
light, giving the specimen a turbid appearance. Both particles contain a high pro-
portion of triglycerides. (Kaplan and Pesce, pp. 427, 661)

2. A trough blood sample for routine therapeutic drug monitoring is usually

obtained

A. just after a dose is administered

B. just before the next scheduled dose
C. at the calculated peak time after a dose
D. one half-life after a dose is administered

The answer is B. Individuals differ markedly in their rates of clearance of drugs

due to differences in absorption, distribution, metabolism, and excretion. Factors
such as age, liver and kidney status, protein binding, and the presence of other
drugs influence serum drug levels. The trough level, obtained immediately
before administering a dose, is frequently used to monitor serum drug concen-
trations and adjust drug dosage regimens. (Kaplan and Pesce, p. 1087)

3. To quantitate urinary vanillylmandelic acid (VMA), which of the following

specimens should be collected?

A. 24-hour urine collection

B. First morning urine sample
C. Random, mid-stream clean catch
D. Two-hour urine collection following the midday meal, 1.e., 2:00-4:00 pm

The answer is A. Vanillylmandelic acid (VMA) is a metabolite of the catechol-

amines: epinephrine, norepinephrine, and dopamine. Due to the potential effects of
exercise, hydration, and body metabolism on excretion rates, a 24-hour collection is
the specimen of choice. (Kaplan and Pesce, p. 1117; Bishop et al., p. 417)
 4. Situation: It is 8:00 am and you are working in the Specimen Receiving and
Processing Area of the laboratory. The following specimens are received.
Which requires intervention before proceeding with processing and testing?

Test requested Specimen received Time collected

A. Alkaline phosphatase EDTA 7:30 am
B. Glucose sodium fluoride 6:10 am
C. Blood gases heparin, in ice slush 7:35 am
D. Electrolytes (Na & K) lithium heparin 5:50 am

The answer is A. Alkaline phosphatase, as with many enzymes, should not be

collected in EDTA or oxalate because these collection tubes chelate ions neces-
sary for enzyme activity. Glucose levels in sodium fluoride specimens are stable
at room temperature for 24 hours. Blood gas specimens collected anaerobically
in heparin and stored in ice water slush are stable for 30 minutes after collection.
Sodium and potassium levels in plasma are stable for 1 week at room tempera-
ture. (Lehmann, pp. 47, 79, 140, 161)

5. A single tube of cerebrospinal fluid is received in the laboratory and the fol-
lowing tests requested: total protein, albumin, IgG quantitation, microbial
culture, Gram stain, leukocyte count, and differential cell count. The speci-
men should be sent to the various laboratories in which order?

A. Chemistry lab, hematology lab, microbiology lab

B. Hematology lab, chemistry lab, microbiology lab
C. Microbiology lab, hematology lab, chemistry lab
D. Hematology lab, microbiology lab, chemistry lab

The answer is C. The microbial culture should be performed first to ensure that
sterility of the specimen is not compromised. Usually, cell counts are performed
next, followed by chemical testing. With low volume specimens, the physician
often prioritizes the remaining tests requested. (Brunzel, p. 368)

6. Which of the following components determines the wavelength of light that

will pass through the sample cuvette in a spectrophotometer?

A. Detector
B. Light source
C. Potentiometer
D. Monochromator

The answer is D. The monochromator isolates the desired wavelength of light

(monochromatic light) and excludes that of other wavelengths. (Burtis and Ash-
wood, pp. 62-64)

7. Which of the following specimens usually requires concentration before

analysis?

A. Urine for osmolality

B. Amniotic fluid for L/S ratio
C. Plasma for making a protein-free filtrate
D. Cerebrospinal fluid for protein electrophoresis
 3°
CLT Review Questions
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low, it must be concentrated 80- to 100-fold before electrophoresis. This is com- ro
monly achieved using commercial concentrator systems. (Brunzel, pp. 376-377; =
Lehmann, p. 32) =
w)

8. You need to prepare a | to 4 (1:4 or 1/4) dilution of a serum specimen using

saline before analysis. Which of the following pipetting steps would result
in this dilution?

A. Pipet 0.5 mL serum, then add 1.0 mL saline

B. Pipet 1.0 mL serum, then add 2.0 mL saline
C. Pipet 1.5 mL serum, then add 4.5 mL saline
D. Pipet 2.0 mL serum, then add 5.0 mL saline

The answer is C. A | to 4 dilution means that of a total volume of 4 parts, 1 part

is sample. The sample volume in choice C is 1.5 mL (1 part) and the total vol-
ume of the mixture is 6.0 mL or 4 parts; hence a | to 4 dilution of the sample is
made. Choices A and B are 1:3 dilutions and choice D is a 1:2.5 dilution. (Bishop
et al., pp. 22-23; Lehmann, p. 1213)

9. Which of the following situations indicates that an instrument problem is

present and requires further investigation?

A. A series of high anion gaps

B. A series of high glucose results
C. A series of low urine osmolality results
D. A series of low urine specific gravity results

The answer is A. The anion gap is a useful quality control tool for an instrument
that performs electrolyte measurements (Na*, K*, Cl~, HCO ;~). Consistently
abnormal gaps (either increased or decreased) in a series of samples can indicate
a problem in one of the electrolyte measurements and requires further investi-
gation before results are reported. (Bishop et al., pp. 274-275; Lehmann, pp.
138-139)

10. The major components of a spectrophotometer are represented in the fol-

lowing diagram. Which component determines the factor “b” in Beer’s law,
A= abc?

A B GeaD
‘ : ;
O- +--+ 4-9)
A. ComponentA
B. Component B
C. Component C
D. ComponentD
The answer is C. The sample cuvette determines the length of the light path
through the sample (i.e., the value of “b” in Beer’s law). Typically, sample
cuvettes with a light path of 1 cm are used. In so doing, the path length (b) and
molar absorptivity (a) for a particular analyte become a constant at a given
wavelength. In which case, the absorbance (A) observed is proportional to the
analyte concentration (c). (Bishop et al., pp. 98-101)

11. Samples for calcium analysis by atomic absorption spectrophotometry

should be diluted with a lanthanum solution because lanthanum ions

A. blank for variations in flame temperature

B. blank for variations in lamp intensity
C. emit light used as the internal standard
D. enhance dissociation of calcium phosphate

The answer is D. Because of the requirement of a cool flame in atomic absorp-

tion spectrophotometry, some calcium salts are not broken into their component
atoms; calcium phosphate is an example. The electrons in these anion-bound
calcium atoms are then unable to absorb the incident wavelength of light and are
not measured. Lanthanum binds the same anions more tightly than does calcium,
which releases calcium from these salts. This allows the calcium electrons to
achieve their ground state, absorb light energy, and be measured. (Kaplan and
Pesce, pp. 96, 549)

12. Ata pH of 7.4, which of the enzymes listed catalyzes the following reaction?

pyruvate + NADH > lactate + NAD

A. Lactate oxidase
B. Lactate dehydrogenase
C. Pyruvate kinase
D. Pyruvate decarboxylase

The answer is B. The International Union of Biochemistry (UB) assigns a sys-

tematic name to each enzyme, which defines the substrate, the reaction cat-
alyzed, and the coenzyme involved, if any. In addition, IUB assigns a “recom-
mended name” that is shorter, trivial, and more useable. None of the following
groups are present in the reaction: oxygen, carboxyl group, phosphate group,
ATP, ADP, etc. Therefore, the enzyme for this reaction is not an oxidase, car-
boxylase, or kinase and choices A, C, and D are eliminated. (Bishop et al., pp.
208-209, 218-219)

13. Chromatographic separation of a mixture of solutes is based on

. variable solubilities of solutes in the mobile and stationary phases

. spectral differences of solutes in the mobile and stationary phases
. selective degradation of solutes by the mobile and stationary phases
S . differential distribution of solutes between the mobile and stationary
DAW
phases

The answer is D. Chromatography is a collective term referring to the process of

separating a mixture of solutes by differential distribution of the solutes between
two phases. One phase, the solvent, is mobile and carries solutes with it as it
 CLT Review Questions 5 >he
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passes over or through the stationary phase. The solutes interact to differing
7
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degrees with the fixed or stationary phase thereby causing separation. Thus,
ro
solutes that differ in their attraction to the stationary phase can be separated from 2
one another. (Kaplan and Pesce, p. 107) =
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14. In a coupled enzymatic method for measuring serum cholesterol, the color
change observed during the indicator reaction is dependent upon the gener-
ation of

A. ATP
B. NAD
C. oxygen
D. hydrogen peroxide

The answer is D. The enzymatic method for measuring total cholesterol incu-
bates serum with cholesterol esterase (to release free cholesterol). Subsequently,
cholesterol oxidase oxidizes the cholesterol producing hydrogen peroxide. In the
presence of peroxidase, the hydrogen peroxide produced oxidizes the reduced
dye to form a colored product. (Kaplan and Pesce, pp. 672-674)

15. pH 8.6 is used for serum protein electrophoresis so that

A. all serum proteins will have a net negative charge

B. all serum proteins will have a net positive charge
C. electroendosmosis is avoided
D. heat production is minimized

The answer is A. Proteins are ampholytes whose terminal amino and carboxyl
groups, as well as ionizable side groups on component amino acids, change their
charges with change in pH. At a pH higher than the pK of these ionizable groups,
dissociable hydrogen ions are lost to the medium resulting in no charge on each
amino group and a negative charge on each carboxyl group. The net charge on the
protein therefore becomes negative. The amount of heat produced and the buffer
migration (electroendosmosis) that occur are determined in large part by the con-
centration of the buffer. (Kaplan and Pesce, p. 201; Bishop et al., pp. 189-192)

16. When quantitating serum protein using the biuret reaction, the biuret
reagent is reacting with

A. peptide bonds in proteins

B. tyrosine residues in proteins
C. free amino groups in proteins
D. ammonia released from proteins

The answer is A. In an alkaline solution, the cuprous ions of the biuret reagent
form coordinate bonds with the carbonyl groups of peptide bonds. This associa-
tion results in the characteristic blue colored complex. (Bishop et al., pp. 186-187)

17. Which one of the following protein fractions, when separated in serum by
electrophoresis on cellulose acetate, contains a single protein?

A. Albumin
B. Alpha,-globulin
 C. Alpha,-globulin
D. Beta-globulin

The answer is A. The large peak of albumin seen on a serum electropherogram

is virtually pure albumin. Because electrophoresis on cellulose acetate separates
proteins according to their net charges, the other peaks seen are mixtures of the
proteins that share approximately the same net charge. (Bishop et al., pp.
189-192)

18. Which of the following statements about the hexokinase reaction for serum
glucose quantitation is true?

. The amount of hydrogen peroxide produced is measured

. During the reaction cupric ions are reduced to cuprous ions
. The reaction generates a green condensation product with o-toluidine
S . The coupled indicator reaction generates NADPH from glucose-6-phos-
Daw
phate

The answer is D. Hexokinase catalyzes the phosphorylation of several mono-

saccharides using ATP as the phosphate donor and produces the corresponding
sugar-6-phosphate. However, the indicator reaction is specific for the substrate,
glucose-6-phosphate. During this reaction, glucose-6-phosphate dehydrogenase
(G-6-PD) catalyzes the reaction of glucose-6-phosphate and NADP to form 6-
phosphogluconate and NADPH. It is the high specificity of the indicator reac-
tion that prevents interference from other monosaccharides. (Bishop et al., pp.
306-308; Lehmann, p. 52)

19. Turbidimetric assays for serum lipase measure the

A. amount of bile acid produced

B. amount of titratable acid produced
C. rate of production of NADH
D. rate of degradation of triglyceride micelles

The answer is D. Lipase acts at the surface of triglyceride micelles, hydrolyzing

terminal fatty acids from glycerol. As the micelles become smaller, they scatter
less light and the substrate suspension becomes less turbid. The rate of clearing
of turbidity reflects the amount of lipase activity. (Kaplan and Pesce, pp.
568-569)

20. Osmolality measurements determine the

A. activity of ions per kilogram of solvent

B. grams of dissolved solutes per kilogram of solvent
C. moles of dissolved solutes per kilogram of solvent
D. equivalents of dissolved solutes per kilogram of solvent

The answer is C. Osmolality is defined as the number of moles of particles per

kilogram of water. It is a measure of a solution’s concentration and it is irrele-
vant whether the particles are ions or nonionized solutes. Therefore, regardless
of molecular weight, size, or charge each dissolved solute contributes equally to
the osmolality value. (Kaplan and Pesce, pp. 271-272)
 CLT Review Questions 7 >
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21. Which of the following formulas can be used to calculate serum osmolality? =
U

A. 2.5 X Nat G
<
B. Nat + K* + Cl- + CO, content =
C. (1.86 X Na*) + (1/18 X glucose) + (1/2.8 X BUN) +9 )
D. (Na* + K*) — (Cl- + HCO,-)

The answer is C. This formula, using routine serum determinations of Na, glu-
cose, and BUN, can be utilized to estimate serum osmolality. Because the body
maintains electrical neutrality, each serum cation is balanced by an anion.
Sodium is the major serum cation; therefore, two (or more accurately, 1.86) X
Na (in mmol/L) accounts for most ions present. Glucose and BUN are also
major contributors to serum osmolality. Dividing glucose (in mg/dL) by 18 and
BUN (in mg/dL) by 2.8 converts these concentrations to mmol/L. The remain-
ing unmeasured solutes that contribute to the osmolality in serum normally
amount to 9 mmol/L. The calculated osmolality is used to determine the osmo-
lal gap by subtracting this calculated osmolality value from the actual or meas-
ured value. An abnormally high osmolal gap can be due to the ingestion of a
volatile substance such as ethanol, methanol, or ethylene glycol. (Bishop et al.,
pp. 257-258; Kaplan and Pesce, pp. 459-461)

22. The following chemical reaction is used to measure the activity of which of
the following serum enzymes?

coo- coo- coo- coo-

] | : line
C=O 4+ H—-C—NHo
H—C—NH2 + C—O sees

| |
CH2 Coo- CH
are
coo-
Ccoo- coo-

A. Alkaline phosphatase
B. Aspartate aminotransferase
C. Gamma glutamyltransferase
D. Lactate dehydrogenase

The answer is B. The International Union of Biochemistry (IUB) assigns a sys-

tematic name to each enzyme, which defines the substrate, the reaction cat-
alyzed, and the coenzyme involved, if any. In addition, IUB assigns a “recom-
mended name” that is shorter, trivial, and more useable. The transfer of an amino
group from one molecule (aspartate) to another (alpha-ketoglutarate) occurs in
this reaction (i.e., amino transfer). In addition, neither lactate, a glutamyl
residue, nor phosphate is present eliminating choices A, C, and D. (Bishop et al.,
p. 220)

23. When using an automated instrument, the amount of carryover between

consecutive samples is not affected by

A. rinsing the probe between samples

B. separating consecutive samples in a tubing by air segments
 C. using a separate reaction chamber for each sample
D. using a serum blank

The answer is D. Carryover is the percent error produced by interaction or cross-

contamination between adjacent samples. All techniques that rinse the compo-
nents that touch adjacent samples or that increase the physical separation
between adjacent samples decrease carryover. (Burtis and Ashwood, pp. 213,
219; Bishop et al., pp. 137-141)

24. When performing a thin layer chromatography procedure, the solvent front
moved 10.0 centimeters. The substance of interest moved 4.0 centimeters.
What is the R,; for the substance of interest?

Ay. O25
B. 0.40
Ce
D. 4.0

The answer is B. The retention time or R,; of a substance or compound is defined

as the distance of spot migration divided by the distance of the mobile phase
migration. (Burtis and Ashwood, p. 111)

25. Calculate the corrected creatinine clearance using these data obtained from
a person with a 1.73 m* body surface area:

Serum creatinine: 1.3 mg/dL

Urine creatinine: 2.4 mg/mL
Urine volume: 1000 mL/24 hour
A. 119 mL/min
B. 128 mL/min
C. 139 mL/min
D. 167 mL/min

The answer is B. The formula for calculating creatinine clearance (CCr) is:
CCr= UeV x 73m

SA CCr = creatinine clearance in mL/minute

U _=urine creatinine
P =plasma/serum creatinine
V =urine volume in mL per minute
SA = patient’s body surface area

When using this formula, it is required that the urine and serum creatinine con-
centrations be in the same units so that the units cancel. Therefore, the urine con-
centration must be converted to 240 mg/dL before using the formula. The urine
volume (V) must also be converted from mL per 24 hours to mL per minutes as
follows:

-urine volume (mL) y hour

_ _ = y jnmL/minut
24 hour 60 minutes mi imei

Because creatinine excretion varies with muscle mass (i.e., body surface area),
comparison to a reference range requires that the clearance be corrected for the
individual’s body surface area in square meters. (Brunzel, pp. 106-109)
 CLT Review Questions 9 >
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26. A serum sample is diluted 1 to 3 (1:3) before analysis and the following As,
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results obtained:
G
ne
Total protein — 4.1 g/dL =
Albumin — 1.5 g/dL w)
Which total protein concentration should be reported?
A. 4.1 g/dL
B. 8.2 g/dL
C. 12.3 g/dL
D. 16.4 g/dL
The answer is C. The dilution factor for the dilution is 3; hence 3 times 4.1 is
12.3 g/dL. (Bishop et al., pp. 22-23)

27. Which of the following formulas is an accurate rearrangement of Beer’s

law, when using a calibration constant (K)?

. c=A/K
b=A eK
Per C/ie
DUALS
aK =a ec
A

The answer is A. When an assay follows Beer’s law, a calibration constant (K) can
be derived and used to calculate the concentration of the analyte in unknown sam-
ples. The factor “K” is determined from the analyte absorptivity (a) and the instru-
ment path length (b). With this substitution and subsequent rearrangement of
Beer’s law, the expression c = A/K is obtained. (Burtis and Ashwood, pp. 59-60)

28. A patient with biliary obstruction has a serum bilirubin assay performed.
The bilirubin results determined using the Jendrassik-Grof method are as
follows:
Total bilirubin: 0.8 mg/dL
Conjugated bilirubin: 1.0 mg/dL
The clinical laboratory technician does not report the results. The results
obtained are most consistent with
A. a technical error occurring during analysis
B. insufficient accelerator added to the total bilirubin reaction
C. a reduced reaction time for the conjugated bilirubin reaction
D. excess diazo reagent added to the conjugated bilirubin reaction

The answer is A. The conjugated fraction of bilirubin cannot exceed the total
amount of bilirubin in a sample. This indicates a technical error during sample
analysis. Each of the reaction conditions presented in choices B, C, and D will
not cause the results obtained. (Bishop et al., pp. 386-388)

29. In an adult, a blood glucose level of 35 mg/dL is

A. normal
B. dangerously low
C. dangerously high
D. physiologically impossible
The answer is B. True hypoglycemia of this magnitude can cause neurologic
symptoms and may result in irreversible damage. A very low serum glucose
value also may be an artifact caused by cellular metabolism or bacterial con-
tamination if serum is not separated from cells promptly. (Kaplan and Pesce, pp.
634-635)

30. Measurements of urinary human chorionic gonadotropin (HCG) in men can

be used to

A. diagnose hypogonadism
B. detect testicular tumors
C. assess pituitary function
D. detect excessive estrogen secretion

The answer is B. In addition to the detection of pregnancy, HCG is frequently

used to detect and monitor germ cell tumors of the testis and ovary. HCG levels
are also used to diagnose and monitor gestational trophoblastic disease such as
hydatidiform mole, gestational choriocarcinoma, and placental-site trophoblas-
tic tumor. (Bishop et al., pp. 490-491)

31. Xanthochromic cerebrospinal fluid is an indicator of

A. bacterial meningitis
B. increased pressure of cerebrospinal fluid
C. increased protein concentration in cerebrospinal fluid
D. cerebral hemorrhage

The answer is D. Xanthochromia in spinal fluid is yellow pigmentation caused

by the presence of bilirubin. The bilirubin results from breakdown of heme
released from erythrocytes after bleeding into the brain or spinal column such as
occurs in cerebral hemorrhage. (Brunzel, pp. 368-370; Bishop et al., p. 534)

32. A creatinine clearance result below the normal reference range most likely
indicates a decrease in

A. hepatic blood flow

B. hepatic creatinine synthesis
C. renal blood flow
D. renal glomerular filtration

The answer is D. A creatinine clearance test determines the volume (mL) of

plasma cleared of creatinine per minute. Creatinine readily passes the glomeru-
lar filtration barrier of functioning glomeruli and is excreted in the urine. No
tubular reabsorption and negligible tubular secretion of creatinine occurs in the
nephrons. Assuming no preanalytical or analytical errors, when a creatinine
clearance is below the appropriate reference interval, it indicates a decrease in
functioning glomeruli, i.e., glomerular filtration. (Brunzel, pp. 106-109)

33. A physician suspects that a patient has Cushing’s syndrome. Based on this
information, which of the following tests would assist in this diagnosis?

A. Cortisol level
B. Vanillylmandelic acid level
 CLT Review Questions 11 Pa)
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D. 24-hour creatinine clearance
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The answer is A. Both Cushing’s syndrome and Cushing’s disease are associated =
with excessive levels of cortisol. Hypercortisolism can be due to tumors of the w)
pituitary, adrenal glands, or ectopic ACTH-secreting tumors. Exogenous admin-
istration of glucocorticoids or ACTH can also result in symptoms of Cushing’s
syndrome. (Bishop et al., pp. 414-415)

34. Which of the glucose tolerances curves in the following figure meet NDDG
(National Diabetes Data Group) criteria for the diagnosis of diabetes mellitus?

Plasma
glucose—mg
/100
mi

A. Curves | and 2
B. Curves 1 and 4
C. Curves 3 and 4
D. Only curve 4

The answer is C. NDDG criteria for the diagnosis of diabetes mellitus include
either (1) fasting serum glucose level greater than 140 mg/dL on more than one
occasion, or (2) two or more serum samples with glucose levels greater than 200
mg/dL following a meal. Curve 3 meets the latter criterion and curve 4 meets
both criteria. (Burtis and Ashwood, pp. 439-441; Bishop et al., p. 307)

35. Identify the results that are not in electrolyte balance. (Results are in
mmol/L.)
Na* K+ CI- CO, content
125 4.5 100 10
135 oi) 95 28
rs Nn 4.0 90 15
VaAw>
150 >.Oene £110 30
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The answer is C. Electrolyte balance is determined by calculating the anion gap

(AG) using the formula: (Na + K) — (Cl + CO, content) or (Na) — (Cl + CO,
content). The latter calculation predominates because potassium can be signifi-
cantly increased in samples that are hemolyzed. The AG or difference obtained
reflects the presence of anions that are not included in the equation. The refer-
ence interval for the anion gap (without K) is 8 to 16 mmol/L; with K, the ref-
erence interval is 10 to 20 mmol/L. (Lehmann, pp. 138-139)

36. Which set of results is consistent with a diagnosis of respiratory acidosis?

Arterial pH Arterial pCO,

A. Decreased Decreased
B. Decreased Increased
C. Increased Decreased
D. Increased Increased

The answer is B. Respiratory acidosis is characterized by a decreased blood pH

caused by an excess of CO , i.e., an absolute excess of carbonic acid. This occurs
when the lungs are not able to adequately expel CO. The carbonic acid (H,CO3)
concentration can be calculated from the pCO, as follows: 0.03 * pCO, =
H,CO;. When there is an excess of carbonic acid relative to the bicarbonate con-
centration in the blood, the pH will decrease. Note that to evaluate acid-base dis-
orders, the pO, is not needed. (Lehmann, p.163; Bishop et al., pp. 241-243)

37. Review the following serum test results:

Creatinine 2.5 mg/dL (0.7-1.5 mg/dL)
Cholesterol 220 mg/dL (< 220 mg/dL)
Glucose 110 mg/dL (70-110 mg/dL)
Urea 40 mg/dL (8-26 mg/dL)
Uric acid 6.9 mg/dL (2.5-7.0 mg/dL)
These results are most consistent with

A. compromised renal function

B. impaired glucose metabolism
C. diagnosis of gouty arthritis
D. increased risk for coronary artery disease

The answer is A. Urea, a product of protein metabolism, and creatinine, a by-

product of muscle metabolism, are dependent on the kidney for elimination from
the body. Hence, elevated serum values are associated with renal disease or loss
of renal function. Whereas elevations in urea can also occur due to nonrenal fac-
tors, these conditions will not demonstrate the magnitude of creatinine increase
also present in these results without compromised renal function. (Lehmann, pp.
155-156)

38. The amniotic fluid from a 40-year-old female is tested and the following
results obtained:

Test Result Reference Interval

L/S ratio: 1.6 220
Alpha-fetoprotein: normal normal
 CLT Review Questions 13
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Based on these results, if the fetus were delivered today it could have
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A. Down’s syndrome r
B. an open neural tube defect i
‘
C. respiratory distress syndrome w)
D. an increased risk of renal failure

The answer is C. An L/S ratio less than 2.0 is associated with increased risk of
respiratory distress syndrome in the neonate. A decrease in alpha-fetoprotein
(AFP) is associated with Down’s syndrome; whereas, an increase is associated
with open neural tube defects. Fetal renal function cannot be assessed from the
results provided. (Burtis and Ashwood, pp. 906-917)

39. A plasma sample was analyzed using ion selective electrodes (ISE) and the
following electrolyte results obtained:

Na* = 140 mmol/L

K* = 14.0 mmol/L
C15 = 112 mmo
HCO,~ = 18 mmol/L
These results are consistent with a specimen that
A. is severely lipemic
B. is slightly hemolyzed
C. was collected in an EDTA tube
D. needs to be diluted and reanalyzed

The answer is C. The result that is of most concern is the potassium of 14.0
mmol/L, which is incompatible with life. Potassium EDTA is a commonly used
anticoagulant tube for the collection of blood plasma. Occasionally, an EDTA
plasma specimen is inadvertently analyzed for electrolytes, as in this case.
Lipemia can affect electrolyte results but would cause a false decrease in elec-
trolyte values if an indirect ISE method was used. Slight hemolysis is not cor-
rect because of the magnitude of increase in the potassium result. Note that the
potassium value increases only ~ 0.6% with the release of 10 mg/dL hemoglo-
bin from erythrocytes. Lastly, a potassium of 14.0 mmol/L is within the linear
range of most potassium methodologies, eliminating the need to dilute this sam-
ple. (Burtis and Ashwood, pp. 37-38)

40. A patient suffering from an acute hemolytic episode has a total bilirubin of
2.2 mg/dL (0.2-1.1 mg/dL). Based on this information, which of the fol-
lowing conjugated and unconjugated bilirubin results would you expect?
(Reference values are in parentheses.)

Conjugated Unconjugated
(0 — 0.2 mg/dL) (0 — 1.1 mg/dL)
AOrt 21
BeOS es
Cr i0 ih
DIG 0.6

The answer is A. Acute hemolytic anemia can result in prehepatic jaundice char-
acterized by increased serum bilirubin due to a process that precedes bilirubin
processing by the liver. Despite a healthy liver, its ability to rapidly process the
additional unconjugated bilirubin presented is compromised. This is reflected by
an increased unconjugated bilirubin fraction with a normal conjugated fraction.
(Kaplan and Pesce, pp. 511-512)

41. Which of the following urine specimens is most useful when screening for
glucosuria?

A. First morning specimen

B. 2-hour postprandial specimen
C. 24-hour urine specimen
D. Midstream clean catch specimen

The answer is B. A 2-hour postprandial specimen collected after a meal is an

ideal specimen to screen for glucosuria. In a healthy individual, glucose does not
appear in the urine because it is reabsorbed by the renal tubules. However, in an
uncontrolled diabetic individual, the amount of glucose presented to the tubules
exceeds their renal capacity for reabsorption. Because the amount of glucose in
the urine ultrafiltrate is dependent on the glucose concentration in the plasma,
specimens collected on these individuals during a fasting state may not detect
any glucose. (Brunzel, pp. 55, 172-174)

42. What is the longest time that a urine specimen can remain at room temper-
ature before it is no longer considered acceptable for analysis?

A. 1 hour
B. 2 hours
C. 3 hours
D. 4 hours

The answer is B. Due to the changes that can take place in unpreserved urine,
specimens should be analyzed within 2 hours of collection or precautions taken,
such as refrigerate the specimen or add an appropriate preservative. (Brunzel,
pp. 58-59; NCCLS, p. 4)

43. Which of the following situations requires corrective action before pro-
ceeding with specimen testing?

A. Room temperature of the laboratory is 25°C

B. Refractometer result obtained using Type I water is 1.000
C. Temperature of the refrigerator that stores the QC materials reads 2°C
D. Reagent strip protein result is trace when using negative control material

The answer is D. Quality control materials are used to assess whether a test is
performing properly, i.e., they monitor analytical performance. A negative con-
trol material should produce negative results when analyzed. A trace protein
indicates a change in performance and is not acceptable. Hence, intervention is
required to identify and correct the cause of the false-positive result before ana-
lyzing any patient samples. (Brunzel, pp. 34-40, 148-152)

44. The urinalysis reagent strips from four different bottles are evaluated using
the current quality control (QC) materials. Which bottle of reagent strips is
acceptable for use today?
 CLT Review Questions 15 Pa)
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A. Bottle #1: expiration date is today; QC acceptable =
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B. Bottle #2: expiration date was yesterday; QC acceptable
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C. Bottle #3: expiration date is next week; QC not acceptable ~
D. Bottle #4: expiration date is tomorrow; QC not acceptable =
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The answer is A. Quality control materials monitor the performance of a test,
ie., each of the tests on the reagent strip. Acceptable QC results must be
obtained before the reagent strips can be used to test patient samples. Reagent
strips, as with other testing systems (e.g., kits), can be used until their expiration
date is passed or exceeded. In the case of bottle #1, that would be the next day.
(Brunzel, pp. 39-41)

45. Which protein test is not able to detect immunoglobulin light chains (i.e.,
Bence Jones proteins) in urine?

A. Immunoelectrophoresis
B. Reagent strip protein test
C. Sulfosalicylic acid (SSA) precipitation test
D. Protein coagulates between 40 to 60°C

The answer is B. Immunoglobulin light chains will not be detected by commer-

cial reagent strip protein tests based on the “protein error of indicators.” These
reagent strip tests are most sensitive for albumin. Originally, immunoglobulin
light chains (or Bence Jones proteins) were recognized by their unique solubil-
ity characteristics, i.e., coagulates between 40 to 60°C and redissolves at 100°C.
Sulfosalicylic acid is a general protein-precipitating agent and will precipitate all
proteins, including immunoglobulin light chains. Immunoelectrophoresis is a
definitive method for identifying specific types of immunoglobulin polypep-
tides. (Brunzel, pp. 169-172)

46. When drugs containing free sulfhydryl groups are excreted in the urine, they
can cause false-positive results for which reagent strip test?

A. Blood
B. Ketones
C. Leukocyte esterase
D. Nitrite

The answer is B. Compounds that contain free sulfhydryl groups react with
sodium nitroprusside (nitroferricyanide) to produce a false-positive reagent test-
strip test for ketones. Examples of drugs containing free sulfhydryl groups
include MESNA, a chemotherapy agent; penicillamine, a chelating agent, and
captopril, an antihypertensive drug. (Brunzel, p. 179)

47. Which of the following sets of urinalysis results, physical appearance and
specific gravity (SG), is physiologically possible and indicates a concen-
trated urine?

SG Color
A. 1.000 colorless
B. 1.015 brown
C. 1.030 yellow
D. 1.050 amber
The answer is C. The range of physiologically possible urine specific gravity is
1.002 to ~ 1.040. Both choice A, a SG equal to that of pure water, and D the body
is unable to produce. Specific gravity values greater than 1.040 can be observed in
urine that is contaminated with x-ray contrast dye. Urine color can provide a crude
indicator of urine concentration. Typically, urine is a shade of yellow with the depth
of the color indicating a more concentrated specimen, i.e., a pale yellow sample is
less concentrated than a dark yellow urine. (Brunzel, pp. 121-122, 128-129)

48. A urinalysis is performed on a specimen from a patient with active diabetes

insipidus. Which of the following laboratory data sets is most consistent
with this diagnosis?
SG
(refractometer) Glucose Urine Volume/day
A. 1.005 negative 3100 mL
Baet.020 negative 2500 mL
C 1,005 positive 3500 mL
Da1:020 positive 2000 mL

The answer is A. Diabetes insipidus, a metabolic disorder, is characterized by

polyuria (excretion of = 3 L/d) and polydipsia. Due to either defective production
of arginine vasopressin (antidiuretic hormone) or lack of renal response to the
hormone, these individuals are unable to reabsorb water in their renal tubules.
Hence, they produce copious amounts of dilute (low SG) urine. In contrast, indi-
viduals with uncontrolled diabetes mellitus could produce large volumes of high
specific gravity urine due to the presence of glucose. (Brunzel, pp. 102, 273, 300)

49. The following results are obtained on a fresh randomly collected urine spec-
imen:
Parameter Result Confirmatory test Result
pH 15:5
SG) 1025 Refractometer 1.027
Blood _ trace
Protein 30 mg/dL
Glucose 100 mg/dL Clinitest positive
Ketone negative
Bilirubin _ negative Ictotest positive
Urobilinogen 1.0 mg/dL
Nitrite negative
Leukocyte esterase _ positive
Microscopic Exam: 2-5 RBCs per high power field
5—10 WBCs per high power field
Which of the following statements regarding these results is true?
. An abnormal amount of bilirubin is present in the urine
. Ascorbic acid is causing the positive leukocyte esterase
. The blood present is causing the protein result to be positive
P=
ceh
SW . Radiographic contrast media (x-ray dye) is causing the high specific
gravity

The answer is A. The Ictotest is more sensitive for bilirubin than the reagent strip
test. Hence, it is possible to have a positive Ictotest but a negative reagent strip
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test. Ascorbic acid does not have any effect on the leukocyte esterase test of any af
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reagent strip (see manufacturer’s product insert). The reagent strip protein test is
)
primarily sensitive to albumin. Hence, a trace blood result, which according to 4
the reagent strip manufacturer corresponds to ~ 0.2 to 0.6 mg/dL hemoglobin, =
is insufficient to cause a positive test. The specific gravity of 1.025 is within the )
reference range. Radiographic contrast media in urine causes specific gravity
results to exceed those physiologically possible, i.e., > 1.040. (Brunzel, pp. 154,
156, 171, 183-184)

50. Which of the following sediment components is the best indicator that an
infection or inflammatory process is taking place in the kidney and not in
the lower urinary tract?

A. RBCs
B. Bacteria
C. WBC casts
D. Granular casts

The answer is C. Because casts are only formed in the kidney, the components
entrapped within them also originate there. White blood cells respond to infec-
tive and inflammatory processes by localizing in the affected tissue. Therefore,
WBC casts are indicative of an infection or inflammatory process occurring in
the kidney. Blood cells can pathologically enter the urinary tract at any point.
The presence of bacteria is useful in diagnosing a urinary tract infection; how-
ever, their presence does not indicate at which level of the urinary tract the infec-
tion resides, i.e., is the infection in the urethra, bladder, renal pelvis, or renal
interstitium? (Brunzel, pp. 235-236, 254)

51. Urine sediment that contains red blood cells, red blood cell casts, and pro-
tein is characteristic of

A. bladder infection
B. Fanconi syndrome
C. nephrotic syndrome
D. acute glomerulonephritis

The answer is D. In acute glomerulonephritis, glomerular inflammation and

injury alters the permeability of the glomerular filtration barrier such that red
blood cells and plasma proteins, particularly albumin, enter the renal tubules. As
casts form in the distal tubules, the red blood cells present are incorporated into
the cast matrix. (Brunzel, pp. 234-235, 277)

52. Hyaline casts are found in increased numbers in the urine sediment

A. when the urine is alkaline

B. following strenuous exercise
C. when examined using bright light
D. whenever an abnormal amount of protein is present

The answer is B. The number of hyaline casts in urine sediment increases fol-
lowing exercise and is not considered pathologic, particularly when they are the
only abnormality present. In these cases, temporary and minor dehydration
enhances stagnation of the ultrafiltrate and increased cast formation. (Brunzel,
pp. 229-233; Strasinger, p. 88)
53. Which type of microscopy would best aid in the differentiation of red blood
cells from the form of monohydrate calcium oxalate crystals that resemble
RBCs?

A. Darkfield microscopy
B. Phase-contrast microscopy
C. Polarizing microscopy
D. Interference-contrast microscopy

The answer is C. Both the monohydrate and dihydrate forms of calcium oxalate
demonstrate birefringence when using polarizing microscopy. In contrast, cells,
such as blood cells, epithelial cells, bacteria, etc., are not capable of refracting
light; hence, they are not birefringent. This fact enables the differentiation of
crystalline entities from look-alike cellular components in urine sediment.
(Brunzel, pp. 15-16, 246-247)

54. During the microscopic examination of a urine sediment, a clinical labora-

tory technician observes an entity approximately the size of a white blood
cell that demonstrates a “flitting or jerky motion.” The entity observed is
most likely a

A. bacterium
B. glitter cell
C. pinworm
D. trichomonad

The answer is D. Trichomonads exhibit a characteristic flitting or jerky motion

when observed alive in fresh urine sediment. They are protozoan flagellates with
anterior and posterior flagella and an undulating membrane. However, urine is
not an ideal medium for their survival and trichomonads can rapidly die, losing
their motility. Dead trichomonads round up and can become impossible to dif-
ferentiate from white blood cells. Their identification relies predominantly on
their characteristic motion or the observation of flagella and an undulating mem-
brane. (Brunzel, pp. 258-259)

55. Which of the following urinalysis findings include contradictory results that
should not be reported?

A. pH 5.0, small blood, cystine crystals

B. pH 6.0, bilirubin positive, ammonium biurate crystals
C. pH 7.0, protein trace, calcium oxalate crystals
D. pH 7.5, nitrite positive, amorphous phosphates

The answer is B. Ammonium biurate crystals are found in alkaline or neutral

urine (= pH 7.0) and will dissolve upon heating or the addition of acetic acid.
Hence, there is a conflict in the reported pH and the crystal identified. Ammo-
nium biurate crystals can resemble some forms of sulfonamide drug crystals, and
it is the pH that assists in the proper identification of these similar appearing crys-
tals. No conflicting results are present in the other choices. (Brunzel, p. 252)

56. The following crystals are observed in a randomly collected urine specimen
with a pH of 7.0.
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The identity of these crystals is most likely
A. cystine
B. uric acid
C. triple phosphate
D. ammonium biurate

The answer is C. Both triple phosphate and ammonium biurate crystals can be
present in urine with an alkaline pH. However, ammonium biurate crystals have
a yellow to brown coloration and are primarily spherical in shape. The most
common forms of triple phosphate crystals are a 3- to 6-sided prism, frequently
described as “coffin lids.” Cystine and uric acid crystals are present only in
acidic urines. (Brunzel, pp. 243-252)

57. When present in the urine, which of the following substances could cause
false-positive reagent strip blood results?

A. Ascorbic acid
B. Myoglobin
C. Free-sulfhydryl drug
D. X-ray contrast media

The answer is B. The reagent strip test for blood is based on the pseudoperoxidase
activity of the heme moiety. Myoglobin is also a heme-containing protein capable
of oxidizing the chromogen on the reagent strip pad. (Brunzel, pp. 154, 158-162)

58. In which of the glucose tolerances shown in the figure would you expect to
find concurrent glycosuria?

ml
glucose—mg
Plasma
/100

30 60 90 120 150 180

Minutes
(Tietz, 3rd., p. 252)
20
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A. Curves 1 and 2
B. Curves | and 3
C. Curves 3 and 4
D. Only curve 4

The answer is C. The normal renal threshold for glucose is a plasma level of 160
to 180 mg/dL. There is a limited amount of reabsorption mechanism in the prox-
imal convoluted tubules. At blood glucose levels higher than the renal threshold,
the limited reabsorption allows excretion of the excess glucose in the urine. Both
curves 3 and 4 exceed this renal threshold value. Individuals with renal disease,
which includes many diabetic patients, may have even lower renal thresholds for
glucose. (Brunzel, p. 172)

59. A physician wants a urinalysis performed on a midstream clean catch urine

specimen to evaluate whether a woman has a urinary tract infection. Which
of the following urinalysis results suggests that a new specimen should be
collected?

A. Chemical exam: blood positive

B. Chemical exam: nitrite negative
C. Physical exam: pale yellow, clear
D. Microscopic exam: many squamous epithelial cells

The answer is D. The presence of many squamous epithelial cells in a specimen

indicates that it is not a midstream collection. The epithelial cells originate from
the vaginal and perineal areas and indicate that the urine can also be contami-
nated with the normal flora (bacteria) that also resides in these areas. (Brunzel,
pp. 56-57, 225-226)

60. The following results are obtained on a fresh, randomly collected urine
specimen:
Parameter Result
pH 5:5
SG 1.025
Blood small
Protein 500 mg/dL
Glucose negative
Ketone negative
Bilirubin negative
Urobilinogen 1.0 mg/dL
Nitrite negative
Leukocyte esterase negative
Microscopic Exam: 5-10 RBCs per high power field
2-5 WBCs per high power field
2-5 fatty casts
0-2 waxy casts
Which of the following disorders is most consistent with these results?
A. Cystitis
B. Nephrotic syndrome
C. Acute pyelonephritis
D. Acute glomerulonephritis
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r)
(GFB). Consequently, serum lipids are also able to pass the GFB into the urine te
and can appear in the urine sediment as free fat globules, in casts, or in cells £
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called oval fat bodies. (Brunzel, pp. 238, 282-283)

CLS Review Questions

1. Which of the following analytes can deteriorate if a blood specimen is

exposed to light?

A. Bilirubin
B. Calcium
C. Cholesterol
D. Glucose

The answer is A. Bilirubin degrades upon exposure to light, fluorescent as well

as indirect or direct sunlight. Specimens should be stored in the dark and refrig-
erated unless analyzed within three hours. (Bishop et al., pp. 386-388)

2. Which of the following collection tubes is the specimen of choice for the
determination of glycated hemoglobin?

A. Citrate tube
B. EDTA tube
C. Red/marble top tube
D. Ammonium heparin tube

The answer is B. Whole blood collected in EDTA is the preferred specimen.

Most methods require subsequent preparation of a hemolysate using a cell-
lysing agent. Whole blood specimens can be stored up to 5 days at 2-5°C.
(Lehmann, p. 50; Kaplan and Pesce, pp. 635-637)

3. Which of the following serum samples is satisfactory for alkaline phos-

phatase measurement?

A. Sample frozen overnight

B. Sample refrigerated for 1 hour
C. Sample with moderate hemolysis
D. Sample maintained at room temperature for 2 hours

The answer is A. Alkaline phosphatase in serum specimens is stable at room

temperature for up to 4 hours. Significant increases in alkaline phosphatase
activity will be obtained if samples are refrigerated or frozen. It is postulated that
low temperatures cause complexes between ALP and lipoproteins to dissociate.
Slight hemolysis is acceptable; however, more severely hemolyzed specimens
should be recollected. (Kaplan and Pesce, pp. 521-522)

4. A clinical laboratory scientist (CLS) is summoned to the emergency room

to draw blood on Jane Doe. At the same time, numerous injury victims
begin to arrive by ambulances from a multiple car accident. The CLS does
 not want to disturb the now busy ER staff. According to the room board,
Jane Doe is in Ward D. The CLS goes to Ward D and collects blood from
the only woman present. She is unable to verify that it is actually Jane Doe
because the patient does not speak English and does not have an identifica-
tion bracelet. However, the woman nods approvingly when asked if her
name is Jane Doe. The CLS labels the blood specimen as “Jane Doe” and
returns to the laboratory. What should be done next?

A. Proceed with testing; woman positively identified herself

B. Specimen should not be used; positive identification of patient was
never made
C. Specimen should not be used until an ER staff member comes to the lab-
oratory to sign a waiver verifying patient’s identity
D. Proceed with testing; “Jane” is a female name and she was the only
female present in Ward D, so it must be her

The answer is B. A patient must be positively identified before their blood is col-
lected and labeled as such. If a patient is unable to identify themselves, then
another health care worker (nurse, physician, etc.), family member, or visitor
must verify their identity. Incorrectly identified samples can produce life-threat-
ening consequences when results are reported on the wrong patient. (Bishop et
al., p. 41)

5. Which of the following changes occurs in a serum specimen that is main-

tained at 4°C for 8 hours?

A. Amylase activity decreases

B. Alkaline phosphatase activity increases
C. Lactate dehydrogenase activity increases
D. Alanine aminotransferase activity decreases

The answer is B. Alkaline phosphatase (ALP) activity falsely increases during

storage. This phenomenon has been attributed to the dissociation of complexes
formed between ALP and lipoproteins at low temperatures. In contrast, lactate
dehydrogenase activity decreases with refrigeration and samples should be
maintained at room temperature. Alanine aminotransferase (ALT) and amylase
activity is stable in refrigerated samples for 7 days or several months, respec-
tively. (Bishop et al., pp. 221, 223; Kaplan and Pesce, pp. 568, 610)

6. Which of the following measurements usually takes place at room temper-

ature?

A. pO, by blood gas analyzer

B. Sodium by potentiometry
C. Ionized calcium by ion selective electrode
D. Creatinine by kinetic afkaline picrate method

The answer is D. The kinetic alkaline picrate or Jaffe method is a spectrophoto-

metric method based on the differential rate of color formation of noncreatinine
chromogens versus creatinine. This reaction can be performed at room tempera-
ture. In contrast, blood gas analysis and potentiometric methods, such as sodium
and ionized calcium analysis, require that measurements occur in a controlled
environment usually maintained at 37°C. (Kaplan and Pesce, pp. 281-285)
 CLS Review Questions 23 >
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7. A centrifuge is loaded with patient samples and turned on. It begins to £
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vibrate and dance across the table top. Which of the following statements
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best accounts for this observation? —
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A. The brake was left “ON” o)
B. The brushes need to be replaced
C. The rate of acceleration was too high
D. The tubes are not balanced in the carriers

The answer is D. The balancing of specimen tubes in carriers is critical for

proper functioning of a centrifuge. When carriers are not properly balanced, a
centrifuge vibrates and can do so quite vigorously, such that it will move across
a flat surface. Newer centrifuges will automatically decelerate and shut down
when carriers are improperly balanced. (Kaplan and Pesce, pp. 24-25)

8. Which of the following devices is used in a spectrophotometer to determine

the wavelengths of light that pass through the sample cuvette?

A. Detector
B. Light source
C. Monochromator
D. Photomultiplier

The answer is C. The monochromator, usually either a prism or diffraction grat-

ing, isolates a wavelength or range of wavelengths of light that pass through the
sample cuvette in a spectrophotometer. The light source, often a tungsten-halo-
gen lamp, provides white light, 1.e., light of all wavelengths to the monochro-
mator. One type of detector in a spectrophotometer is a photomultiplier tube that
is sensitive to radiant energy, i.e., light. (Kaplan and Pesce, pp. 89-91)

9. When performing a thin layer chromatography procedure, the solvent front

moved 10.0 centimeters. The substance of interest moved 2.5 centimeters.
What is the R; for the substance of interest?

Aci0:25
B. 0.40
@. 235
D. 4.0

The answer is A. The retention time or R; of a substance or compound is defined

as the distance of spot migration divided by the distance of the mobile phase
migration. (Burtis and Ashwood, p. 111)

10. Which of the following enzymes catalyzes the conversion of glucose to

hydrogen peroxide and gluconic acid?

A. Peroxidase
B. Hexokinase
C. Glucose oxidase
D. Glucose-6-phosphate dehydrogenase

The answer is C. Glucose oxidase catalyzes the oxidation of glucose by oxygen

to form gluconic acid and hydrogen peroxide. Glucose is quantitated by deter-
mining the amount of oxygen consumed in the reaction (amperometry) or by
using a second “indicator” reaction to measure the amount of hydrogen perox-
ide produced. (Bishop et al., p. 307; Kaplan and Pesce, pp. 634-635)

11. Which of the following constituents has the greatest effect on serum osmo-
lality?

A. Glucose
B. Protein
C. Sodium
DieWrea

The answer is C. Osmolality is a measure of a solution’s concentration based on

the number of solutes present per kilogram of solvent. Each solute regardless of
molecular weight contributes equally to the osmolality. The major osmotic
solutes in serum are sodium, chloride, glucose, and urea. The concentration of
sodium far exceeds that of any other serum solute. Typical solute levels in nor-
mal serum include: sodium — 140 mmol/L; glucose — 5.5 mmol/L (or 100
mg/dL); urea — 2.5 mmol/L (15 mg/dL). In addition, the molar amount of the
various serum proteins is very low. (Bishop et al., pp. 256-258)

12. When measuring serum bilirubin, the purpose of adding caffeine-sodium

benzoate or dyphylline to the reaction mixture is to

A. accelerate the reaction with unconjugated bilirubin

B. stop the reaction by destroying excess diazo reagent
C. enable azobilirubin formation with conjugated bilirubin
D. shift the wavelength absorbed by azobilirubin for increased sensitivity

The answer is A. Unconjugated bilirubin reacts very slowly with the aqueous
diazotizing color reagent used in bilirubin assays. However, in the presence of
an accelerating reagent, such as caffeine-sodium benzoate (Jendrassik-Grof
method) or dyphylline (modified Jendrassik-Grof method), unconjugated biliru-
bin’s solubility is enhanced and it can readily participate in the intended reaction
to form azobilirubin. (Bishop et al., pp. 386-388; Kaplan and Pesce, pp.
523-527)

13. When iontophoresis is used to collect sweat for chloride analysis, pilo-
Carpine is used to

A. clean the skin area

B. complex with chloride
C. complete the circuit
D. induce sweat secretion

The answer is D. Pilocarpine is driven into the skin surface by iontophoresis (the
migration of ions induced by direct current). It stimulates the production of
sweat, which is subsequently collected on preweighed filter paper or gauze for
the analysis of chloride or sodium. (Bishop et al., pp. 477-478)

14. When using atomic absorption spectrophotometry for calcium quantitation,

lanthanum or strontium is routinely added to each sample to
 CLS Review Questions 25 >
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. prevent ionization of calcium atoms
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. avoid interference from phosphate in the sample And
. reduce fluctuations from the hollow-cathode lamp
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The answer is C. The atoms produced by the fuel-rich flame used in atomic
absorption spectrophotometry (AAS) are in their ground state and readily avail-
able for light absorption. However, one problem with AAS due to the cooler
flame temperature is the inability of the flame to dissociate samples into free
atoms. For example, phosphate can interfere with calcium analysis in specimens
by the formation of calcium phosphate. In order to prevent this interference, lan-
thanum or strontium, both of which form stable complexes with phosphate, is
added prior to analysis. (Bishop et al., pp. 103-105)

15. Ion-selective electrodes compare the voltage (potential) of the measuring

electrode to the

A. reference voltage
B. resistivity of the sample
C. conductivity of the sample
D. current required to establish the voltage

The answer is A. Ion-selective electrodes are potentiometric measurements

based on the potential (voltage) difference that develops between two electrodes
under conditions of zero current. The reference electrode provides a stable, eas-
ily reproducible half-cell potential (which does not change) while the indicating
or measuring electrode produces a half-cell potential dependent on the “activity”
of the analyte being measured. The potential difference between that develops
between the measuring and reference electrode correlates to concentration of
analyte in the specimen. (Kaplan and Pesce, pp. 278-281)

16. Which of the following statements best describes the principle of pO, meas-
urement used in blood gas analyzers?

. H* are generated by a reaction at the electrode surface

. The amount of O, oxidized to hydrogen peroxide is measured
. The number of electrons used to reduce O, is measured
. A voltage between the measuring half-cell and a reference half-cell is
GaaS
determined

The answer is C. The electrode for pO, measurements is based on amperometry.

In amperometry, a current is measured while a fixed potential is applied. In the
pO, electrode, a known stable voltage (potential) is maintained between an
anode and a platinum cathode. As oxygen diffuses through a membrane it is
reduced at the cathode by electrons furnished by the anode, i.e., O. + 2H* +
2e— > H,O,. The amount of current (electron flow) is measured and expressed
as the pO, in mmHg. (Kaplan and Pesce, pp. 277, 287-288)

17. Which of the following methods is not used to quantitate serum albumin?

A. Nephelometry
B. Electrophoresis at pH 8.6
26 Ts Clinical Chemistry

C. Sulfosalicylic acid (SSA) precipitation test

D. Dye-binding method using bromcresol green

The answer is C. Bromcresol green, under appropriate conditions of pH and

ionic strength, binds specifically to albumin. This shifts the wavelength of light
absorbed by the dye. Electrophoresis of serum proteins results in a virtually pure
band of albumin, in contrast to the other bands that are mixtures of proteins.
Nephelometry is specific for an individual protein by virtue of antigen-antibody
recognition. Sulfosalicylic acid is a general protein precipitant and is not specific
for albumin. (Kaplan and Pesce, pp. 518-519)

18. If a moderately hemolyzed serum specimen is used for protein elec-

trophoresis, which of the following protein fractions will be elevated?

A. Albumin
B. Alpha,-globulin
C. Beta-globulin
D. Gamma-globulin

The answer is C. Hemolysis causes an increase primarily in B-globulins, the

fraction where free hemoglobin migrates. However, a small amount of a hemo-
globin-haptoglobin complex can also appear between the a, and fractions. (Bur-
tis and Ashwood, p. 131)

19. LDL cholesterol can be estimated using the Friedewald formula:

triglyceride
LDL = Total cholesterol — HDL —
5
This calculation should not be used when the
A. HDL cholesterol is greater than 40 mg/dL
B. triglyceride level is greater than 400 mg/dL
C. plasma shows no visible evidence of lipemia
D. total cholesterol is elevated based on the age and sex of the patient

The answer is B. The formula estimates cholesterol contained in LDL particles

by subtracting cholesterol in other lipoprotein particles from total cholesterol.
An essential assumption is that 20% ('/;) of VLDL particles is cholesterol and
that measured triglyceride accurately estimates the amount of VLDL. When the
triglyceride result is excessively high (> 400 mg/dL), this assumption is not
valid. (Burtis and Ashwood, p. 488)

20. Using the following figure of “drug concentration versus time after oral
dose,” calculate this drug’s half-life in the circulation.

rw
a

(ug/ml)
concentration
Drug
OFF 12 3 4 5 6

Time after oral dose (h)

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D. 4h =
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The answer is B. The biologic half-life of a drug is the length of time required
for the blood concentration to decrease by one-half. In the figure, the blood con-
centration is approximately 4 g/mL at 2 h and approximately 2 g/mL at 3.5
h; thus the concentration has decreased by one-half in 3.5 — 2 = 1.5 h. (Burtis
and Ashwood, pp. 608-610)

21. The following data are obtained using a cholesterol method:

Sample Absorbance
150 mg/dL standard 0.200
Normal control 0.200 (mean: 150 mg/dL; 1SD = 15)
Abnormal control 0.400 (mean: 275 mg/dL; 1SD = 25)
Patient 0.500
The patient’s cholesterol result should be reported as
A. 60 mg/dL
B. 150 mg/dL
C. 375 mg/dL
D. 500 mg/dL

The answer is C. Beer’s law states that the absorbance of a solution is directly
related to its concentration. Rearrangement yields the formula: C, = A,/A, X C,
where the subscript u denotes the unknown values and s denotes the standard
values. (Kaplan and Pesce, pp. 38-39)

22. The following results are obtained from a 28-year-old diabetic patient:
Analyte Result Reference Interval
Nat 140 mmol/L (136-145)
K* 3.8 mmol/L (3.55.0)
Cl- 101 mmol/L (99-109)
Glucose: 215 mg/dL (70-105)
BUN: 25 mg/dL (10-20)
Serum osmolality: 328 mOsmol/kg (275-295)
Based on this data, what is the patient’s osmolal gap?
A. 8 mOsmol/kg
B. 27 mOsmol/kg
C. 48 mOsmol/kg
D. 52 mOsmol/kg

The answer is B. A common formula used to calculate osmolality, in

mOsmol/kg, is

Glucose (mg/dL) rn BUN (mg/dL)

Serum Osmolality = 2 < Na* (mmol/L) +
18 2.8
The osmolal gap (OG) is then calculated as follows:
Osmolal gap (mOsmol/kg) = measured osmolality — calculated osmolality

(Kaplan & Pesce, pp. 271-272)

 23. Using the following data, calculate the corrected creatinine clearance.

Serum creatinine: 1.8 mg/dL

Urine creatinine: 2.7 mg/mL
Urine volume: 640 mL/24h
Body surface area: 1.25 m?

A. 41 mL/min
B. 67 mL/min
C. 92 mL/min
D. 132 mL/min

The answer is C. The formula for calculating a corrected creatinine clearance

(C¢,) is:
Gus UVa LS m? Cc, = creatinine clearance in mL/minute
p= Op SA U = urine creatinine
P =plasma/serum creatinine
Vs = urine volume in mL per minute
SA = patient’s body surface area
When using this formula, it is required that the urine and serum creatinine con-
centrations be in the same units so that the units cancel. Therefore, the urine con-
centration must be converted to 270 mg/dL before using the formula. The urine
volume (V) must also be converted from mL per 24 hours to mL per minutes as
follows:
urine volume (mL) 1 hour
= Vin mL/minute
24 hour 60 minutes
Because creatinine excretion varies with muscle mass (i.e., body surface area),
comparison to a reference interval requires that the clearance be corrected for the
individual’s body surface area in square meters. (Brunzel, pp. 106-109)

24. An aspartate aminotransferase (AST) result obtained on a serum specimen

diluted 1 to 3 (1:3) is 42 U/L. Which of the following results should be
reported?

A. 84 U/L
Ibi, JUAS UME
C. 168 U/L
D. 210 U/L

The answer is B. The dilution factor is 3; therefore, the undiluted sample has a
concentration of 3 X 42 = 126 U/L. (Bishop et al., pp. 22-23)

25. A serum specimen is being analyzed for the activity of an enzyme and the
following kinetic data obtained:
Time (min) Absorbance
0 0.020
1 0.200
2 O35
3 0.395
4 0.435
5 0.480
Select the statement that best summarizes these results.
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culation

The answer is B. The rate of change of absorbance (change in absorbance per

minute) is not constant for any of the data given. This indicates substrate exhaus-
tion where there is insufficient substrate present for all of the enzyme present to
be continuously active during the analysis. Use of a serum dilution will allow
sufficient substrate for zero-order kinetics and still produce a measurable change
in absorbance. (Kaplan and Pesce, pp. 1065-1068)

26. A serum protein electrophoresis is performed and unexpected results

obtained. All protein bands migrated further than usual and the bands were
further apart from each other. Which of the following would account for the
results obtained?

A. The support medium has deteriorated

B. A higher voltage was used during analysis
C. The wrong buffer was used; ionic strength higher than required
D. The wrong buffer was used; pH was significantly lower than required

The answer is B. A higher voltage will cause proteins to migrate faster and to
separate more from each other. A buffer of a higher ionic strength, as well as one
with a lower pH, would reduce the distance of protein migration. A deteriorated
support medium would not produce the changes observed. (Kaplan and Pesce,
pp. 207-208)

27. The normal ratio of bicarbonate ion to carbonic acid in arterial blood is

A. 0.03:1
Bo1:1.8
Ca 20e1
D, 6:1:7:4

The answer is C. The Henderson-Hasselbalch equation defines the ratio of base

to acid that is required for a given pH. At normal arterial pH the ratio of con-
centrations of bicarbonate ion to carbonic acid is 20:1. The pKa of this whole
blood buffer system at 37°C is 6.1. (Bishop et al., p. 241)

28. Increased serum uric acid is found in each the following conditions except

A. gout
B. hypothyroidism
C. Lesch-Nyhan syndrome
D. renal failure

The answer is B. Thyroid hormones have no specific effect on formation or

elimination of uric acid. Gout is the disease caused by deposition of excessive
uric acid in body spaces, e.g., joints. Lesch-Nyhan syndrome is a rare inborn
error of metabolism in which the salvage enzyme of purine catabolism is defi-
cient. This results in excessive production of the purine catabolite uric acid.
Renal failure results in inability to clear the blood of waste products including
uric acid. (Bishop et al., pp. 348-350)

29. Which of the following is not a criterion for the diagnosis of diabetes mellitus?

A. A fasting glucose = 126 mg/dL

B. Aserum glucose = 40 mg/dL within 3h after an oral dose of glucose
C. Classic symptoms and a plasma glucose = 200 mg/dL at anytime
D. A serum glucose = 200 mg/dL at 2h after an oral glucose dose

The answer is B. The diagnostic criteria for diabetes mellitus was revised by the
American Diabetes Association and published in Diabetes Care 1997;
20:1183-1201. Currently, all of the situations described except choice B, a low
serum glucose, are diagnostic of diabetes mellitus. (Burtis and Ashwood, p. 439)

30. If LDL receptors are nonfunctional due to disease, the plasma level of which
lipid would increase the most?

A. Fatty acids
B. Cholesterol
C. Cholesterol esters
D. Triglycerides

The answer is B. LDL is the major carrier of cholesterol and is considered an

atherogenic lipoprotein. Because approximately 50% of LDL lipid is choles-
terol, an increase in plasma LDL will increase the total cholesterol. LDL is
cleared from the plasma by the liver. The apolipoprotein B moiety of LDL binds
to specific hepatocyte receptors, the receptors are subsequently internalized, and
the LDL is catabolized. When these receptors are not present or non-functional,
plasma total cholesterol levels are increased. (Kaplan and Pesce, pp. 651-652)

31. Which of the following serum protein electrophoresis patterns is most typi-
cal of the nephrotic syndrome?
albumin alpha, alpha, beta gamma
A. vy 1 t i! +
B. + t t fi f
Crit Y normal normal Y
D. normal t Y i fies

The answer is A. In the nephrotic syndrome, an increased permeability of the

glomerular membrane allows proteins, particularly albumin due to its high
plasma concentration, to be lost in the urine in large quantities. As a result, the
concentration of the remaining large MW proteins (e.g., a-macroglobulin)
“appear” to be present in an increased concentration. (Lehmann, p. 40)

32. Which analyte is most likely to be elevated in a specimen drawn 2 hours

after an uncomplicated myocardial infarction?

A. CK-MB (CK-2)
B. Myoglobin
C. TroponinI
D. TroponinT
 CLS Review Questions 31 ~~
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The answer is B. Following an acute MI, myoglobin is the earliest cardiac pt=
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marker. It begins to rise within 2-3 h and peaks at 6-9 h. For comparison, CK- G
MB begins to rise at 4-6 h and usually peaks within 12-24 h; the troponins, I an
and T, begin to rise at 4-8 h and usually peak within 18 h. (Lehmann, p. 104) £
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33. Which of the following serum results correlates best with the rapid cell
turnover associated with chemotherapy treatment regimens?

A. Creatinine of 2.5 mg/dL

B. Potassium of 5.0 mmol/L
C. Urea nitrogen of 30 mg/dL
D. Uric acid of 10.0 mg/dL

The ae D. Chemotherapy destroys cells releasing their DNA and RNA,

which must be processed. The purine bases, adenine and guanine, derived from
DNA and RNA are degraded and their ring structures are converted to uric acid
for excretion in the urine. (Anderson and Cockayne, pp. 371-372)

34. Which set of serum electrolyte results (in mmol/L) is most likely obtained
from a serum with an elevated lactate level?

Na* K* Cl- HCO,;—

m2) 4.5 100 10
135 oie) 95 28
. 145 4.0 90 1s)
VOW>
150 5.0 110 30

The answer is C. As lactic acid is produced it dissociates into H* ions and lac-
tate anions. Because the body maintains electrical neutrality, as lactate accumu-
lates, another anion is eliminated. In the case of excessive production of lactic
acid, bicarbonate is used to neutralize and eliminate the H* ions produced. The
end result is a metabolic acidosis with an increased anion gap. (Anderson and
Cockayne, pp. 421-423)

35. The following arterial blood gas results are obtained:

pH 7.28
pCO, 53 mmHg
pO, 75 mmHg
HCO,- 26 mmol/L
These results correlate best with a patient experiencing

A. metabolic acidosis
B. metabolic alkalosis
C. respiratory acidosis
D. respiratory alkalosis

The answer is C. Based on the pH alone, this patient is experiencing acidosis.

Next, the pCO, exceeds the “normal” reference range (~32—-48 mmHg) indicat-
ing a respiratory component. The normal bicarbonate value (22-26 mmol/L)
indicates that compensation has not yet occurred. (Lehmann, p.163; Kaplan and
Pesce, pp. 471-475)
36. A patient with intermittent hypertension has an elevated value for urinary
catecholamine metabolites (e.g., vanillylmandelic acid [VMA]). This result
may indicate

A. hyperaldosteronism
B. hypercortisolism
C. idiopathic hypertension
D. pheochromocytoma

The answer is D. Pheochromocytoma is a catecholamine-secreting tumor of the

adrenal medulla. Epinephrine and norepinephrine are catecholamines. Most
pheochromocytomas produce a mixture of the two. The release of cate-
cholamines by the tumor accounts for the patient’s hypertension. Catecholamine
metabolites, including VMA, are excreted in the urine. (Kaplan and Pesce, pp.
924, 930-932; Anderson and Cockayne, p. 550)

37. Blood from a newborn has low thyroxine (T,) and elevated thyroid-stimu-
lating hormone (TSH) compared to reference ranges for that age. These
results are most consistent with

congenital hypopituitarism
congenital primary hypothyroidism
congenital secondary hypothyroidism
>Caw a normal response to pregnancy-induced changes in maternal thyroid
function

The answer is B. Production of T, by the thyroid gland has a negative feedback

relationship with thyroid-stimulating hormone (TSH) produced by the anterior
pituitary gland. Congenital abnormalities that prevent adequate production of T,
result in a high level of TSH through this feedback loop. The elevated T, values
seen in maternal serum are an artifact caused by an estrogen-induced increase in
synthesis of thyroxine-binding globulin. (Bishop et al., p. 440; Anderson and
Cockayne, pp. 512-513)

38. In which of the following situations will the patient have a “normal” urine
level of human chorionic gonadotropin (HCG)?

A. Ten days following a spontaneous abortion

B. During the 10" week of a normal pregnancy
C. During a molar pregnancy (hydatidiform mole)
D. During the third trimester of a normal pregnancy

The answer is A. HCG is produced by trophoblastic tissue, absorbed into the

maternal plasma, and then excreted in the urine. Loss of trophoblastic tissue, as
in spontaneous abortion, results in rapid urinary clearance of the hormone and
values that are less than expected for the presumed period of gestation. Tro-
phoblastic tumors, such as molar pregnancy, are associated with elevated values
in the absence of pregnancy. In a normal pregnancy, HCG rises in maternal
blood soon after implantation of the fertilized ovum and doubles approximately
every two days during the first trimester. A very slow decline then occurs
through the rest of the gestation period. (Bishop et al., pp. 422, 490-491; Ander-
son and Cockayne, pp. 659-660)
 CLS Review Questions 33 >
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39. The following results are obtained from a patient whose admission diagno- <
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sis is biliary obstruction:
rs
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Serum: Conjugated bilirubin _—_Increased
Total bilirubin Increased
Urine: Bilirubin Positive
Urobilinogen Increased
Which of the results obtained is inconsistent with the admission diagnosis?
A. Serum conjugated bilirubin
B. Serum total bilirubin
C. Urinary bilirubin
D. Urinary urobilinogen

The answer is D. Urobilinogen is formed in the intestinal lumen by bacterial action

on bile. Approximately 20% of the urobilinogen is reabsorbed into the portal
blood, removed by the liver, and re-excreted into the bile. Two to five percent of
the urobilinogen escapes hepatic removal and is excreted by the kidneys in the
urine. A patient with obstructive liver disease excretes less bilirubin into the intes-
tine; hence, less urobilinogen is formed and ultimately the urine urobilinogen
decreases. In contrast, urine bilirubin, the water-soluble conjugated form,
increases because of regurgitation from the bile canaliculi into the blood due to the
biliary obstruction. (Brunzel, pp. 180-183; Anderson and Cockayne, pp. 284-286)

40. Blood and cerebrospinal fluid (CSF) samples were collected from a patient
within 30 minutes of each other. Which set of glucose results indicates pos-
sible bacterial meningitis?
Blood CSF
A. 60 mg/dL 40 mg/dL
B. 100 mg/dL 60 mg/dL
C. 200 mg/dL 30 mg/dL
D. 200 mg/dL 120 mg/dL
The answer is C. In the absence of bacteria or increased numbers of leukocytes,
the glucose concentration in CSF should be 60 to 80% of the concurrent con-
centration in blood. (Bishop et al., p. 307)

41. Which of the following enzymes provides the best indication of obstructive
liver disease, i.e., cholestasis?

A. Amylase
B. Alkaline phosphatase
C. Aspartate aminotransferase
D. Lactate dehydrogenase

The answer is B. Amylase, an enzyme of pancreatic origin is unaffected by liver

obstruction. Each of the remaining choices are enzymes present in liver tissue.
However, only the synthesis of alkaline phosphatase (ALP), which is localized
in cell membranes, is induced due to biliary obstruction. Both aspartate amino-
transferase (AST) and lactate dehydrogenase (LD) are cytoplasmic enzymes
released upon cell damage or death. Hence, depending on the extent and dura-
tion of the obstructive disease process, normal values can still be obtained for
LD and AST. If the disease process causes hepatic cell damage or death,
increases in LD and AST will also be observed. (Burtis and Ashwood, pp.
366-367; Kaplan and Pesce, pp. 515-516)

42. In a cerebrospinal fluid (CSF) sample, which of the following proteins is

quantitated to assess the permeability of the blood/brain barrier?

A. Albumin
B. IgG
C. Transferrin
D. Prealbumin

The answer is A. Albumin is usually employed as the reference protein for per-
meability because it is not synthesized to any extent in the CNS. In a CSF sample
with no blood contamination, the albumin present comes from the plasma by pass-
ing the blood/brain barrier. An increase in the permeability of the blood/brain bar-
rier to plasma proteins can be due to high intracranial pressure (e.g., brain tumor,
intracerebral hemorrhage) or due to an inflammatory process (e.g., bacterial or
viral meningitis). (Bishop et al., pp. 197-198; Brunzel, pp. 375-376)

43. A maternity patient complains of dysuria during a monthly visit with her
doctor. The physician suspects a lower urinary tract infection (e.g., cystitis)
and requests a urinalysis and urine culture. Which type of urine specimen
should be collected from this patient?

A. Random
B. Catheterized
C. First morning
D. Midstream clean catch

The answer is D. The specimen type (random, first morning, etc.) is not as impor-
tant as the collection technique used in obtaining the specimen. A midstream
clean catch will eliminate potential bacterial contamination from the perineum
and vulva and is the specimen of choice for microbial culture in uncatheterized
patients. A catheterized specimen would also be acceptable; however, in this case
the pregnant female is unlikely to be catheterized. (Brunzel, pp. 53-57)

44. Urine preservation by refrigeration can cause

A. decreased pH due to glycolysis

B. increased bacteria due to proliferation
C. photo-oxidation of bilirubin to biliverdin
D. increased turbidity due to precipitate of solutes

The answer is D. Refrigeration can induce the precipitation of urine solutes. This
amorphous and crystalline material will cause a reduction in the visual clarity of
the specimen. (Brunzel, pp. 58-60)

45. Four calibration solutions were evaluated for use as the daily calibration
check for the refractometer at the physiological “upper reference range” for
urine specific gravity (SG). Which calibration solution should be selected?
 CLS Review Questions 35 Pa)
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B. Calibrator B - SG 1.025
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C. Calibrator C - SG 1.035 ¥
D. Calibrator D - SG 1.055 =
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The answer is C. Urine SG can vary from 1.002 to 1.035 depending on an indi-
vidual’s hydration. Values below or above this range are physiologically impos-
sible and require further investigation. Radiographic contrast media in urine can
typically produce SG values greater than 1.040 and adulteration of urine with
water can produce values near 1.000. (Brunzel, pp. 153-156)

46. All of the following are acceptable preparations of urine sediment for
microscopic examination except

A. filling a chamber of a commercial standardized slide

B. over-filling the chamber of a commercial standardized slide
C. transferring, using a disposable pipette, several drops of sediment onto a
microscope slide and coverslipping
D. transferring, using a calibrated automatic pipette, 20 wL of sediment
onto a microscope slide and coverslipping

The answer is C. A standardized slide should be used for microscopic examina-

tions because of the enhanced reproducibility of results. If unavailable, an exact
amount of sediment quantitatively delivered onto a slide and coverslipped can be
used. Of particular note is that the coverslip size and weight should be stated in the
procedure and used at all times because the weight and size of the coverslip will
affect the depth (i.e., volume) of urine sediment viewed. (Brunzel, pp. 210-211)

47. Which of these sugars cannot be detected in urine using the copper reduc-
tion test?

A. Fructose
B. Galactose
C. Arabinose
D. Sucrose

The answer is D. The copper reduction test detects carbohydrates by the reduc-
ing power of their free aldehyde groups. Sucrose is a disaccharide that has no
free aldehyde group and does not produce the yellow-orange salts of oxidized
copper. Sucrose is not absorbed or produced by the body. It only appears in urine
as an artifact. (Brunzel, p. 176)

48. Which of the following tests is not used to assess the kidney’s ability to con-
centrate the urine?

A. pH
B. Refractive index
C. Osmolality
D. Specific gravity

The answer is A. Refractive index, osmolality, and specific gravity are methods
of measurements used to assess the concentration of dissolved solutes in urine.
Urine pH, a measure of hydrogen ion concentration, reflects the diet and the
body’s regulation of its acid-base balance. (Brunzel, pp. 128-136)
 Clinical Chemistry
ected SLES I) inner ion Fence

49. All of the following substances can affect the detection of urine glucose
using regent strips except

A. ascorbic acid
B. bleach
C. free-sulfhydryl drugs
D. galactose

The answer is D. All urine reagent strips utilize the enzyme, glucose oxidase,
which is specific for glucose; hence, no other sugars (e.g., galactose) can react.
In contrast, false-negative urine glucose can result from cellular or bacterial gly-
colysis if an unpreserved urine specimen is left at room temperature for a pro-
longed period of time. Another cause for a false-negative glucose is excessive
amounts of ascorbic acid (= 50 mg/dL) in the urine. Note, however, that Chem-
strip reagent strips (Boehringer Mannheim Corp, Indianapolis, IN) are NOT
affected by the presence of ascorbic acid due to a patented iodate scavenger pad
that eliminates this interference. In contrast, urine contaminated with bleach will
produce a false-positive glucose. (Brunzel, pp. 58-59, 189-190; Strasinger, pp.
60-61)

50. Review the following urinalysis results:

Macroscopic Exam:
Parameter Result
Di O25
SG 1.020
Blood — small
Protein 30 mg/dL
Glucose negative
Ketone negative
Bilirubin negative
Urobilinogen 1.0 mg/dL
Nitrite _ negative
Leukocyte esterase negative

Microscopic Exam: 5—10 RBCs per high power field

0-2 WBCs per high power field
0-2 granular casts
few transitional epithelial cells
few sulfonamide crystals
Which result(s) requires additional action before reporting?
IN Blood vs. RBCs; test for ascorbic acid
B. Sulfonamide crystals; perform confirmatory test and check patient med-
ications
G. Granular casts; should see larger amount of protein, perform protein pre-
cipitation test
D: pH and crystal identification; sulfonamide crystals precipitate in alkaline
urine

The answer is B. Sulfonamide crystals should be confirmed before reporting by

performing a chemical test and by ensuring that the individual is actually taking
a sulfonamide-containing medication. (Brunzel, p. 249)
 CLS Review Questions 37
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51. Which of the following crystals can be present in an alkaline urine? &
U

A. Cystine r]
i
B. Calcium oxalate =
C. Triple phosphate _ )
D. Sodium urate

The answer is C. Triple phosphate is magnesium-ammonium phosphate, a salt

that can precipitate in urine with an alkaline pH. At an acid pH, the salt dissoci-
ates into its soluble component ions. The other crystals listed are observed in
their crystalline forms in neutral or acid urine. (Brunzel, pp. 241-253;
Strasinger, pp. 92-95)

52. The presence of waxy casts in urine sediment and a fixed urine specific
gravity of 1.010 correlates best with

A. cystitis
B. glomerulonephritis
C. acute pyelonephritis
D. renal failure

The answer is D. Casts are formed in the distal and collecting tubules of the
nephron. Therefore, cystitis, an infection of the lower urinary tract (e.g., the uri-
nary bladder), does not induce cast formation. The remaining conditions can all
present with a variety of casts. However, renal failure is characterized by the
presence of waxy and broad casts. In addition, the fixed specific gravity indi-
cates the inability of the nephrons to selectively reabsorb and secrete solutes, a
hallmark of renal failure. (Brunzel, pp. 287-292)

53. Urine sediment that contains free fat globules and fatty casts is characteristic of

A. a bladder infection
B. the Fanconi syndrome
C. the nephrotic syndrome
D. acute glomerulonephritis

The answer is C. In the nephrotic syndrome, increased permeability of the

glomerular filtration barrier allows the passage of plasma proteins, particularly
albumin, and lipids into the urine. The lipids that are able to cross the filtration bar-
rier can get enmeshed in casts that are forming in the distal tubules. Note that the
lipid can be either cholesterol or neutral fats (triglyceride) and can be free floating,
in casts, or in cells called oval fat bodies. (Brunzel, pp. 238, 255-256, 277)

54. Which of the following statements about finely granular casts in urine sed-
iment is true?

A. They are indicative of end-stage renal disease

B. They are frequently seen when women have trichomoniasis
C. Numerous finely granular casts are diagnostic for acute glomeru-
lonephritis
D. A few finely granular casts can be seen in urine from normal healthy
individuals
The answer is D. The granules in finely granular casts are the by-products of
protein metabolism excreted by renal tubular epithelial cells. Hence, they are
seen in urine from normal healthy individuals. Waxy casts are usually observed
with end-stage renal disease; whereas in acute glomerulonephritis, red blood cell
and hemoglobin casts are considered pathognomonic. Vaginal trichomoniasis
and urine cast formation are unrelated processes. (Brunzel, p. 237)

55. When examining “unstained” urine sediment, cellular detail is best when
observed using

A. bright-field microscopy
B. darkfield microscopy
C. phase-contrast microscopy
D. polarizing microscopy

The answer is A. Bright-field microscopy, with optimized adjustments, enables

detailed viewing of unstained urine sediment components. In contrast, phase-
contrast microscopy can produce bright haloes that reduce the visualization of
detail and dimension. (Brunzel, pp. 13-17)

56. The following urinalysis results are obtained on a urine specimen:

Reagent strip blood: negative
Microscopic exam: 10-15 RBCs per high-power field
Which of the following statements best explains these results?
. The microscopically identified RBCs are really yeast
. Myoglobin is causing a false-negative reagent strip blood test
. Ascorbic acid is causing a false-negative reagent strip blood test
S . The microscopically identified RBCs are really monohydrate calcium
Daw
oxalate crystals

The answer is C. Ascorbic acid is a reducing substance that can cause the reagent
strip blood test to be falsely negative with some reagent strips, i.e., Multistix.
Note that Chemstrip reagent strips are not affected by urine ascorbic acid
because of an iodate scavenger pad on their blood and glucose reaction pads.
Even though the reagent strip tests are less sensitive to intracellular hemoglobin
than they are to free hemoglobin, they should be positive in the presence of this
number of RBCs. The identification of the cells can be confirmed by addition of
weak acetic acid that will lyse RBCs but not yeast or WBCs. Monohydrate cal-
cium oxalate crystals can be readily differentiated from RBCs using polarizing
microscopy. (Brunzel, pp. 158-162, 188-190, 218-219)

57. Review the following urinalysis results:

Macroscopic Exam:
Parameter Result
pH_ 6.0
SG. 17020
Blood moderate
Protein 500 mg/dL
Glucose negative
Ketone negative
Bilirubin negative
Urobilinogen 1.0 mg/dL
Nitrite negative.
Leukocyte esterase negative
 CLS Review Questions 39
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Microscopic Exam: 10-25 RBCs per high-power field; dysmorphic Ft
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forms present
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2-5 WBCs per high-power field 4
2-5 hyaline casts £
2-5 RBC casts
U
0-2 granular casts
few uric acid crystals
These results are most consistent with a diagnosis of
A. gout
B. glomerulonephritis
C. pyelonephritis
D. urinary-tract obstruction

The answer is B. Glomerulonephritis is an inflammation of the glomeruli that

results in proteinuria and hematuria. Classic urine microscopic findings include:
increased RBCs, often dysmorphic; increased WBCs, RBC and hemoglobin
casts; granular casts and occasionally WBC and renal cell casts. (Brunzel, pp.
276-278, Strasinger, p. 32)

58. The following urinalysis results are obtained:

Glucose by reagent strip: negative
Ketones by reagent strip: positive
These results are most consistent with
A. starvation
B. polydipsia
C. diabetes mellitus
D. diabetes insipidus

The answer is A. Ketones (acetoacetate, B-hydroxybutyrate, and acetone) are

produced when the liver must oxidize fatty acids due to limited carbohydrate
availability. As a result, large amounts of acetyl CoA are formed that exceed the
Krebs cycle capacity, and the liver mitochondria begin active ketogenesis to
reduce the levels of acetyl CoA. Note that this process will occur in any state
where insufficient carbohydrates are available for cellular energy requirements.
(Brunzel, pp. 177-178; Strasinger, pp. 62-63)

59. Each day, two laboratories perform an inter-laboratory urinalysis correla-

tion. After analysis is completed in lab A, a urine specimen is selected and
sent to lab B. Today, the physical and chemical examinations correlate but
the microscopic results do not. Review the results obtained.
Lab A Lab B
RBCs/hpf 5-10 25-50
WBCs/hpf 0-2 5-10
Which of the following situations could account for this discrepancy?
A. Lab B concentrated a smaller volume of specimen
B. Lab A centrifuged the specimen twice as long as Lab B
C. Lab B centrifuged the specimen at a lower speed than Lab A
D. Lab A used the brake on the centrifuge when processing the specimen

The answer is D. If the brake is used after the centrifugation of urine, urine sed-
iment components can become resuspended leading to falsely low or decreased
numbers of sediment entities, i.e., RBCs, WBCs. The other options describe sit-
uations that would result in higher microscopic results obtained by Lab A com-
pared to Lab B. (Brunzel, pp. 39-41, 417)

60. Which of the following is an “initial” step in a protocol for troubleshooting

an automated method when quality control results are not acceptable?

A. Repeat analysis of QC materials using a fresh aliquot or different vial

B. Recalibrate the instrument, then reanalyze controls and patient samples
C. Change reagents, then repeat analysis using a new lot number of QC
materials
D. Perform periodic maintenance, then recalibrate and reanalyze controls
and patient samples

The answer is A. Actions necessary to bring a system back into control vary.
Troubleshooting should always occur in a stepwise fashion and documentation
must be maintained, e.g., in an “out-of-control” log book. The easiest and first
step when QC results are not acceptable is to simply repeat the analysis using a
fresh aliquot of the QC material or open a new bottle of the same lot number.
Controls can deteriorate or become contaminated while in use. Instrument recal-
ibration, changing reagents, and performing periodic maintenance may have to
be performed to get a system back into control; however, these are usually not
“initial” steps taken to investigate and resolve unacceptable QC results. (Kaplan
and Pesce, pp. 394-395)

References
Anderson SC, Cockayne A. Clinical Chemistry. Philadelphia: WB Saunders
Company, 1993.

Bishop ML, Duben-Engelkirk JL, Fody EP (eds). Clinical Chemistry: Princi-

ples, Procedures, Correlations (3rd ed). Philadelphia: Lippincott, 1996.

Brunzel NA. Fundamentals of Urine and Body Fluid Analysis. Philadelphia:

WB Saunders Company, 1994.

Burtis CA, Ashwood ER (eds). Fundamentals of Clinical Chemistry (Sth ed).

Philadelphia: WB Saunders Company, 2001.

Kaplan LA, Pesce AJ. Clinical Chemistry: Theory, Analysis, and Correlation
(3rd ed). St. Louis: Mosby, 1996.

Lehmann CA (ed). Saunders Manual of Clinical Laboratory Science. Philadel-

phia: WB Saunders Company, 1998.

Strasinger SK. Urinalysis and Body Fluids (3rd ed). Philadelphia: FA Davis,
1994.
Hematology and Hemostasis
a2)
Chapter Authors Bernadette F. Rodak
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Susan J. Leclair
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Ex
CLT Review Questions Contributors =f©

1. The internationally accepted method of hemoglobin measurement requires Heather DeVries

the conversion of hemoglobin to
George A. Fritsma
A. carboxyhemoglobin Kimberly Kinney
B. cyanmethemoglobin David L. McGlasson
C. oxyhemoglobin
D. sulfhemoglobin

The answer is B. Hemoglobin in the circulation is normally found in several

forms, including oxyhemoglobin, deoxyhemoglobin, carboxyhemoglobin, and
methemoglobin. Each of these compounds has a separate peak absorbance and is
therefore measured spectrophotometrically at different wavelengths. Conversion
of these forms of hemoglobin to methemoglobin (oxidation of the Fe*? to Fe*>)
and reaction of the methemoglobin with KCN to form cyanmethemoglobin (hemi-
globincyanide) results in a stable compound that can be measured spectrophoto-
metrically at 540 nm. The only form of hemoglobin found in the circulation that
will not form cyanmethemoglobin is sulfhemoglobin, which, except in rare cases,
is present only in very small amounts. (Rodak, 1995, pp. 133-134)

2. The “rule of three” means that the

A. MCV is three times the MCH

B. RBC count is three times the Hb
C. HCT is three times the MCH
D. HCT is three times the Hb

The answer is D. In the healthy individual, the hematocrit in percent is roughly

three times the hemoglobin value in g/dL, which is, in turn, roughly three times
the RBC count (ignoring the power of 10). This “rule of three” can be used to
evaluate the probable acceptance of CBC results quickly. If the rule of three does
not apply to a given sample, it can indicate a patient abnormality or an error in
sample collection or testing. (Rodak, 1995, p. 137)

3. Which of the following will result in a falsely decreased erythrocyte sedi-

mentation rate (ESR)?

A. Presence of codocytes
B. Inflammatory reaction

41
42 2. Hematology and Hemostasis

C. Marked anemia
D. Slight tilting of the sedimentation rate tube

The answer is A. The process of red-cell sedimentation in the Wintrobe or West-

ergren tube requires rouleaux formation as the first step. Any condition or event
that interferes with formation of rouleaux by red blood cells will result in a
falsely decreased ESR value. The presence of codocytes or target cells impairs
rouleaux formation. Severe anemia and any tilting of the tube during the test will
result in a falsely elevated sedimentation rate value. The presence of an inflam-
matory state will cause a true increase in the value. (Stevens, p. 221)

4. One hundred fifty three nucleated RBCs are reported on a 100 cell differ-
ential. The uncorrected WBC count is 11.9 X 10°/L. The corrected WBC
count X 10°/L is

A. 3.6
B. 4.7
Ce
Des.0

The answer is B. The methods used to count WBCs will include any nucleated
cells in that total. The following formula is used to correct the WBC count for
the presence of nucleated RBCs in the peripheral blood:
number of white blood cells counted (or 100)
Corrected WBC = < WBC count
number of total nucleated cells +
number of NRBCs
=100/253)< 19ex107/2
SA AO

(Stevens, p. 119)

5. After staining a peripheral blood smear with Wright’s stain and a buffer with
the correct pH, the RBCs appear pale pink and the WBCs stain very weakly
with little-to-no nuclear detail. One possible explanation is

A. the patient is experiencing diabetic alkalosis

B. the smear was stained while still wet
C. there was excessive washing of the smear
D. the slide was not on a flat surface, causing pooling of stain

The answer is C. Excessive washing of the smear will cause the stain to fade.
(Rodak, 1995, p. 153)

6. Given the following data, calculate the manual WBC count per pL:
Dilution: 1:20
Depth: 0.1 mm
Area counted: 4 mm?
Total number of cells counted: 120

A. 600
B. 6,000
C. 60,000
D. 600,000
 CLT Review Questions 43

The answer is B. The formula for a manual cell count is:

WBC Count = 22: of calls counted X dilution reciprocal

area in mm? counted

120620
0.4
= 6000 y>
A
uv

ans
(Stevens, p. 115) eae
© y
7. Which of the following conditions would introduce a source of error into a a
o ro}
manual WBC count? te
©

A. Uneven distribution of leukocytes in the counting chamber

B. Immediate counting of cells
C. A sample with an extremely low WBC count
D. Using a 2% (vol/vol) solution of acetic acid as the diluting fluid

The answer is A. Erroneous results can be due to contaminated diluting fluid,

incorrect diluting or loading of the hemocytometer, and an uneven distribution
of leukocytes in the counting chamber. (Stevens, pp. 114-119)

8. False-positive results may occur in the screening solubility test for hemo-
globin S due to

A. decreased plasma proteins

B. hypolipidemia
C. adding more blood to the reagent than calléd for by test procedure
D. a hemoglobin value of less than 7.0 g/dL

The answer is C. Positive results in a screening solubility test for hemoglobin S

are dependent on the relative insolubility of hemoglobin S, which creates a tur-
bid solution. False-positive results in the screening solubility test for hemoglo-
bin S may be caused by anything that increases that turbidity. Too much whole
blood increases the potential for turbidity, as does the presence of excess plasma
proteins or lipids. (Rodak, 1995, p. 675)

9. After a gentle inversion of tube no. | of a freshly collected cerebrospinal

fluid specimen, the specimen appeared slightly turbid (1+) and pale yellow.
After centrifugation, the supernatant was clear and yellow. Which of the fol-
lowing statements is correct?

A. Methemoglobin is present
B. A traumatic tap has occurred
C. Free hemoglobin is present
D. Pathologic bleeding has occurred

The answer is D. If methemoglobin is present, the supernatant is brown. The

supernatant is colorless after a traumatic tap, and a recent hemorrhage into the sub-
arachnoid space will result in hemolysis and the release of free hemoglobin; as a
result the supernatant will be pinkish. Xanthochromia, or a yellow color, results
from the breakdown of hemoglobin into bilirubin. It suggests bleeding into the
subarachnoid space within the last two or three weeks. (Rodak, 1995, p. 637)
44 2. Hematology
and Hemostasis

10. The traditional diluent of choice for quantifying spermatozoa in seminal

fluid contains

A. sodium bicarbonate and formalin

B. methylene blue
C. dilute acetic acid
D. normal saline

The answer is A. Formalin preserves and immobilizes spermatozoa so counting

is more accurate. Stain is necessary when evaluating morphology. It is not rec-
ommended to evaluate morphology in a hemocytometer changer. Dilute acetic
acid is used to lyse red blood cells, which are not normally found in seminal
fluid. Normal saline will simply dilute the fluid and will not immobilize sper-
matozoa, thus decreasing the accuracy of the count. (Strasinger, p. 163)

11. The following erythrocyte indices are obtained for a specimen:

MCV: 88 fL
MCH: 30 pg
MCHC: 34 g/dL
These erythrocytes on a Wright-stained smear should appear
A. hypochromic, microcytic
B. normochromic, microcytic
C. normochromic, normocytic
D. hypochromic, normocytic

The answer is C. The MCV, MCH, and MCHC are all within reference ranges;
therefore, the erythrocytes are normal-sized with normal concentration of hema-
tology. (Harmening, p. 604)

12. An increase in metamyelocytes, myelocytes, and promyelocytes in the

peripheral blood can be referred to as

A. Pelger-Huét anomaly
B. a shift to the left
C. agranulocytosis
D. leukocytosis

The answer is B. A shift to the left means there is an increase in immature gran-
ulocytes (metamyelocytes, myelocytes, promyelocytes, and blasts). Pelger-Huét
anomaly is an inherited condition in which hyposegmentation of the polymor-
phonuclear granulocyte nucleus occurs. Agranulocytosis is the decrease or
absence of granulocytes in either the bone marrow or peripheral blood. Leuko-
cytosis is a general term referring to an increase of WBCs in the peripheral
blood. (Harmening, p. 267)

13. Only 2.0 mL of blood is collected in a vacuum tube containing powdered

EDTA that is designed for a 7.0 mL draw. Which of the following test results
can be expected if this specimen is used?

A. Falsely lowered RBC count

B. Falsely elevated hemoglobin
 CLT Review Questions 45

C. Erroneously decreased microhematocrit

D. ESR of expected value

The answer is C. Since excessive anticoagulant causes shrinkage of red cells, the
ESR and microhematocrit are affected. The number of red cells is not altered,
nor is the amount of hemoglobin. Note that the calculated hematocrit as deter-
mined by electrical impedance instruments does not reflect this morphologic
change. (Brown, p. 8) ALY

2%
> uv
om

14. The following values were plotted during the first six days of a new lot of ge
S g
control for leukocyte determination using an electronic particle counter: Ex
=z©

EPO
6.7 Ns ee Ns
6.6 oe ae Oe ese
Day 1 2 3 4 5 6

The coefficient of variation (CV) is 3.5%. Assume that these results are rep-
resentative of the laboratory’s usual performance of leukocyte count in the
normal and low ranges. Evaluation of the statistical pattern and the coeffi-
cient of variation indicate that
A. corrective action is unnecessary since the CV and plotted data are
acceptable
B. a dilutor check is necessary
C. the control may be deteriorating
D. calculation of a new mean and standard deviation is necessary

The answer is C. Continuously increasing variance in one direction points to a

segment, control-sample, or instrument problem. If the drift were upward, one
would suspect a dilutor error. In this instance the drift is downward; therefore the
more likely factor is a deterioration of the control. Other possibilities are reagent
deterioration and an electronic problem with the counting instrument. (Brown,
p. 26)

15. While performing a WBC differential count on a capillary blood smear, no

platelets were observed. What action should be taken?

A. Report the findings to your supervisor immediately

B. Request a venous sample for an absolute platelet count
C. Look at the edge of the smear for platelet clumping
D. Report out the absence of platelets

The answer is C. Because of the nature of platelets, slides not prepared imme-
diately after a capillary puncture may have excessive platelet clumping along
the tail and margins of the stained slide. Slides with excessive clumping cannot
be properly evaluated for platelet numbers and should be remade. (Henry, p.
597)
46 2 Hematology and Hemostasis

16. A patient’s hemoglobin level is 12.3 g/dL. The erythrocytes appear nor-
mochromic on the Wright-stained smear. The hematocrit value that corre-
lates with these data is

A. 0.34 L/L
B0377/i
C. 0.40 L/L
D. 0.43 L/L

The answer is B. When RBCs are normochromic, an “average” MCHC of 33.3%

can be inserted in the formula, which then can be solved for the Hct. This rela-
tion holds only if the RBCs are normochromic (have a normal MCHC of approx-
imately 33-36%).

MCHC = Hb/Hct
33 Sax
Beer en es Pane)
x = PBIB B38}
x = )'S69700:0:37
(Brown, p. 106)

17. A falsely elevated hematocrit is obtained on a defective centrifuge. Which

of the following values will not be affected?

A. MCH
B. MCV
Cy MEGHG
D. All of the above

The answer is A. The MCV and MCHC use the hematocrit in their calculation.
Therefore, only the MCH that uses Hb and RBC count would be unaffected by
a falsely elevated hematocrit. (Brown, p. 106)

18. A patient’s hematologic results from an electrical impedance instrument are:

WBG3 2.0707/E
RBG 2:83)4104/E
Hb: 11.5 g/dL
Het: 0.34 L/L
PLIs ~6GO05 1027/1

Blood-smear evaluation for quality-control purposes reveals acceptable cell

distribution; normochromic, normocytic RBCs; 2 leukocytes per 40X field;
and 10 platelets per oil-immersion field. The next step would be

. report the results as obtained

. repeat the leukocyte count
. repeat the platelet count
. repeat
GTaAwPS the RBC count ©

The answer is C. In general, one platelet per oil-immersion field is equal to

10,000—40,000/microliter (10-40 X 10°/L). Therefore, this patient’s platelet
count would be expected to be greater than 100 X 10°/L and should be eee
All other data are compatible. (Brown, p. 104)
 CLT Review Questions 47

19. What effect would the use of a buffer with a pH of 6.0 have on a Wright-
stained smear?

A. RBCs would be too pink

B. WBCs would be well differentiated
C. RBCs would be too blue
D. RBCs would lyse
a)
The answer is A. The pH of the buffer is critical in a Romanowsky (Wright)
2%
> uv
om
stain. When the pH is too low (usual range is 6.4-6.7), the red cells take up more
acid dye (eosin) and become too pink. Also, the white cells do not differentiate £¢
© gy
well, giving poor nuclear detail. (Brown, p. 101) Ex
=z6
20. Which of the following red-cell inclusions can be detected with a supravital
preparation that uses new methylene-blue N as the dye reagent but are not
visible with Romanowsky stain?

A. Howell-Jolly bodies
B. Heinz bodies
C. Malarial trophozoites
D. Siderotic granules (Pappenheimer bodies)

The answer is B. There are only a few red-cell inclusions that cannot be seen on
a Romanowsky stain. Heinz bodies, since they are composed of precipitated glo-
bin, have the same net charges as nonprecipitated globin and therefore are not
visible with a stain based on acid-base principles. (Brown, p. 115)

21. Which of the following contain RNA and are usually identified by staining
with brilliant cresyl blue or new methylene blue?

A. Auer rods
B. Reticulocytes
C. Siderotic granules
D. Howell-Jolly bodies

The answer is B. Brilliant cresyl blue and new methylene blue precipitate ery-
throcyte ribosomes into a network so that reticulocytes can be distinguished
from cells containing Heinz bodies, Pappenheimer bodies, or Howell-Jolly bod-
ies. (Brown, p. 113)

22. A manual hemoglobin determination using the cyanmethemoglobin reagent

is performed on a known sickle-cell patient’s whole blood. The
blood/reagent mixture appears cloudy. The correct procedure is to

A. report the result as greater than 20 g/dL

B. allow the mixture to stand for at least 10 more minutes
C. recollect the specimen, making sure that there is a proper ratio of anti-
coagulant to whole blood
D. redilute the blood/reagent mixture using a 1:1 dilution (1/2 by the new
dilution notation) with distilled water, determine the new value, and
* multiply the result by two

The answer is D. The blood/reagent mixture must be crystal clear prior to read-
ing in the spectrophotometer. In situations of suspected hemoglobinopathies
Sl
a Hematology aand Hemostasis

such as S or C, dilution with distilled water clarifies the solution and allows for
accurate readings. Since the mixture has experienced an additional dilution, the
value must be multiplied by 2. (Brown, p. 84)

23. The leukocyte count for a patient is 28.0 X 10°/L. The differential shows 58
orthochromic normoblasts and 10 polychromatophilic normoblasts per 100
WBCs. The leukocyte count is closest to

A. 2.8 X 10°/L
BlGd 10a
Calica OL:
D. 28.0 X 10°/L

The answer is B.

Corrected WBC = Dumber of white blood cells counted (100) \ We count

total of white blood cells counted (100) +
total number of NRBCS
_ 100 x 128.0 10%]
168
= 16.7 X 10°YL
(Stevens, p. 119)

24. Using the estimated mean and standard deviation from the previous month,
the following results were obtained the first two days new controls were used.
Instrument: particle counter
Dilutor: automatic
Assay values (published)
Normal WBC: $2 2.0.6
Abnormal WBC: 15.5 + 0.9
Normal RBC: 4.58 + 0.09
Abnormal RBC: 1.54 + 0.12

Laboratory Values

8.4 car he ae Re 15.6 -A eae

VS eee oO co

7.6 14.4 *
Normal WBC Abnormal WBC

4 68 —= : ; NOT ers
OOOO =
4.60 el
- ee
= 1.50 Se
. -
4.52 1.40
Normal RBC Abnormal RBC

These results indicate

. poor mixing of controls

. no obvious errors
. lysing agent expired
p>
GOW. diluent contaminated with bacteria
 CLT Review Questions 49

The answer is B. Standard quality-control limits are + 2 SDs. Since all the
results fall within the accepted published range, no obvious error is present. No
trends are represented in the data. Poor mixing would produce data that had a
trend, and expired lysing reagent would tend to increase the WBC determina-
tions. Diluent contamination would affect both WBC and RBC determinations,
with an upward trend as bacterial growth increased. (Henry, p. 91)

AL
1)
25. The leukocyte count for an adult patient is 18.0 < 10°/L. The differential ea
2
~

shows:
ge
S w
Polymorphonuclear neutrophils: 56% Ex
Band neutrophils: 5% so
te
©
Lymphocytes: 25%
Monocytes: 10%
Eosinophils: 3%
Basophils: 1%
The above data reveal an absolute increase in
A. polymorphonuclear and band neutrophils
B. lymphocytes and monocytes
C. monocytes and polymorphonuclear neutrophils
D. eosinophils and basophils

The answer is C. Absolute cell count = number of cells in percent times total
WBC count. Although the percentages for polymorphonuclear neutrophils and
monocytes fall within the reference range, these forms are increased in absolute
numbers because the total count is increased. (Stevens, pp. 10, 11)

26. Below are hematologic anticoagulants and corresponding characteristics of

each. Select the one anticoagulant that does not match its characteristic.

A. Dipotassium EDTA—prevents platelet clumping

B. Sodium citrate—used for routine coagulation studies
C. Heparin—suitable for blood smears
D. Double oxalate—produces morphologic artifacts

The answer is C. Heparin is not suitable for blood smears because it gives a
bluish background on Romanowsky-stained smears. (Rodak, 1995, p. 10)

27. A student consistently makes peripheral blood smears that are too thin. You
instruct the student to try

A. using a smaller drop of blood

B. using only capillary blood
C. increasing the angle of the spreader slide
D. applying more pressure on the spreader slide

The answer is C. Increasing the angle of the spreader slide results in a thicker
smear. Using a smaller drop of blood or applying pressure can result in a thin-
ner smear. Both capillary and anticoagulated blood should render equally satis-
factory smears if other factors are correct, such as the angle of the spreader slide
of blood. (Stevens, pp. 24-26)
and the size of the drop
50 2. Hematology and Hemostasis

28. The most reliable criterion used to determine the maturity of a Wright-
stained white blood cell is the

A. size of the nucleus

B. color of the nucleus
C. nucleus-to-cytoplasm ratio
D. structure of the nuclear chromatin

The answer is D. The maturation stage of blood cells can best be determined by
evaluation of the nuclear chromatin structure or pattern. The chromatin-pattern
changes are more consistent. Size or color variables can be affected by slide
preparation, quality of stain, and staining techniques. (Brown, p. 59)

29. Which characteristic differentiates the myelocyte from other myelocytic

cells?

A. A kidney-bean-shaped nucleus
B. Presence of coarse nuclear chromatin
C. Presence of nucleoli
D. Appearance of specific granules

The answer is D. Identification of the myelocyte depends on noting the first

appearance of specific granules. Other morphologic features that are helpful
include the fine texture of the nuclear chromatin, absence of nucleoli, and lack
of indentation in the nucleus. (Brown, p. 59)

30. Hematologic testing on an adult patient provides the following data.

Hb: 7.5 g/dL

Het: O6) IEL,
WBC: 14:6e% 107/15
neutrophils 80%...
lymphocytes 17%
monocytes 3%
These results would best correlate with
A. normochromic RBCs, relative lymphocytopenia
B. hypochromic RBCs, absolute lymphocytopenia
C. normochromic RBCs, absolute lymphocytopenia
D. hypochromic RBCs, relative lymphocytopenia

The answer is D. The MCHC is 28.9%, which is below normal (32-25%). To

determine whether the lymphocytopenia is absolute or relative, one must deter-
mine the actual number of lymphocytes per liter: 17% of 14.6 X 10°/L is 2.5 X
10°/L. The reference range for lymphocytes in the adult patient is 1.5 — 4.5 x
10°/L. (Brown, p. 104)

31. Vigorous mixing of a whole-blood specimen collected with EDTA as the

anticoagulant results in a/an

A. acceptable specimen for routine hematologic tests

B. acceptable specimen for special tests, such as leukocyte alkaline phos-
phatase
 CLT Review Questions 51

C. falsely elevated WBC count

D. falsely decreased hematocrit

The answer is D. If anticoagulated blood is mixed too vigorously, red cells will
be lysed by the force of the mixing and hemolysis will result. The degree of
hemolysis is directly proportional to the number of red cells lysed, and a falsely
lowered hematocrit will result. (Stevens, p. 200)
uv

2%
> uv
BD
32. Aclinical laboratory technician is reviewing a smear for quality-control pur-
poses. The smear is wedge-shaped with smooth edges and extends over ge
S
approximately 60% of the surface of the slide. On low-power (10X) exam- Ex
ination, it is noted that granulocytes are clustered at the tail of the smear. On
=z©
high (40X) magnification, the RBCs appear a buff pink. White cell nuclei
appear dark blue to purple. This evaluation indicates that the smear is

A. acceptable
B. unacceptable because the smear is too long
C. unacceptable because the white cells are clustered at the tail
D. acceptable even though the RBCs are stained lightly

The answer is C. The smear should cover at least half the slide, and the edges
should be smooth without any scratches or erratic areas. The quality of stain at
the levels of magnification noted is acceptable. White blood cells should be
evenly distributed throughout the body of the smear and not clustered at the
edge. (Rodak, 1995, pp. 146-148)

33. A patient is admitted to the hospital with a WBC count of 250 X 10°/L. One
parameter that may be falsely elevated by this WBC count is the

A. hemoglobin
B. MCV
C. platelet count
D. reticulocyte count

The answer is A. Elevated WBC counts cause turbidity in the solution when
whole blood is diluted with HiCN reagent whether this occurs in the manual pro-
cedure or in an automated instrument. This turbidity will affect the absorbance
reading, and the dilution must be centrifuged prior to reading. (Brown, p. 84)

34. A positive sickle-cell screening using the protein-solubility method means that

A. the patient has a genotype of hemoglobin SS

B. the patient has a genotype of hemoglobin AS
C. hemoglobins D, Barts, or S may be present
D. hemoglobin S or C is definitely present

The answer is C. A protein-solubility screening test indicates the presence of any

sickling hemoglobin or hemoglobin that is not soluble in dithionite. These types
of hemoglobins include, but are not limited to, S, D, Barts, and some C. (Rodak,
1995,
p. 675)

35. During the examination of a cerebrospinal-fluid specimen from a 45-year-

old man, the clinical laboratory technician noted the presence of rare
Ba
————————————————
2S patclooyand\Nemost ass a

choroid plexus cells in a total WBC count of 6/mm°?. These results are
indicative of

A. malignant disease
B. inflammatory disease
C. degenerative disease
D. normal state

The answer is D. The total number of WBCs counted is within the standard ref-
erence ranges. Choroid plexus cells make up part of the lining of the cere-
brospinal space. They will be found in both normal and abnormal cerebrospinal
fluids and, since they were seen in a patient with a normal WBC count, can be
presumed to be part of the normal shedding of these cells into the CSF. (Stevens,
p. 286)

CLS Review Questions—Hemostasis

1. Oral anticoagulant therapy with coumarins may do all of the following

except

A. prolong the prothrombin time

B. act in the peripheral blood to decrease factor activity
C. prolong the APTT
D. be neutralized by protamine sulfate

The answer is D. The administration of coumarin interferes with the synthesis of

factors II, VII, IX, and X in the liver by interfering with the utilization of vita-
min K. The prothrombin time is prolonged since it is sensitive to the decrease of
three out of four vitamin-K-dependent factors (II, VII, and X). The APTT may
be prolonged due to decrease of factor [X. Protamine sulfate may be used to
counteract the effect of heparin, but not coumarins. (Henry, pp. 653-654)

2. Blood collected for anticoagulation testing should be collected in

A. 3.5% sodium citrate with a 9:1 blood to anticoagulant ratio

B. 3.2% sodium citrate with a 9:1 blood to anticoagulant ratio
C. 4.0% sodium citrate with an 8:1 blood to anticoagulant ratio
D. 3.8% sodium citrate with a 10:1 blood to anticoagulant ratio

The answer is B. (NCCLS, H21-A3, p. 4)

3. All of the following conditions may cause an increased (prolonged) throm-

bin time except

A. hypofibrinogenemia
B. increased fibrin-degradation products
C. heparin therapy
D. decreased prothrombin

The answer is D. Fibrin-degradation products interfere with the polymerization

of fibrin, heparin acts along with antithrombin III to neutralize thrombin, and
decreased fibrinogen levels result in prolonged thrombin times. (Brown, p. 222)
 CLS Review Questions 53

4. The APTT is a screening test for all coagulation factors in the intrinsic path-
way except which of the following?

A. VU
Baix
Cat
D. XI

The answer is D. The APTT is not sensitive to deficiencies of factor XIII. (Har- >
a
mening, p. 504) a
0
~~
6
5. The coagulation factor that is decreased in hemophilia A is factor £
Y
=
and
Hemo

The answer is C. Factor VIII is severely decreased in hemophilia A. Factor IX

is decreased in hemophilia B. (Harmening, pp. 535-536)

6. Thawing of platelet-poor plasma that has been stored at —40°C for coagu-
lation studies should be performed at what temperature?

A. 0-4°C
B. 4-8°C
C. 10—20°C
D. 35-38°C

The answer is D. Thawing of freshly frozen plasma for use in coagulation stud-
ies should be performed as rapidly as possible without damage to the proteins.
37°C is the preferred temperature. (Rodak, 1995, p. 554)

7. Which two plasma coagulation factors are the least stable in vitro?

A. VII and IX
B. V and VIII
C. XI and XII
D. I and III

The answer is B. Factors V and VIII may lose as much as 50% activity at room
temperature after 4-8 hours. (Harmening, p. 495)

8. Aclinical laboratory technician notes that a specimen for an APTT has been
stored at room temperature for five hours prior to testing. The CLT should

A. perform the APTT and report the results

B. perform the APTT and report the results, noting the delay in processing
C. dilute the sample 1:1 with buffered saline to correct the pH and perform
the APTT
D. request a new sample

The answer is D. Samples for APTT should be held at room temperature for no
more than four hours. (Stevens, p. 270; NCCLS H21-A3, 3rd ed)
54 2. Hematology and Hemostasis

9. Disseminated intravascular coagulopathy (DIC) may display which of the

following coagulation problems?

A. Activation of the extrinsic system and a prolonged bleeding time

B. Activation of the intrinsic system and a decreased factor VIII
C. Activation of both the intrinsic and extrinsic systems and a consumption
of platelets
D. A prolonged bleeding time and a reduction of factor VII

The answer is C. All of the other descriptions are just contrived situations.
(Henry, p. 652)

10. A new lot of controls for prothrombin time has a mean of 12.2 sec with an
SD of 0.4 sec. Which of the following control results would not be accept-
able?

Am lesec
Ba Lindysec
Carl ousec
Del Gsec

The answer is A. Control ranges are generally given as + 2 SD values or, in this
case, from 11.4 to 13.0 sec. (Stevens, p. 13)

11. An upward trend was observed over a six day period in a quality control plot
for a prothrombin time procedure performed on a photo-optical instrument.
This observation indicates a

A. decrease in standard deviation values and thus a change in the reference

range for the procedure
B. loss of precision
C. decreased coefficient of variation
D. loss of accuracy but not precision

The answer is B. Shifts, trends, and increased scatter on a quality control plot all
indicate a loss of precision with an increase in standard deviation and coefficient
of variation. (Stevens, p. 358; Rodak, 1995, p. 40)

12. A specimen is being tested from a patient with severe jaundice. The pro-
thrombin time performed on an electro-optical instrument is 7.4 sec (control
12.0 sec). The clinical laboratory technician should

. request a new sample, drawn preferably as a microsample

. dilute the sample 1:1 and rerun the sample multiplying the result by 2
. perform the test on an electromechanical instrument
S . put a patient blank prior to the patient’s sample in the electro-optical
Daw
instrument

The answer is C. The patient’s jaundice may be causing the electro-optical

instrument to report a false value. Repeating the procedure using a mechanical
instrument will allow for an accurate result. (Rodak, 1995, p. 626)

13. Plasma is diluted in a fibrinogen-activity determination to decrease the

 CLS Review Questions 55

. amount of thrombin necessary

. influence of inhibitors
. amount of calcium needed
S
Ua. effect of deficiencies in other coagulation factors

The answer is B. Dilution of the plasma in this procedure produces an excess of

thrombin, thus nullifying the effect of inhibitors and making fibrinogen the rate-
limiting factor. (Brown, p. 229) A

BY
> uv
om &

CLS Review Questions—Hematology ge

S
Ex
=z6
1. As the supervisory clinical laboratory scientist, you are asked to review a
Wright-stained peripheral blood smear that shows clumping of leukocytes
and platelets. Which of the following is the most probable cause for these
morphologic changes?

A. Smear was made from lh-old heparinized blood

B. Smear was made from lh-old EDTA blood
C. Excessive pressure was applied when making the smear from blood in
the tip of a venipuncture needle
D. Smear was made using fresh capillary blood

The answer is A. The effect of heparin on RBC morphology is negligible, but

clumping of both leukocytes and platelets is seen. Nonanticoagulated blood will
show no visible leukocyte artifacts, although platelet clumping is seen. (Stiene-
Martin, p. 12)

2. An EDTA-anticoagulated tube is received in the laboratory only partially

filled, causing excessive concentration of EDTA. Since the patient was
undergoing an MRI and would not be available to provide another specimen
for an hour, the physician requested that the laboratory perform any test that
would be reliable. Which of the following procedures would be accurate on
this sample?

A. Platelet count
B. Hemoglobin
C. Peripheral blood smear
D. Spun hematocrit

The answer is B. Excessive EDTA causes RBCs to shrink, resulting in a

decreased spun hematocrit, and ESR. It also causes platelets to break up, falsely
increasing the platelet count. Degenerative changes will occur in the WBCs,
causing difficulty in interpreting a peripheral blood smear. The hemoglobin,
however, is unaffected, since cells are hemolyzed in the reaction process.
(Rodak, 1995, p. 137; Stiene-Martin, p.11)

3. Which of the following is appropriate in preparing an EDTA-anticoagulated

specimen for analysis when it has been standing in a rack and not on a
mechanical rotator?

A. Shake vigorously by hand

B. Invert gently at least 60 times
56 2. Hematology and Hemostasis

C. Mix for a minimum of two minutes using a vortex mixer

D. Invert 4-6 times

The answer is B. Inverting gently a minimum of 60 times by hand will ensure

adequate mixing. An alternative is to place the specimen on a mechanical rota-
tor for two minutes. Vigorous mixing or use of a vortex will hemolyze the cells
and invalidate the results. (Henry, p. 483)

4. A patient has a hematocrit of 0.15 L/L (15%). In order to obtain an accept-

able wedge peripheral-blood smear, the clinical laboratory scientist should
make the following adjustment.

A. Use a hemocytometer cover glass as the spreader slide

B. Push the spreader slide 50% slower than usual
C. Permit some of the blood to get in front of the spreader slide
D. Increase the angle of the spreader slide greater than 45°

The answer is D. When a specimen has a very low hematocrit, increasing the
angle of the spreader slide higher than the normally recommended 30-45°
results in a thicker smear. (McKenzie, p. 604; Stiene-Martin, p. 24)

5. When performing a manual differential on a Wright-stained blood smear,

the clinical laboratory scientist noted a purplish black precipitate over the
slide. One cause of this precipitate is

A. precipitation of paraproteins from the patient’s blood

B. insufficient rinsing of the stain and buffer mixture
C. insufficient aging of the Wright’s stain before use
D. failure to remove stain from the back of the slide

The answer is B. When the stain and buffer mixture is not completely rinsed
from the slide, the stain may precipitate on the dried smear. One way to redis-
solve the precipitate is to cover the slide with Wright’s stain for 5-10 seconds
and flush with deionized or distilled water. (Stiene-Martin, p. 33)

6. An automated platelet count performed on a venous blood specimen col-

lected in EDTA is 40 X 10°/L. The clinical laboratory scientist notes platelet
clumps on the Wright-stained blood smear. The CLS should

perform a manual platelet count using the same specimen

redraw the specimen in sodium oxalate and repeat the count
redraw the specimen in sodium citrate and repeat the count
hig inform the physician that an accurate platelet count cannot be obtained
OW
on the patient

The answer is C. In vitro platelet aggregation in EDTA-anticoagulated blood is

the most common cause of a spuriously low platelet count. The large platelet
aggregates may be counted as leukocytes by the instrument, resulting in a low
platelet count. It is thought that platelet-specific antibodies that react only in
EDTA and react best at room temperature cause the agglutination. When platelet
clumping is suspected, the specimen should be redrawn in a sodium citrate tube
and the count repeated on this specimen. The platelet count from the citrated
tube should be multiplied by 1.1 to correct for the dilution. (Harmening, p. 599;
Rodak, 2002, Chap. 13)
 CLS Review Questions 57

7. A patient who underwent a bone-marrow transplant had daily leukocyte

counts performed. Laboratory policy required that counts below 2.0 X
10°/L be performed manually. Since transplant patients usually have
decreased counts, the laboratory scientist prepared a standard WBC
Unopette (self-contained diluting device) resulting in a 1/20 dilution.
Eighty-four leukocytes were counted in the entire area on both sides of the
Neubauer hemocytometer. How should the leukocyte count be reported?
vn

A. 0.4 X 10°%L >8

B. 0.8 X 109/L 2 a
Cr09 < 107/L, mo E
DeateO Xe 1107/1, Ex
Ys
tie
The answer is C. The entire area on both sides of the hemocytometer is 9 mm? Lo)

x 2 = 18 mm’. The depth of the hemocytometer is 0.1 mm. The formula for cell
counts using the Neubauer hemocytometer is:

_# cells counted x gijution factor = cells/mm? or cells X 10°/L

area X depth

Se 20-933 celis/mm:.or:0:0« 102/L

(RS SeOeil

(Stiene-Martin, p. 334; Rodak, 2002, Chap 13)

8. A new clinical laboratory scientist in a hematology/oncology clinic consis-

tently reads microhematocrit-control and patient values higher than co-work-
ers do. Which of the following actions of the CLS could explain this dis-
crepancy?

. Buffy coat is not being included

. Time of centrifugation is too long
. Speed of centrifugation is too high
. Microhematocrit tubes are allowed to sit and are not read within a few
GTaAW>
minutes of centrifugation

The answer is D. Allowing microhematocrit tubes to sit in the horizontal posi-

tion longer than a few minutes after centrifugation may yield falsely elevated
results. Answers A, B, and C would not result in elevated results. (Stiene-Mar-
tin, p. 112)

9. An EDTA specimen from a known sickle-cell anemia patient is received for

a microhematocrit and a hemoglobin determination using the cyanmethemo-
globin principle. Values obtained are a hemoglobin of 10.7 g/dL and a hema-
tocrit of 0.22 L/L. The CLS should

A. centrifuge the hemoglobin and read the supernatant as the test sample
B. mix the hemoglobin dilution 1/2 with distilled water, then read and mul-
tiply the results by 2
C. repeat the hematocrit using heparinized hematocrit tubes
D. repeat the procedure and, if similar results are obtained, report them
immediately

The answer is B. Hemoglobins S and C can cause turbidity in the hemoglobin

solution, causing falsely elevated results. The test sample can be cleared by
diluting 1/2 with distilled water and multiplying the resultant value by 2. (Stiene-
Martin, p. 110; McKenzie, p. 608)

10. A hemoglobin value of 12.5 g/dL best correlates with a hematocrit value of

Al 0253 /L
B= Oso
C2 0375020
D. 0.428 L/L

The answer is C. The mean corpuscular hemoglobin concentration in a nor-

mochromic cell is approximately one-third of the cell volume. Therefore, the
hemoglobin will be approximately one-third of the packed-cell volume. (Stiene-
Martin, pp. 112-113)

11. A patient has an RBC count of 2.70 X 10!7/L, a hemoglobin of 5.5 g/dL, and
a hematocrit of 0.19 L/L. What erythrocyte morphology would you expect
to see on the peripheral blood smear?

A. Microcytic, hypochromic cells

B. Macrocytic, hypochromic cells
C. Normocytic, hyperchromic cells
D. Normocytic, normochromic cells

The answer is A. The formula for calculating the mean corpuscular volume
(MCV) is
MCV = Hct «INO
RBC
MCVe= 19 x 10
sa):
770 TO3a

The normal range of the MCV is approximately 80-100 fL. An MCV of 70

fL indicates that the erythrocytes are smaller than normal, i.e., microcytic.
The formula for calculating the mean cell hemoglobin concentration
(MCHC) is:
Hgb
SSE a |
Hct oe

ay)
MCHC = 19 x 100 = 28.9 g/dL

The normal range of the MCHC is approximately 32-36 g/dL. Values below
32.0 g/dL indicate hypochromia. (Stiene-Martin, p. 113)

12. When reviewing a peripheral blood smear, the clinical laboratory scientist
notes many macrocytes. The MCV has been reported as 85 fL. This appar-
ent discrepancy may indicate that

. the smear was made from the wrong sample

. the smear should be closely checked for spherocytes
. the patient may have a hemolytic anemia
VAwPS>
. cold agglutinins may be present
 CLS Review Questions 59

The answer is A. When many macrocytes are seen on a blood smear, one would
expect to see an MCV close to or above 100 fL. Although an MCV of 85 fL
would be possible with spherocytes, the smear would not demonstrate macro-
cytes. A hemolytic anemia with many reticulocytes could cause a blood smear to
appear macrocytic, but the MCV would not be as low as 85 fL. Cold agglutinins
cause a falsely increased MCV. When there is lack of correlation between a
hemogram and the blood smear, the identification on both the blood smear and
the hemogram should be verified. If no laboratory error is discovered, the auto- >
mated count should be repeated, and the blood smear should be prepared and D
evaluated again. (Stiene-Martin, p. 594) £
2)
et
©
E
13. In the performance of a modified Westergren ESR, what is the recom- G
=
mended dilution? and
Hemos

A. 1/2 (1 volume diluent + 1 volume blood)

B. 1/3 (1 volume diluent + 2 volumes blood)
C, 1/4 (4 volume diluent + 3 volumes blood)
D. 1/5 (1 volume diluent + 4 volumes blood)

The answer is D. The modified Westergren ESR uses 4 volumes of whole blood
diluted with 1 volume of either 0.109 m trisodium citrate or 0.85% sodium chlo-
ride prior to testing (1/5 dilution). (Stiene-Martin, p.117)

14. A Miller disc is used to perform reticulocyte counts. After counting 500
RBCs in square B, a total of 40 reticulocytes are seen in square A. How
should the reticulocyte count be reported?

A = 1/9B

A. 01%
B. 0.9%
C. 44%
D. 8.0%

The answer is B. In the calibrated Miller disc, square B is one-ninth of square A.

When 500 RBCs are counted in square B, theoretically the number of reticulocytes
in 4,500 RBCs have been counted. The percent of reticulocytes is calculated as

; _ Total reticulocytes in square A

Reticulocytes (7) = “Tai RBCs in square B X 9 nig
+ 109 = 0.88 ~ 0.9%
500 K 9
(Stiene-Martin, p. 115)

15. Given the following results on a male patient, calculate the reticulocyte-
production index (RPI)?
OO) aE EMmatClegyiand W608 Se ——————————

RBC count: 2.80 X 10'7/L

Hemoglobin: 9.0 g/dL
Hematocrit: 0.29 L/L
Uncorrected reticulocyte count: 3.0%
A. 0.1
B. 1.0
Careg
D33:0

The answer is B. Reticulocytes normally remain in the peripheral blood approx-

imately one day. When the bone marrow is under stress, as in anemia, reticulo-
cytes may be released into the peripheral blood earlier than normal and thus may
spend 2-3 days in the peripheral circulation. The reticulocyte-production index
takes this increased circulation time into consideration and is a general indicator
of the rate of effective erythropoietic response. Calculation:

RPI = Reticulocytes (%) X patient hematocrit (L/L)/normal hematocrit (0.45)

maturation time in peripheral blood
With a hematocrit of 0.29 the maturation time is 2.0

RPI = 3.0 X —— POG 10

(Stiene-Martin, p. 116)

16. Many schizocytes (schistocytes) are seen on a peripheral blood smear. One
of the most common causes for these cells is

A. presence of an abnormal hemoglobin

B. high-titer cold agglutinins
C. deficiency of spectrin
D. microangiopathic anemia

The answer is D. Schizocytes are fragmented RBCs resulting from intravascular

fragmentation caused by fibrin in small vessels or small-vessel disease. They
may be seen in severe burns, megaloblastic anemia, and microangiopathic
hemolytic anemia. (Stiene-Martin, p. 270)

17, What erythrocyte morphology would be expected on the peripheral blood

smear of a 50-year-old alcoholic with advanced cirrhosis?

A. Pseudomacrocytosis, acanthocytes, codocytes

B. Anisocytosis, micropherocytes, schizocytes
C. Macrocytosis, schizocytes, dacryocytes
D. Microcytosis, polychromasia, echinocytes

The answer is A. Pseudomacrocytosis is common in cirrhosis. The RBCs appear

larger than normal due to an increase in surface area-to-volume ratio, but there
is no increase in MCV or MCH. Both acanthocytes and codocytes may be seen
in alcoholic cirrhosis as a result of abnormalities in plasma lipids that may alter
the lipid composition of the cell membrane. (McKenzie, pp. 196-197)

18. Which of the following procedures is not necessary to confirm the majority
of iron related anemias?
 CLS Review Questions 61

A. Bone marrow evaluation

B. Ferritin
C. RBC indices, including RDW
D. Serum iron and total iron-binding capacity

The answer is A. Iron related anemias may have numerous causes and can be
confused with other diseases such as the thalassemias. It is important to deter-
mine the diagnosis and cause with as little trauma and cost to the patient as pos- ey

By
> vu
sible. The above tests can usually provide the necessary information without the oD &

need for a bone marrow aspiration. (Stiene-Martin, pp. 176, 180)

ge
S y
Ex
19. A patient has a WBC count of 70.0 X 10°/L, immature granulocytes, and xe}
te
dacryoctyes on the peripheral blood smear. On the differential, 10 cells are 6
seen that have a single nucleolus, marked cytoplasmic granularity, and cyto-
plasmic blebs. What is the most likely identification of these cells?

A. Myelocytes
B. Lymphoblasts
C. Micromegakaryocytes
D. Plasma cells

The answer is C. The cells described are most likely micromegakaryocytes,

which may be seen in myeloproliferative disorders (CML, AMM, etc). (McKen-
zie, p. 485)

20. The background of a peripheral blood smear stained with Romanowsky-

type stain appears very blue. The RBCs are stacked like coins. Fifteen per-
cent of the WBCs are the size of a small lymphocyte with very blue cyto-
plasm. The nucleus is eccentric and there is a clear area next to it. These
cells should be reported as

A. nucleated RBCs
B. blasts
C. plasma cells
D. micromegakaryocytes

The answer is C. Plasma cells have an eccentrically placed nucleus and a perin-
uclear hof. The cytoplasm stains deep blue due to the numerous ribosomes pres-
ent. Plasma cell dyscrasias are usually accompanied by increased immunoglob-
ulins, which may cause the entire Romanowsky-stained smear to have a blue
background. (Stiene-Martin, p. 318)

21. A hemoglobin electrophoresis pattern on cellulose acetate at pH 8.6 demon-

strates a band in the S region. Which of the following is the best test to con-
firm the identity of this hemoglobin?

A. Alkali denaturation
B. Hemoglobin electrophoresis on citrate agar, pH 6.0
C. Hemoglobin solubility
D. Heat stability

The answer is B. Alkali denaturation is used for the differentiation of Hb F and

Hb A, which do not migrate in the S region. Acid electrophoresis is a useful pro-
62 Ee
Oe
ee 2. eHEMatology
Hematology and
and Hemostasis
NCMOSlAs|S

cedure for fractionation of various hemoglobins. At pH 6.0-6.2, it distinguishes

HbS from HbD. Hemoglobin solubility is a screening test for sickling hemoglo-
bins and does not differentiate between those and hemoglobin S. Heat stability
is a nonspecific test for unstable, abnormal hemoglobins. (Stiene-Martin, pp.
198-199)

22. A falsely elevated G-6-PD assay using the fluorescent spot test may be seen
in patients with

A. an increased RBC count

B. a change in drug dosage
C. the presence of many reticulocytes
D. a deficiency of pyruvate kinase

The answer is C. Young RBCs (reticulocytes) produced in response to hemoly-

sis have nearly normal G-6-PD levels. Accurate results may be obtained on
patients with increased reticulocytes by centrifuging the specimen and removing
the top layer before testing (contains reticulocytes), or by delaying testing for
2-4 months. (Stiene-Martin, p. 263)

23. A 12-year-old child has had a mild chronic anemia. The physician orders an
osmotic fragility test, since the patient’s father had a splenectomy as a
teenager due to chronic hemolysis. The result is normal. Which of the fol-
lowing procedures would be most helpful to confirm the diagnosis of hered-
itary spherocytosis?

A. Hemoglobin electrophoresis at both alkaline and acid pH

B. Sucrose hemolysis test
C. Fluorescent spot tests for both G-6—PD and PK
D. Osmotic fragility with incubation of specimen at 24 hours at 37 degrees
before testing

The answer is D. Hemoglobin electrophoresis identifies abnormal hemoglobins,

such as S and C. Sucrose hemolysis test is a screening test for paroxysmal noc-
turnal hemoglobinuria. Fluorescent spot tests identify some RBC enzyme defi-
ciencies. The incubated osmotic fragility test will identify patients with a minor
population of spherocytes. (Rodak, 1995, p. 208)

24. A peripheral blood smear contains 80% blast cells, which stain positively
with Sudan black B and peroxidase. This result is consistent with a diagno-
sis of

A. acute lymphoblastic leukemia

B. acute undifferentiated leukemia
C. chronic myelocytic leukemia
D. acute myeloblastic leukemia

The answer is D. Lymphoid cells characteristically do not stain with Sudan black
B and peroxidase. Undifferentiated cells have not matured enough to stain posi-
tively with either Sudan black B or peroxidase. Chronic myelocytic leukemia does
not show 80% blast cells (unless the patient is in myeloblastic crisis). Therefore,
this pattern is most consistent with acute myeloblastic leukemia in which blasts
stain positively for Sudan black B and peroxidase. (McKenzie, p. 364)
 CLS Review Questions 63

25. Specimens for leukocyte alkaline phosphatase stain will yield the most reli-
able results if smears are made from

A. blood anticoagulated with EDTA

B. blood anticoagulated with 3.2% sodium citrate
C. a finger stick and stored at room temperature for 24h
D. capillary blood and stained immediately
4

2%
> uv
The answer is D. EDTA has an inhibitory effect of LAP stain. Fresh capillary om &

blood stained immediately is the preferred specimen, since delay in staining the
blood smear causes loss of LAP activity. (Stiene-Martin, p. 395; Rodak, 2002, ge
Sg
Chap. 28) Ex
xe}
=e
ro
26. The presence of microorganisms, increased protein, and a high leukocyte
count in cerebrospinal fluid (CSF) will cause the CSF to appear

A. bloody
B. oily
C. cloudy or turbid
D. clear and colorless

The answer is C. An increased WBC, increased protein, and presence of

microorganisms can cause cloudiness or turbidity in CSF. Red blood cells from
subarachnoid or intracerebral hemorrhage cause blood to be present in CSF. A
traumatic tap may also cause blood to be present in the CSF and must be ruled
out as a source. An oily appearance can result from injection of radiographic
contrast media. (Brunzel, pp. 368-369)

27. Acytospin smear of CSF from an adult contains a few lymphocytes, mono-
cytes, and ependymal cells. These findings indicate that the patient has

A. meningeal melanoma
B. bacterial meningitis
C. normal cytology in CSF
D. a traumatic brain injury

The answer is C. Normal CSF contains lymphocytes and monocytes. A few

ependymal cells (cells that line the ventricles) may also be seen without indi-
cating pathology. In meningeal melanoma, tumor cells would be seen.
Increased neutrophils would indicate bacterial meningitis. Traumatic brain
injury would likely be accompanied by RBCs. (Brunzel, pp. 370-374; Rodak,
1995, p. 638)

28. Using an undiluted CSF specimen, 150 WBCs are counted in the four large
corner squares on one side of the hemocytometer. What is the total WBC
count per mm??

A. 38
B.3/5
@ 7150
1Dye34750

The answer is B. Use the following formula.

64 2s Hematology and Hemostasis

a no. of cells counted X dilution factor

COUSUTE = area X depth
Since the fluid was undiluted, the dilution factor is 1. The area is 4 mm? and
depth is 0.1 mm.

BME | ls
4X01 04 rena
(Rodak, 1995, p. 636; Rodak, 2002, Chap. 41)

29. In selecting material for smears of bone-marrow cell morphology, the clin-
ical laboratory scientist should select

A. gray particles floating in blood and fat droplets

B. the last material aspirated
C. material free of fat
D. clotted specimens

The answer is A. Gray particles of marrow are visible with the naked eye floating
in blood and fat droplets. These serve as landmarks for the microscopic review of
stained bone-marrow smears. (Rodak, 1995, p. 161; Rodak, 2002, Chap. 15)

30. The type of bone-marrow specimen that is most valuable in estimating mar-
row cellularity and histologic structure is a

A. thin smear of aspirated marrow

B. thick smear of aspirated marrow
C. touch preparation of biopsied marrow
D. sectioned preparation of biopsied marrow

The answer is D. The histologic architecture and cellularity of bone marrow are
best evaluated in a sectioned biopsy preparation because the relation of cells to
each other is preserved. Individual cell morphology is best evaluated by thick or
thin smears or touch preparations. (McKenzie, p. 619; Rodak, 1995, p.160;
Rodak, 2002, Chap. 15)

31. The following results are obtained on a bone-marrow differential:

Myeloblasts
Promyelocytes
Myelocytes —

Neutrophilic bands
Segmented neutrophils
Eosinophils
Basophils
Lymphocytes
Monocytes LO)
1
i
=
Ne
SS
Plasmacytes a

Normoblasts 60
What is the myeloid:erythroid ratio (M:E)?
AX, Ose
Beovet
 CLS Review Questions 65

C, 2.0:1
D. 3.0:1

The answer is A. The total percentage of myeloid cells (neutrophils, eosinophils,

and basophils) observed in relation to the total percentage of erythroid precur-
sors gives the M:E ratio. In the example given, the total of myeloid cells is 30%
and the total of normoblasts is 60%; therefore, the M:E ratio is 30:60, or 0.5:1.
(Stiene-Martin, pp. 383-384) 2

2%
> Vv
om &

32. A properly calibrated and controlled instrument that uses the principle of gE
cy
electronic impedance produces repeated (<3) values on a blood sample: Ex
o
RBC: 4.01 K 10'7/L =e
6

HB: 12.0 g/dL

MCY: 80fL
MCH: 32 pg

The most likely explanation for these results is

A. iron-deficiency anemia
B. hereditary spherocytosis
C. high titer of cold agglutinins
D. high reticulocyte count

The answer is B. In hereditary spherocytosis, the MCHC is often increased

(greater than 36%) because of a decrease in cell surface area. The MCV is often
in the low-normal range. In iron-deficiency anemia, one would expect a
decreased MCHC. Cold agglutinins would cause a falsely decreased RBC and
elevated MCY, along with an elevated MCHC. A high reticulocyte count might
influence the MCV but would not affect the MCHC. (Stiene-Martin, pp. 254,
541)

33. The following information is obtained from an electronic cell counter:

MCV 75 fL (N = 80-100 fL)

RDW 20% (N = 11-14)
Based on the above parameters, what RBC morphology would be expected
on the peripheral blood smear?
A. Normocytic cells that vary little in size
B. Microcytic cells that vary little in size
C. Microcytic cells with significant variation in size
D. Macrocytic cells with significant variation in size

The answer is C. The MCV of 75 fL is decreased, suggesting microcytosis. An

RDW of 20% is increased, and a variation in the size of the RBCs would be
expected. Such a peripheral-blood morphology may be seen in iron deficiency
or sideroblastic anemia. (Stiene-Martin, p. 130)

34. On a cytocentrifuge preparation of pleural fluid, cells are noted that are
round with centrally located nuclei giving the cells a “fried egg” appear-
ance. Some have multiple nuclei. These cells should be identified as
 . reactive lymphocytes
. hairy cells
. mesothelial cells
. tumor cells
QUAY

The answer is C. Reactive lymphocytes tend to be pleomorphic with stretched

out cytoplasm. Hairy cells have projections on the cytoplasm. Mesothelial cells
have central nuclei and blue cytoplasm and may be single or multi-nucleated.
Tumor cells tend to occur in clusters and have molded nuclei, i.e., it is difficult
to assess where one cell ends and the other begins. (Rodak, 1995, pp. 641-642)

35. Which of the following would be an acceptable specimen for semen analy-
sis?

A. Collected at home using an ordinary condom

B. First morning specimen collected at home and transported to the labora-
tory 2 hours later
C. Collected in the office and maintained at 2—8°C until examination
D. Collected at the office without a condom and examined within one hour

The answer is D. Semen specimens should be collected without use of a condom

unless a special nonspermicidal condom is used. The specimen should be exam-
ined within one hour of collection. It must be kept at a temperature between 20°
and 40°C. (Brunzel, p. 336)

CLS Review Questions—Hemostasis

1. Coagulation studies are ordered on a patient with a hematocrit of 65%. What

volume of sodium citrate should be used to collect a volume of 5 mL
blood/anticoagulant solution?

The answer is B. The amount of sodium citrate in evacuated tubes will provide
a 1/9 ratio when the hematocrit is less than 55%. The ratio may be adjusted
according to the following formula:

C = 1.5 X 10-3 (100 -—H) xX V

Where C = volume of sodium citrate in mL, V = volume of whole blood
and anticoagulant in mL, and H = hematocrit (%). The amount of sodium
citrate to be used when the patient’s hematocrit is 65% will be:
1.85 X 10-3 (100
- 65) X 5 = 32 mL
(Rodak, 1995, p. 553)

2. Samples for laboratory studies involving hematology, chemistry, and hemo-

stasis require the collection of tiger-top serum separator tube, a tube con-
taining sodium citrate, and an EDTA tube. What should be the order of draw
in order to preserve the integrity of the specimen for coagulation studies?
 CLS Review Questions 67

A. Tiger top, sodium citrate, EDTA

B. Sodium citrate, EDTA, tiger top
C. Tiger top, EDTA, sodium citrate
D. Sodium citrate, tiger top, EDTA

The answer is D. If the tube for coagulation is drawn as part of a series, it should
be drawn first or immediately following a non-additive tube. It should not fol-
low any additive tube, as additives may be transferred into the specimen. i“
> uv
(NCCLS H21-A2, 1998; Rodak, 2002, Chap. 2) ans
as
3. A specimen for determination of activated partial thromboplastin time
ge
© gy
Ex
(APTT) for monitoring heparin therapy is collected in sodium citrate at 9:30 o
am and allowed to remain at room temperature in the collection center until te
©
delivery to the laboratory at 2:30 pm. What effect will storage have on the
results?

A. Shortened due to increased glass activation

B. Prolonged due to deterioration of factor VIII
C. Shortened due to platelet neutralization of heparin
D. No effect

The answer is C. Factor VIII is relatively stable over 5 hours, but platelet release
of heparin-neutralizing proteins shortens the APTT within one hour of collec-
tion. (Rodak, 2002, Chap. 47)

4. A patient with anatomic bleeding and poor wound healing has the following
hemostasis findings:

APTT: 31.5 S (normal 25.2—35.4)

PT: 11.2 S Mormal 10.5—13.1)
Platelet count: 195,000 (normal 150—400,000/mm+?)
Platelet aggregation: normal response to all agonists
What is the logical next hemostasis test to perform?
A. Lupus anticoagulant screen
B. Test for single factor inhibitor
C. Test for factor XII deficiency
D. Test for factor XIII deficiency

The answer is D. Patients with factor XIII deficiencies have poor wound heal-
ing, although not all have severe bleeding. All of the other tests would be per-
formed only if the APTT were prolonged, which it is not in this case. (Rodak,
2002, Chap. 47)

5. The coagulation factor deficiency that can display both an abnormal PT and
APTT is factor

The answer is C. Main laboratory features of patients with a factor X deficiency

are prolonged PT and APTT assays. (Harmening, pp. 540-541)
68 2 Hematology and Hemostasis

6. A patient has an abnormal thrombin time and a normal reptilase time. Which
of the following can produce this result?

A. Afibrinogenemia
B. Elevated fibrin degradation products
C. Heparin
D. Coumadin

The answer is C. Reptilase is unaffected by the presence of heparin, hirudin, and

antithrombins. (Harmening, p. 534)

7. A patient has a normal prothrombin time (PT) and a prolonged activated

partial thromboplastin time (APTT). To distinguish whether the prolonga-
tion of the APTT is caused by a factor deficiency or an inhibitor, the clini-
cal laboratory scientist should first

A. mix | part patient plasma and | part normal plasma and repeat both the
PT and APTT
B. mix | part patient plasma and 1 part normal plasma and repeat the APTT
only
C. perform a factor X assay; if prolonged, a factor X deficiency is indicated
D. perform a plasma thrombin time test

The answer is B. To distinguish whether a factor deficiency or an inhibitor is

responsible for a prolonged PT, APTT, or thrombin time (TT), a mixture of equal
parts of patient and normal reagent plasma should be prepared and tested fol-
lowing the protocol for the procedure that showed the prolongation. Only the
system that showed the abnormal result is tested. If the result on the mixture is
corrected, a factor deficiency is suspected and the mixing test is repeated fol-
lowing incubation at 37°C. If the original prolonged test is corrected by the mix-
ing procedure at both stages (with and without incubation), a factor deficiency
is likely. If either mixing test yields prolonged results, an inhibitor is suspected.
(Rodak, 1995, p. 578)

8. The most frequent hereditary condition predisposing to venous thrombosis is

A. dysfibrinogenemia
B. protein S deficiency
C. protein Z deficiency
D. activated protein C resistance

The answer is D. Activated protein C resistance is the most frequent hereditary

condition predisposing to venous thrombosis, being found in 16-30% of patients
with acute venous thromboembolism. (Hoffman, Benz, Shattil, et al, DueiG:
Stiene-Martin, p. 678)

9. An unexpectedly small anticoagulant response to heparin therapy may be

caused by decreased levels of

antithrombin
platelet factor 4
factor XIII
a
OUthromboxane
 CLS Review Questions 69

The answer is A. Antithrombin complexes with and inhibits thrombin and other
activated serine proteases, e.g., factors XIa, Xa, [Xa. Heparin serves as a cofac-
tor for this reaction. Low levels of antithrombin result in decreased neutraliza-
tion of these factors in the face of high levels of heparin therapy since both
antithrombin and heparin are required. (Stiene-Martin, p. 677)

10. In the performance of coagulation tests, the abnormal control yields unac- a

ee
> vu
ceptable results for both the PT and APTT. The normal control is within oS

acceptable limits for both procedures. What is the appropriate action for the
clinical laboratory scientist? 2
S gy
Ex
A. Perform preventive maintenance on the instrument before retesting the = 6
controls
B. Repeat the abnormal control on a new bottle of control material before
proceeding with the analysis
C. Continue with the procedure and report out only those patient results that
are in the normal range
D. Continue with the procedure and report out only those patient results that
are in the abnormal range

The answer is B. Since two test procedures are out of control, the integrity of the
abnormal control should be questioned. A new bottle of abnormal control should
be tested before any other action is taken. (Rodak, 1995, p. 563)

11. Unfractionated heparin must have which one of the following coagulation
inhibitors present in normal amounts in order for it to properly anticoagulate
a patient?

A. Protein C
B. Protein S
C. Antithrombin III
D. Alpha-, antiplasmin

The answer is C. In its natural state AT-III is a slow progressive inhibitor. How-
ever, in the presence of heparin it becomes a very potent inhibitor of coagula-
tion. Therefore the efficacy of heparin therapy depends on the level of AT-III.
(Harmening, p. 503)

12. An 18-year-old female was scheduled to have her wisdom teeth removed.
Because the patient had a history of frequent nosebleeds, heavy menstrual
periods, and easy bruisability, the surgeon ordered a full coagulation screen.
The following results were obtained:

Prothrombin time: 11.8 sec (N = 10-12 sec)

APT T: 40 sec (N = 25-35 sec)
Platelet count: 300 x 10°/L (N = 150 — 450 X 10°/L)
Based on these results, what additional procedure should be performed?
A. Factor VII assay
B. Vitamin K level
C. Platelet-aggregation studies
D. Thrombin clotting time
70 2: Hematology and Hemostasis

The answer is C. The history and laboratory findings suggest a qualitative

platelet disorder of von Willebrand’s disease. Platelet-aggregation studies should
be performed using arachidonic acid, ADP, and collagen. Also a ristocetin cofac-
tor test should be performed. If von Willebrand’s disease is present, cofactor test
may be decreased. Although a factor-VIII assay might be helpful, there is no
indication for a factor-VII assay or a vitamin-K level (PTT is normal). (Stiene-
Martin, p. 666)

13. The formation of D-dimer is the by-product of the effect of plasmin on

A. fibrin degradation products

B. cross-linked fibrin
C. fibrinogen
D. plasminogen

The answer is B. D-dimers are the proteolytic product of cross-linked fibrin

caused by the serine protease plasmin. (Harmening, p. 557)

14. What reagent is added to conventional aggregometry to test platelets for

release, as well as aggregation?

A. ATP
B. Firefly luciferase
C. Ristocetin
D. ADP

The answer is B. With the addition of firefly extract, luciferase, to conventional

platelet aggregometry, two results can be monitored at the same time. This is
called lumiaggregometry. The firefly extract illuminates when in contact with
energized ATP. Platelet-dense granules contain both ADP and ATP. When
platelets are activated, they release their granules and aggregate with each other.
ADP causes the platelets to aggregate and ATP causes the luciferase to glow.
Two photodetector systems in lumiaggregometry monitor both aggregation and
granule release. This test can detect faulty release of granules and storage pool
diseases. (Rodak, 1995, p. 559)

15. In the performance of platelet aggregometry on patient samples, the instru-

ment should be set to 100% transmittance using

A. patient platelet-poor plasma (PPP)

B. patient platelet-rich plasma (PRP)
C. control platelet-poor plasma
D. control platelet-rich plasma

The answer is A. The instrument should be adjusted to 100% transmittance using

patient PPP. (Stiene-Martin, p. 711)

16. Which of the following conditions can cause a prolonged thrombin clotting
time?

A. Prothrombin deficiency
B. Coumadin therapy
 CLS Review Questions 71

C. Antithrombin deficiency
D. Hypofibrinogenemia

The answer is A. (Rodak, 2002, Chap. 43)

17. The most common generalized hemostatic disorder is

a
A- vitamin K deficiency

3%
> uv
mo &
B. liver disease
C. hemophilia ge
D. von Willebrand’s disease Sg
Ex
ao)
The answer is B. The liver is responsible for production of nearly all plasma pro- me
6
coagulants and coagulation system regulatory proteins. Liver disease particu-
larly affects production of the vitamin K dependent factors: prothrombin, factors
VII, IX, X, protein C, and protein S. Liver disorders include hepatitis, cirrhosis,
cancer, poisoning, obstructive jaundice, and others. (Rodak, 2002, Chap. 43)

References
Brown BA. Hematology: Principles and Procedures (6th ed). Philadelphia: Lea
& Febiger, 1993.

Brunzel NA. Fundamentals of Urine and Body Fluid Analysis. Philadelphia:

WB Saunders, 1994.

Harmening DM. Clinical Hematology and Fundamentals of Hemostasis (3rd

ed). Philadelphia: FA Davis, 1997.

Henry JB (ed). Clinical Diagnosis and Management by Laboratory Methods

(20th ed). Philadelphia: WB Saunders, 2001.

Hoffman RL, Benz EJ, Shattil SJ, et al (eds). Hematology: Basic Principles and
Practice (3rd ed). Philadelphia: Churchill Livingstone, 2000.

McKenzie SB. Textbook of Hematology (2nd ed). Baltimore: Williams &

Wilkins, 1996.

Rodak BF (ed). Diagnostic Hematology. Philadelphia: WB Saunders, 1995.

Rodak BF (ed). Hematology: Clinical Principles and Applications (2nd ed).

Philadelphia: WB Saunders, 2002.

Stevens ML. Fundamentals of Clinical Hematology. Philadelphia: WB Saun-

ders, 1997.

Stiene-Martin EA, Lotspeich-Steininger CA, Koepke JA (eds). Clinical Hema-

tology: Principles, Procedures, Correlations (2nd ed). Philadelphia: Lippincott
Williams & Wilkins, 1998.

Strasinger SK. Urinalysis and Body Fluids (3rd ed). Philadelphia: FA Davis,
1994.
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Immunohematology
Chapter Author Kathryn Doig

CLT Review Questions Contributor

1. Whole blood collected in citrate-phosphate-dextrose with adenine (CPDA- Susan J. Beck P

3)
1) may be stored for up to <
~
fe)
A. 48 hours 6
E
B. 21 days cd)
<=
C3) .days = fe)
¢
D. 42 days 5
=
The answer is C. Blood collected in CPDA-1 is “good” for 35 days, mainly E
because the additive adenine provides a substrate from which erythrocytes can
synthesize ATP. (Vengelen-Tyler, p. 162)

2. The temperature of a refrigerator that contains stored blood or blood prod-

ucts should not exceed

Re ACss
B. 6°C
Cc. 8°C
D. 10°C

The answer is B. According to American Association of Blood Banks (AABB)

standards, the temperature in a refrigerator used to store blood or blood products
must be maintained between 1—6°C. The refrigerator must also have a recording
thermometer and an alarm system; often the alarm is set to trigger at 7°C. (Ven-
gelen-Tyler, p. 182)

3. The results of a physical examination performed on a female blood donor

are as follows:

Last donation: 3 months ago

Age: 65 years
Hemoglobin: 12.8 g/dL
Pulse: 95 beats/min
Blood pressure: 170/90 mmHg
Weight: 112 lb
Temperature: 38°C

How many of the given values fall outside the acceptable limits set by the
AABB and would result in the deferral of the donor?
73
7A 3._Immunohematology

A. None
B. One
C. Two
D. Three

The answer is B. Although several values are close to the limits, only one falls
outside the acceptable range and would result in the donor being deferred. The
oral temperature may not exceed 37.5°C. Other limits are as follows:
Last donation: minimum interval is 8 weeks between donations
Age: blood donors must be at least 17 years of age
Hemoglobin: 212.5 g/dL
Pulse: 50-100 beats/min with no pathologic irregularity
Blood pressure: no higher than 180 mmHg systolic and 100 mmHg diastolic
Weight: 110 lb or more may donate 450 mL + 45 mL, plus 30 mL
for processing tubes
(Vengelen-Tyler, pp. 90, 94-95, 103)

4. Which of the following is a preferred method for packing red blood cell
products for shipping?

A. Wrap the component unit in a plastic bag and place on dry ice in an insu-
lated cooler
B. Place the component unit in a plastic bag with crushed ice and seal care-
fully before placing in an insulated cooler
C. Place the component unit in the bottom of a cardboard box and place on
top a well-sealed plastic bag of wet ice
D. Place a previously chilled component unit in an insulating material such
as plastic air bubble packing or Styrofoam fragments in an insulated cooler

The answer is C. During shipping, red blood cell components must be maintained
at a temperature of 1—-10°C. At the low end of that range, freezing must be
avoided because the cells will lyse when intracellular water expands as it freezes.
At the other extreme, the temperature cannot rise above 10°C without the risk of
bacterial growth. The use of dry ice or directly placing the blood bag in contact
with wet ice risks freezing. The use of insulation around a blood bag without
including something to continue chilling is inadequate to hold the temperature
below 10°C. Therefore, the preferred shipping method uses wet ice in a bag sep-
arated from the blood bag to keep the temperature low, but above freezing, while
shipping in either a cardboard box or insulated cooler. (Vengelen-Tyler, p. 183)

5. Which of the following individuals may be considered for autologous blood

collection though not generally for allogeneic whole blood donation?

A. Individual with a blood pressure of 160/98

B. Individual 15 years of age
C. Individual with a temperature of 37.5°C (99.5°F)
D. Individual with a hemoglobin of 12.6 g/dL

The answer is B. The acceptable blood pressure for any donor is180/100 or
lower. The maximum body temperature for any donor is 37.5°C (99.5°F). The
minimum hemoglobin for allogeneic donation is 12.5 g/dL. The minimum age
for donation is 18 years. However, pediatric patients may be considered for
 CLT Review Questions 75

autologous donation if the parents approve, the volume collected is suitably

adjusted for weight, and the patient is provided with emotional preparation and
support for the invasive procedure. (Vengelen-Tyler, pp. 90, 94, 113)

6. Below are the results of testing on a donor unit:

ABO group: A
Rh testing: negative
Weak D testing: positive
Which of the following is the proper labeling for this unit?
A. Discard—Rh typing invalid
B. Use for plasma components only
C. A negative
D. A positive
Pa)
fe)
The answer is D. Donor units must be tested for the weak D phenotype. When 2
fe)
it is found to be present, the unit is considered Rh-positive and must be labeled ~
©
as such. Weak D cells carry D antigens that can be antigenic if transfused into £
Vv
Rh-negative (i.e., D-negative) recipients. Labeling weak D-positive donor units AS
fe)
as Rh-positive avoids this risk. (Vengelen-Tyler, p. 150) S
>
£
7. Amale donor appears generally healthy and has no history of recent surgery
E
or travel outside the United States. He takes blood-pressure medication
twice daily. Physical examination reveals weight 155 Ib, hemoglobin 15.5
g/dL, blood pressure 140/75 mmHg, oral temperature 37°C, and pulse 55
beats/min and regular. Based on the data provided, the clinical laboratory
technician should

/A. consult the physician regarding the donor’s medication

B. accept the donor for plasma donation only —~
C. defer the donor based on the blood-pressure measurement
D. defer the donor based on the hemoglobin measurement

The answer is A. Taking medication is not automatically a cause for donor defer-
ral, as most medications will not affect the recipient. However, the collection
facility must be concerned about the ability of a donor taking medication for an
underlying medical condition to tolerate the donation process. Therefore, the
blood-bank physician should be consulted to assess the safety of the donation for
the donor. (Vengelen-Tyler, p. 164 or Std B1.900)

8. All of the following steps are important for procedures that use antiglobulin
serum except

A./antiglobulin serum can be added any time up to 40 min after completion

of washing .
B. the cell button should be fully resuspended in the residual saline after
decanting and before addition of wash saline -
C. the volume of wash saline should fill the tube at least three-quarters full 4

D. washing is performed in as short a period of time as possible

The answer is A. The antiglobulin serum must be added immediately following

the completion of washing. If this is not done, cell-bound IgG may detach from
76 3. Immunohematology

the red cells, thus reducing reaction strength. Further, detached antibodies
remain free in the fluid medium and can inhibit the antiglobulin serum when it
is added, thereby giving a false-negative reaction. (Vengelen-Tyler, p. 263)

9. A test tube containing known antibody and unknown cells has been incu-
bated and spun. After dislodging the cell button completely, several large
agglutinates are apparent with no small clumps or free cells visible. The
background solution is clear. This reaction should be graded as

A. 4+
B. 3+
C. 2+
D. 1+

The answer is B. Using a semiquantitative method of grading reaction strength

provides additional information that can be useful in solving problems such as
ABO discrepancies or atypical antibodies. A 4+ reaction appears as a single
large agglutinate. The description above is 3+. A 2+ reaction may include sev-
eral large agglutinates in a background of smaller clumps, but no free red cells.
A 1+ reaction is characterized by multiple small clumps and a background of
numerous free red cells. (Vengelen-Tyler, p. 646)

10. When performing ABO typing by the gel method in microtubes, the cells
appear pelleted at the bottom after centrifugation. What is the interpretation
of this appearance?

A. The test is negative

B. The test is weakly positive
C. The test is strongly positive
D. The test cannot be interpreted until the cells are resuspended

The answer is A. In a gel assay, a negative test appears with all cells in the bot-
tom of the microtube. Positive tests, even those that are weakly positive, will
have agglutinates trapped above the bottom of the microtube. (Vengelen-Tyler,
pp. 265-266)

11. The presence of anti-A, is usually detected by the

A. antibody screening procedure (indirect Coombs’ test)

B. reverse ABO grouping procedure
C. red-cell typing antisera
D. use of A, cells

The answer is B. Anti-A, will react with the A, cells used in reverse ABO group-
ing. Anti-A, will not react with Group O cells used for antibody screening. Other
antibodies, such as red-cell typing antisera, will not react with anti-A, since no
A, antigen is present. Anti-A, is not expected to react with A, cells. The pattern
of reaction with A, cells but not O cells or A, cells confirms the identity of the
antibody as anti-A,. (Vengelen-Tyler, p. 274)

12. The ABO typing of a patient’s sample yields the following results:
 CLT Review Questions 77

Patient cells + Patient serum

Anti A Anti B A, Cells _B Cells
0 0 4+ 3+
The patient’s ABO blood group is
A. O
B. A
B
D. AB

The answer is A. In ABO typing, reagent antisera of known specificity are

tested against the patient’s red cells to detect the antigens on the cells. This is
known as forward grouping, or front typing. A negative reaction with anti-A
indicates that the A antigen is not present on the cells. Similarly, failure to react
with anti-B indicates the lack of the B antigen on the cells. Lack of both anti-
za
gens defines the individual as group O. In the ABO system, individuals typi- co)
cally possess in their serum the antibodies against the antigens that they lack on AS)
°
P™)
their cells. The presence of these antibodies is detected by testing the patient’s ©

serum against cells known to possess the A antigen and other cells known to S
oY
possess the B antigen. This is known as reverse grouping, or back typing, and <=
°
can be used to confirm the forward grouping. This patient’s serum reacted with ¢
=]
both the A cells and the B cells, indicating the presence of both anti-A and S
anti-B in the serum. This is the expected reaction of a group O individual. E
(Vengelen-Tyler, p. 270)

13. The results of D typing on a patient using a high-protein anti-D reagent are

Room
temperature 37°C AHG Check cells
Patient cells + anti-D 0 2+ Not performed
Patient cells + Rh control 0 2+ Not performed
AHG = antihuman globulin

Which of the following is the correct interpretation of these results?

A. Rh-negative, weak D-positive
B. Rh-positive, weak D-positive
C. Rh-negative, weak D-negative
D. Invalid Rh typing

The answer is D. When Rh or D typing is performed using a high-protein

reagent, a high-protein control reagent is also reacted with a separate aliquot of
the cells. This control lacks anti-D and is expected to give a negative reaction.
Reaction of the Rh control serum with the cells is not due to anti-D reacting with
the D antigen on the cells but due to an interaction of the high protein matrix of
the anti-D reagent. Therefore, a positive reaction with the Rh control serum pre-
vents interpretation of the presence or absence of D antigen on the tested cells,
yielding an invalid Rh or D typing. (Vengelen-Tyler, p. 308)

14. Which of the following is characteristic of the reactivity of Rh group anti-

bodies?
I) rr

A. Bind complement and cause in vitro hemolysis

B. Do not react with enzyme-treated cells
C. React better at 37°C than at room temperature
D. Tend to be saline agglutinins

The answer is C. Most antibodies in the Rh system result from immunization

due to either pregnancy or transfusion. They tend to be IgG, reacting best at 37°C
in potentiating media or with antiglobulin or enzyme procedures. They rarely
bind complement. (Harmening, p. 137)

15. Which of the following lists four antibodies that all generally react best
below 37°C?

A. Anti-A, anti-P,, anti-Le’, anti-M

B. Anti-B, anti-K, anti-I, anti-Fy*
C. Anti-H, anti-S, anti-Jk?, anti-Le?
D. Anti-B, anti-N, anti-E, anti-Jk°

The answer is A. The antibodies that usually react strongly at 4°C are anti-A,
anti-B, anti-H, anti-P,, anti-Le*, anti-Le®, anti-I, anti-M, and anti-N. (Vengelen-
Tyler, pp. 276, 292, 392)

16. From the abbreviated-cell panel depicted below, determine the most proba-
ble antibody or antibodies in the patient’s serum.

Panel
cell
no. Known antigens Test results
Hy leg Check
& ED TEP Ne KG 37°C AHG cells
1 + + - + 0 0 + 0 + 2+ 3+, NR
Ni 0 + + 0 + + 0 0 0 2+
cee (ger ees eer a2 0 0 + + 0 2+ 4+ NP
4 + + 0 0 + + + + + 0 0 2+
SO 20 0 + + 0 + + 0 0 0 2+
AHG = antihuman globulin; NP = not performed

A. Anti-k
B. Anti-e
C. Anti-E
D. Anti-C and anti-e

The answer is C. From the panel antigens shown, possible antibodies are anti-C,
-D, -E, -c, -e, -K, -k, -M, and -N. One first looks for negative test results to rule
out antibodies against antigens present on nonreactive cells. For example, there
are no reactions of patient serum with cell 2 at any phase of testing. Since these
cells are positive for the D, c, e, k, and M antigens, corresponding antibodies must
be absent or a positive reaction would have occurred. Thus, anti-D, -c, -e, -k, and
-M have been eliminated from consideration. The only remaining possibilities are
anti-C, -E, -K, and -N. Since cell 4 also does not react with the patient serum and
has C, K, and N antigens on its surface, anti-C, -K, and -N are eliminated. This
leaves anti-E as the only possible antibody in the patient’s serum. Cell 5 is also
 CLT Review Questions 79

negative when tested against the patient’s serum, but this does not rule out any
additional antibodies. The identification of anti-E is supported since E antigen is
present on both cells 1 and 3, which were reactive with the patient’s serum. The
pattern of reactivity at 37°C, strengthening at AHG is also consistent with anti-E.
Antibodies in the Rh system are usually IgG and react best at 37°C and at the
antiglobulin phase of testing. (Vengelen-Tyler, pp. 394-395)

17. Below are the results of an antibody screen:

LISS 37°C AHG Check cells
Patient serum + screen cell I 0 0 2+
Patient serum + screen cell II 0 0 2+
AHG = antihuman globulin

The correct interpretation of these results is that the >

a
A. check cells did not react as expected; the results of the antibody screen 2
3
cannot be interpreted 6
ad

B. patient serum demonstrates an unexpected antibody reacting against £

@
antigens on both screening cells re
°
C. patient serum demonstrates an unexpected antibody reacting against an ¢
3
antigen present on only one screening cell E
D. patient serum demonstrates no unexpected antibodies E
The answer is D. The antibody-screening test is one example of an indirect anti-
human-globulin test (AHG). The first step in interpretation is to evaluate the
reaction of the check (Coombs’ control) cells. If AHG has been added to the test
and remains active, the addition of antibody-coated check cells will result in
agglutination, as is the case in both tubes above. Since the check cells reacted,
the results of the other phases of testing can be interpreted. No reaction occurred
in either phase of testing or with either screening cell; therefore, the patient
serum does not demonstrate any unexpected antibodies. The presence of most
unexpected antibodies would be detected by a reaction of one or both of the
screening cells at any phase of testing. (Vengelen-Tyler, pp. 262, 383, 394)

18. An antibody identification panel tentatively identified a patient’s antibody

as anti-c. Antigen typing on the patient’s cells to aid in confirmation of the
antibody identification gave the following results:
Anti-c at 37°C
Patient cells 0
Cc control cells 1+
CC control cells 0
Which of the following is the correct interpretation of the results?

A. Antigen typing is an inhibition test; the results indicate that the patient
is C positive
B. The c typing on the patient cannot be interpreted because the positive
control reacted only weakly
The patient is c negative and could have produced anti-c
UO The patient could not develop anti-c, so the antibody identification is in
error
B53. immunohematology

The answer is C. For antisera that are used infrequently, positive and negative
control cells should be tested along with the patient’s cells. Heterozygous con-
trol cells that are weakly positive should be selected to ensure that the antiserum
will react with the patient cells if they too are heterozygous and carry a low dose
of the antigen. Since the control cells reacted as expected, the results of the
patient’s typing can be interpreted. In this case, the results demonstrate that the
patient’s cells lack the c antigen. Individuals can develop antibodies to antigens
that are considered by their immune systems to be foreign; i.e., to antigens they
do not possess. Since this patient lacks the c antigen, the patient could develop
anti-c, so the results of the antigen typing support the tentative identification of
the serum antibody as anti-c. (Harmening, p. 263)

19. An antibody identification panel demonstrates possible anti-E and anti-K in

a patient’s serum. Which of the following group O cells could be used to
absorb the patient serum and separate these antibodies so that anti-K
remains in the absorbed serum?

Reactions of cells with:

Anti-E Anti-K
A. Cell 1 0 0
Be Cell: 2 + 0
Ge Cells 0 +
D. Cell 4 - +

The answer is B. To separate the two antibodies, a cell is selected that carries
only one of the corresponding antigens on its surface. The serum is allowed to
react with these cells so that one antibody will attach to its corresponding anti-
gen present on the cells while the other antibody remains in the serum. In this
case, cell 2 possesses the E antigen and lacks the K antigen. Allowing the serum
to react with cell 2 would permit the anti-E to adsorb to the cells while the anti-
K remains in the serum. The absorbed serum can then be tested to help confirm
the presence of the anti-K. The anti-E can be eluted from the cells and the elu-
ate tested like a serum sample to confirm the presence and identity of that anti-
body. (Vengelen-Tyler, pp. 412-413)

20. A fundamental purpose of the crossmatch is to

A. detect recipient antibodies that are directed against donor red-cell antigens
B. prevent immunization of the recipient
C. prove that a recipient does or does not have an unexpected antibody in
the serum
D. verify that the donor and recipient are Rh-identical

The answer is A. The crossmatch provides considerable safety in transfusion

services. It can demonstrate that the ABO groups of recipient and donor are
compatible, as in giving A blood to an A recipient or O blood to an A recipient.
It can also be used to determine whether a recipient has detectable, unexpected
antibodies directed against donor cells. However, the crossmatch cannot prove
that a recipient has no unexpected antibodies, nor can it guarantee that immu-
nizations will not occur. In the latter instance, for example, an Rh-positive donor
can have a compatible crossmatch with an Rh-negative recipient. However, the
Rh-positive cells, when transfused, may immunize the recipient to produce anti-
 CLT Review Questions 81

D. The crossmatch does not verify that the donor and recipient are Rh-identical.
(Vengelen-Tyler, p. 380)

21. Choose the preferred criteria for donor units when issuing uncrossmatched
blood for a patient for whom no pretransfusion testing can be completed.

A. ABO- and Rh-specific

B. ABO-specific, Rh-negative
C. ABO- and Rh-compatible
D. Group O, Rh-negative

The answer is D. In emergency situations, blood may be issued even though the
recipient is neither typed nor crossmatched. If there is time for typing, blood that
is type-specific (e.g., Group A positive donor to Group A positive recipient)
should be issued. If blood that is type-specific is not available in sufficient quan-
>
tity, type-compatible blood (e.g., Group O negative donor to Group A positive 5)
recipient) may be given. ABO-specific blood that is Rh-negative may be given 2
O°
~
when the recipient’s ABO group has been determined but the Rh status has not. ©
In dire emergencies, when no pretransfusion testing (e.g., ABO grouping and Rh S
Vv
typing) can be completed prior to transfusion, Group O, Rh-negative blood te,
°
should be issued. (Vengelen-Tyler, pp. 473-474) ¢
=)
£
22. The crossmatch can be limited to procedures to detect ABO compatibility if
E

A. the recipient has been transfused within the last 72 hours without reaction
B. the recipient currently has a negative antibody screen and no previous
history of an unexpected antibody
C. the blood selected for the recipient is ABO-group and Rh-type specific
D. the recipient is a newborn who has not yet developed unexpected anti-
bodies

The answer is B. If a recipient has a negative antibody screen that includes an

AHG phase, there is approximately 95% confidence that he/she does not have a
demonstrable unexpected antibody. If the history is also negative, then concern
about the transfusion stimulating a secondary immune response is minimal.
Taken together, a negative history and negative screen indicate that there is neg-
ligible concern for a hemolytic transfusion reaction due to unexpected antibod-
ies. However, the crossmatch must still detect the expected antibodies of the
ABO system. Hence, the purpose of the crossmatch is narrowed to confirming
that the donor and recipient are ABO compatible. This can be determined in the
immediate spin phase since ABO antibodies react best at 22°C or below or a
computer crossmatch may be used. (Vengelen-Tyler, pp. 380-382)

23. Which of the following would be an acceptable alternative for a packed red-
cell transfusion if ABO group-specific blood were not available?

A. Group A recipient with group B donor

B. Group B recipient with group AB donor
C. Group O recipient with a group A donor
D. Group AB recipient with a group B donor

The answer is D. The major crossmatch consists of recipient serum and donor
cells. In option A, the A recipient has anti-B in the serum, which would react
82 3. Immunohematology

with the B cells of the donor. In option B, the B recipient has anti-A, which
would react with the A antigenic sites of the AB donor cells. In option Cethe
group O recipient has anti-A and anti-B; the anti-A would react with the donor’s
group-A cells. In option D, the group AB recipient has neither anti-A nor anti-B
in the serum; therefore, there are no ABO system antibodies to react with the B
cells of the donor. Group A, B, or O blood can be given to an AB recipient, but
only one blood group should be given to a single recipient if possible. (Venge-
len-Tyler, p. 385)

24. A patient has the phenotype O, CDEe. If transfused with blood from six
random group O, Rh-positive donors, the patient could theoretically pro-
duce the antibody

A. anti-D
B. anti-C
C. anti-c
D. none; the patient is Rh-positive

The answer is C. Persons may produce alloantibodies to antigens they lack on

their red cells. This patient, who has C, D, E, and e antigens on his/her red cells,
could produce anti-c if transfused with blood possessing the c antigen. The
chance of such a transfusion is high, since 31% of the white population and 9%
of the African-American population are CDe/cde. (Vengelen-Tyler, pp. 226,
297-298)

25. If the antiglobulin phase of the crossmatch is omitted, which of the follow-
ing antibodies would probably not be detected?

A. Anti-K
B. Anti-A
C. Anti-P,
D. Anti-N

The answer is A. Anti-K reacts best in the antiglobulin phase of testing, as do

most of the antibodies in the Kell system. The same is true of antibodies in the
Kidd and Duffy systems. Therefore, these antibodies may not be detected if the
antiglobulin phase were omitted. Anti-A, anti-P,, and anti-N react best at cold
temperatures and would be detected on immediate spin. (Vengelen-Tyler, p.
317)

26. Below are the results of pretransfusion testing on a recipient with no history
of unexpected antibodies. The donor is group- and type-specific for the
recipient.

LISS Check
IS (37°C) AHG cells
Patient serum + screen cell I NP 0 0 2+
Patient serum + screen cell II NP 0) 0) 2+
Patient serum + donor cells 0) NP NP NP
AHG = antihuman globulin; NP = not performed

Which of the following is a correct interpretation of these results?

 CLT Review Questions 83

A. The compatibility of the donor cannot be determined without continuing

the crossmatch through the antiglobulin phase
B. The compatibility tests indicate compatibility, and the donor unit may be
transfused into the recipient
C. The antibody screen cannot be interpreted because an immediate spin
phase was not performed
D. The antibody screen cannot be interpreted because the check cells
reacted

The answer is B. For a patient without a history of unexpected antibodies and a

currently negative antibody screen through AHG, the crossmatch need only pro-
ceed through the immediate spin phase to assure ABO compatibility. In this case,
the antibody screen is negative in both phases and the check cells reacted, indi-
cating the presence of active AHG in the test system. The antibody screen can
therefore be interpreted as negative. As the immediate spin crossmatch was also
negative, the donor is considered compatible, and the unit may be transfused. >
a
(Vengelen-Tyler, p. 383) =
°
Lad
6
27. Direct antiglobulin testing was performed on a patient suspected of having £
v
autoimmune hemolytic anemia. The following results were obtained: £
re)
¢
=)
Polyspecific AHG Anti-IgG Anti-C3d E
Patient cells 2+ 2+ 0 S
Check cells NA NA 2+
AHG = antihuman globulin; NA = not applicable

What is the best interpretation of these results?

A. The test cannot be interpreted because the check cells did not react as
expected
B. The patient’s cells are coated with IgG
C. The patient’s cells are coated with complement
D. The patient’s cells are coated with IgG and complement

The answer is B. The polyspecific reagent can detect the presence of both IgG
and complement components. The monospecific reagents are then used to deter-
mine which specific molecule(s) are attached to the patient’s cells. Direct addi-
tion of polyspecific and monospecific IgG antihuman sera to washed patient
cells resulted in reactions, indicating that the AHG was added and active and
detecting the presence of IgG on the patient’s cells. Since direct antiglobulin
testing uses antihuman-globulin reagent, check cells must be added to negative
tubes to ensure that the AHG reagent was added and is active. For anti-C3d test-
ing, the check cells must be coated with complement instead of, or in addition
to, antibody. Since the check cells reacted, the anti-C3d added to the test was
active. The test for the presence of the complement component C3d on the
patient’s cells is therefore interpreted as negative. (Vengelen-Tyler, pp. 261-262)

28. Which of the following tests can bé used to determine the dosage of Rh-
immune globulin needed for a postpartum woman to prevent Rh sensitization?

A. D-antigen typing by microplate

B. Donath-Landsteiner test
C. Kleihauer-Betke acid elution
D. Microscopic weak D
84 3. Immunohematology

The answer is C. The Kleihauer-Betke acid-elution test detects fetal cells in the
maternal blood sample. A smear of the mother’s peripheral blood is treated with
citric acid. Fetal hemoglobin resists the acid and remains in the cells while the
adult hemoglobins in the maternal cells are eluted. When the smear is subse-
quently stained with eosin, the fetal cells appear bright pink and the maternal cells
appear as “ghosts.” The proportion of fetal cells to maternal cells is counted and
used to calculate the number of doses of Rh-immune globulin needed to clear the
fetal cells from the maternal circulation. (Vengelen-Tyler, pp. 507, 706-707)

29. All of the women described below, except one, should receive Rh-immune
globulin. All are Rh-negative, weak D-negative, and delivered Rh-positive
infants. Identify the woman who would not benefit from the administration
of Rh-immune globulin (Rhlg).

A. Group O; positive antibody screen; anti-D identified; received antepar-

tum Rhlg
B. Group B; positive antibody screen; anti-D identified; did not receive
antepartum Rhlig
C. Group A; positive antibody screen; anti-K identified; did not receive
antepartum Rhig
D. Group O; negative antibody screen; did not receive antepartum Rhlg

The answer is B. Women are candidates for Rhlg if they are Rh-negative, weak
D-negative, deliver Rh-positive infants, and have not developed endogenous
anti-D. This woman fulfills the first two criteria; however, she appears to have
endogenous anti-D in her serum. This differs from the woman described in
option A. In her case, the anti-D detected and identified is most likely due to
antepartum RhIg administration. She remains a candidate for postpartum Rhlg
to clear her bloodstream of the fetal cells that entered at delivery. (Vengelen-
Tyler, pp. 505-506)

30. Below are the preliminary results of the investigation of a reported transfu-
sion reaction. The transfusion was stopped after infusion of approximately
1/2 of a unit of packed cells because the patient developed a fever. The post-
transfusion sample was collected within 30 minutes of the time the transfu-
sion was stopped. A review of records revealed that the patient was group
A, Rh-positive, while the donor was group O, Rh-negative.

DAT Serum hemolysis

Pretransfusion patient sample neg absent
Posttransfusion patient sample neg absent
These results suggest that the patient
A. is having an acute hemolytic transfusion reaction
B. is having a delayed hemolytic transfusion reaction
C. may be having a transfusion reaction, but it is probably not hemolytic
D. is not having a transfusion reaction

The answer is C. Whenever a patient receiving blood develops a fever, a transfu-

sion reaction is likely. The preliminary laboratory tests will detect acute hemolytic
transfusion reactions, as when ABO-incompatible blood is transfused, and a post-
transfusion sample demonstrates a positive DAT or serum hemolysis while the
pretransfusion sample is negative. Delayed hemolytic reactions do not develop
 CLT Review Questions 85

until several days after the transfusion is complete and, thus, would not be the
cause of the reaction described here. Febrile reactions are the most common and
are due to recipient antibodies directed against WBCs that are present in residual
amounts in most component preparations. Further investigation is required to con-
firm this cause. Until ruled out by further testing, the possibility of a nonhemolytic
transfusion reaction must be maintained. (Vengelen-Tyler, pp. 591-593)

31. Laboratory studies of maternal and cord blood yield the following results:

Maternal blood: Group O, Rh-positive; anti-c identified in serum

Cord blood: Group A, Rh-positive; direct anti-globulin test 2+; anti-c
identified in eluate
If exchange transfusion is required, the best choice of blood is
A. A, Rh-negative, c-positive Pa)
3)
B. O, Rh-positive, c-negative i)
C. A, Rh-positive, c-positive fe)
ww
D. O, Rh-negative, c-negative 6
E
Vv
£
The answer is B. Donor blood of the baby’s ABO group should be selected when te]
¢
known—if it is compatible with the mother’s serum. In this instance, the anti-A =]
in her serum would react with A cells if these were used. Thus, Group O red cells £
should be selected. Since the mother has anti-c in her serum, blood lacking the E
c antigen should be used. Therefore, Group O, c-negative cells, such as
CDe/CDe, should be selected. Since both mother and baby are Rh-positive, Rh-
positive blood should be used to increase the likelihood of obtaining c-negative
blood (D-negative, c-negative blood is rare). (Vengelen-Tyler, p. 504)

32. Fresh frozen plasma should be thawed by

A. allowing it to come slowly to room temperature

B. slow thawing in the refrigerator to prevent bacterial growth
C. rapid thawing in a water bath at 56°C
D. rapid thawing in a microwave not to exceed 37°C

The answer is D. Thawing fresh frozen plasma must occur rapidly enough that
bacteria cannot grow; thus, room-temperature thawing is too slow. Allowing
plasma to thaw in the refrigerator prevents this problem due to the inability of
most bacteria to multiply at 4°C; however, this is impractical because it greatly
increases the time required to thaw the plasma for transfusion. Warming is
required to thaw the plasma in a timely manner. The temperature cannot exceed
37°C because coagulation factors and other plasma proteins will be denatured.
Both microwaves and waterbaths are acceptable as long as the temperature
remains at or below 37°C. (Vengelen-Tyler, p. 170)

33. Which of the following methods is acceptable for disposal of units of blood
that must be discarded?

A. Chemical decontamination by mixing with bleach

B. Freezing with subsequent quick thawing, resulting in hemolysis
C. Incineration
D. Irradiation
86 3. Immunohematology

The answer is C. Incineration and autoclaving are the only acceptable methods
for ensuring that blood-borne pathogens are destroyed. (Vengelen-Tyler, p. 186)

34. The date is February 15th. The expiration dates of four units of packed red
cells in the blood-bank refrigerator are given below. Which of these must be
removed from inventory today?

A. February 14
B. February 15
C. March 1
D. March 14

The answer is A. Unit A has passed expiration and must be removed from inven-
tory. Unit B is usable today but, if not transfused, must be removed from inven-
tory tomorrow. Under exceedingly urgent conditions, if no other options are
available, a unit just past outdate may be transfused. The benefit to the patient
will be reduced as red-cell viability has probably fallen below 70%. However,
this may be preferable to no transfusion or transfusion of incompatible units in
an emergency situation. (Vengelen-Tyler, p. 166)

35. A unit of blood is returned to the blood-transfusion facility. It had been issued
20 minutes previously. A patient emergency prevented the transfusion from
being attempted. The nurse had taken the precaution of placing it in the
refrigerator on the nursing floor where drugs are kept. The unit has not been
entered and still has two segments attached. Assuming that visual inspection
reveals no hemolysis or other abnormalities, can the unit be reissued?

A. Yes; all requirements for reissue have been met

B. No; the unit was not maintained at the appropriate temperature
C. No; at least three segments are required for investigation of a possible
transfusion reaction
D. No; once a unit has left the transfusion facility, it cannot be reentered
into inventory

The answer is A. Most blood banks will accept for reissue a unit of blood that
has been out of their monitored refrigerator for less than 30 minutes. The fact
that this unit was refrigerated during this time provides even greater assurance
that the temperature of the blood did not exceed 10°C. However, well-meaning
hospital staff may place the unit too near the freezer compartment of the nurs-
ing-floor refrigerator; therefore, inspection of the unit for hemolysis is essential
prior to reissue. Additionally, the unit had not been entered, eliminating concerns
of possible contamination and at least one segment was still attached to allow for
any further pretransfusion testing. (Vengelen-Tyler, p. 186)

36. A unit of packed red blood cells is returned to the blood bank beyond the
safe period for reissue. Which of the following describes the appropriate
disposition of the unit?

A. Salvage the red blood cells by glycerolization and freezing

B. Destroy the unit by incineration
C. Return the unit to the refrigerator but quarantine it for three days. Return
it to inventory if there is no evidence of bacterial growth
D. Return to inventory if the unit has not been entered and is not hemolyzed
 CLS Review Questions 87

The answer is B. When red blood cells are outside a monitored refrigerator for
more than 30 minutes, the unit must be destroyed. Acceptable methods for dis-
posal include autoclaving or incineration. (Vengelen-Tyler, p. 46)

37. The Clinical Laboratory Technician (CLT) is working alone in the transfu-
sion service of a community hospital one night when a new Emergency
Department (ED) staff member arrives anxiously stating that the physician
has ordered two units of packed cells STAT and uncrossmatched. Which of
the following must the CLT do?

A. Give a unit of type O neg packed cells to the ED staff member immedi-
ately
B. Instruct the ED staff member to return with a sample of the patient’s
blood for ABO typing after which a unit of type O neg packed cells will
be issued >
C. Provide the ED staff member with an emergency release form for the fo]
=
doctor’s signature and instruct him or her to return immediately after it fe]
=)
is signed 6

D. Ask the ED staff member to complete a form with the patient’s name and £
oY
<=
hospital number, then issue a unit of type O neg packed cells °
<
=)
The answer is C. Issuance of uncrossmatched blood requires the attending physi- =
cian’s signed statement of need. In this circumstance, the transfusion service E
staff member can be preparing two units of uncrossmatched group O negative
cells for release immediately once the ED staff member returns with the signed
form, which will contain appropriate patient information, as well. (Vengelen-
Tyler, p. 386)

38. Which of the following would not cause a unit of blood to be quarantined
for possible contamination?

A. Green appearance to the plasma

B. Purple color to the red cell mass
C. Hemolysis just above the red cell mass
D. Blood in the ports

The answer is A. A green appearance to the plasma is attributable to the break-

down by light of bilirubin in the plasma to biliverdin. This does not equate to
bacterial contamination. However, a purple color to the red cell mass or hemol-
ysis just above it are evidence of contamination. Blood in the ports is not evi-
dence of contamination, but rather that the unit may not be sealed and at risk for
contamination. Therefore, quarantine is indicated for those situations in B-D.
(Vengelen-Tyler, p. 184)

CLS Review Questions

1. A donor unit contains a warm-reacting (37°C) unexpected antibody. That

unit should be

A. treated as any other unit for transfusion

B. used only for purposes other than red-cell transfusion (e.g., plasma com-
ponents)
S83. Immunohematology

C. used only as frozen, deglycerolized red cells

D. used as red blood cells, or the equivalent, with the plasma removed

The answer is D. Donor units containing antibody that is reactive at 37°C

should be processed into components that contain only minimal amounts of
plasma. The antibody contained in the unit will be reduced in quantity, and
when transfused will become diluted within the recipient’s body. (Harmening,
p. 234)

2. All of the following tests on donor units are required at the donor center except

A. HBsAg
B. anti-HTLVI
C. anti-Epstein-Barr
D. anti-HCV

The answer is C. Epstein-Barr virus, the causative agent for infectious mononu-
cleosis, can be transmitted by transfusion. However, this occurrence is rare.
Since the disease is usually mild and the transmission rate by transfusion is low,
testing for this virus is not required. Hepatitis B and C viruses and HTLV I cause
serious diseases that are the more common causes of transfusion-transmitted
infections. All units transfused must be tested for exposure to these viruses.
(Vengelen-Tyler, p. 150)

3. A donor history reveals the following information:

Traveled to an area endemic for malaria 18 months ago; has had no anti-
malarial drugs or malarial symptoms
Has seasonal hay fever; presently asymptomatic
Has not eaten for the past 12 hours
Takes an occasional sleeping pill
How many of these results exclude the person from giving blood for routine
transfusion?
A. None
B. One
C. Two
Dihtee

The answer is A. Although none of the conditions listed should exclude the
donor, items concerning hay fever, fasting, and sleeping pills do warrant addi-
tional consideration. If the donor is taking aspirin-containing medications, the
blood should not be the only source of platelets for a patient. Because lack of
eating often causes more donor reactions than usual, a light snack before dona-
tion is advisable. The occasional use of hypnotics is acceptable, but it is advised
in such instances that the physician be consulted and donor’s verbal approval to
donate be documented in the donor record. (Vengelen-Tyler, p. 104)

4. The clinical laboratory scientist is determining hemoglobin values on

donors using the copper sulfate method. When a drop of one donor’s blood
was added to the 1.053 specific gravity copper sulfate solution, the drop
sank into the solution about 1/2 inch, hesitated there, and then rose. This
indicates that
 CLS Review Questions 89

. the donor has sufficient hemoglobin to be accepted for donation

. the copper sulfate solution is contaminated and should be replaced
. the donor is anemic and should not be accepted for donation
GaAwmS
. the donor is acceptable only if female

The answer is C. In the copper sulfate method of hemoglobin determination, a

drop of blood with a hemoglobin concentration of 12.5 g/dL or greater will sink
in a solution of specific-gravity 1.053. The failure of the blood to sink indicates
that the donor’s hemoglobin level is less than 12.5 g/dL, and, therefore, the
donor is anemic. Since donation may be risky for this donor, the donor should
be deferred. In past years, different minimum hemoglobin concentrations were
specified for male and female donors. Currently, a single value has been estab-
lished for all donors, regardless of gender. (Vengelen-Tyler, pp. 95, 711)

5. A unit of whole blood is spun using a heavy spin, and the plasma is removed >
fo)
into a transfer pack 24 hours after collection. The plasma unit is then frozen 2
fe}
solid and later thawed at 4°C, at which time the liquid portion is removed. ~
©
The remainder of the plasma unit should be £
co)
<=
A. labeled as cryoprecipitated AHF and frozen at —30°C °
c
B. labeled as fresh frozen plasma and frozen at — 18°C 5
E
C. placed in the refrigerator and labeled liquid plasma
D. discarded due to incorrect preparation
E
The answer is D. The described procedure would result in the preparation of
cryoprecipitated AHF; however, it is necessary to begin such preparation
within eight hours of whole-blood collection to preserve the labile clotting fac-
tor. Therefore, the cryoprecipitated AHF cannot be transfused. The remainder
of the whole-blood unit may be used as RBCs and plasma. (Vengelen-Tyler, p.
724)

6. A small urban hospital specializing in gastrointestinal surgery maintains a

limited blood inventory for emergencies. The minimum inventory is to be
maintained at 6 units O pos packed cells, 6 units A pos packed cells, and 2
units O neg packed cells. In addition, 3 units of type A fresh frozen plasma
(FFP), 3 units of type O FFP, and 6 units AB FFP are also kept in the freezer.
Ideal inventory is considered to be two units more of each item. An inven-
tory check on June | indicates the following:

Number Component Type Outdate

6 packed cells A pos June 15
6 packed cells O pos June 2
4 packed cells O neg June 10
4 FEP A Sept 15
3 BFP. O Aug 11
7 FFP . AB Nov 2
Which of the following must be ordered?

A. Group O FFP
B. Group O neg packed cells
C. Group O pos packed cells
D. Group AB FFP
oO Swllmmunohemstolgy

The answer is C. All of the inventory items meet at least minimum acceptable
levels, however, the O pos packed cells will be out-dated the next day, so a new
ideal supply should be ordered. To avoid wasting these units, they may have
been shipped several days earlier to another institution more likely to use them
before the outdate. (Vengelen-Tyler, p. 80)

7. The effectiveness of leukocyte-reduced red blood cells can be maximized by

A. leuko-reduction immediately before infusion or at the bedside

B. mechanical buffy coat removal
C. freezing and deglycerolization
D. pre-storage filtration

The answer is D. Leukocyte-reduced red blood cells are used for patients who
experience adverse reactions to white blood cell components. The method of
removing the white blood cells as well as the timing are the two factors deter-
mining the number of white blood cells that can be removed from a unit of blood
and the quality of the component. Filtering using special filters minimizes dam-
age to the white blood cells, thus reducing the release of substances that can trig-
ger allergic or febrile reactions even in the absence of intact cells. Further, such
filters are most effective in actually reducing the number of intact cells remain-
ing in the unit after leuko-reduction. During storage, white blood cells lyse,
releasing their contents, therefore, filtration prior to storage is preferred. (Ven-
gelen-Tyler, p. 175)

8. Place the steps below in the proper order for preparing cryoprecipitated anti-
hemophilic factor (AHF) from whole blood. Some steps may be repeated.

. Centrifuge at 1-6°C using a heavy spin

. Thaw at 1-6°C
. Separate the plasma
. Freeze the bag
7 13354234
. 1,3,4,2,4
wo le A
»153,4.2
ee
qd
2

The answer is A. Blood is separated by “heavy spin” centrifugation at 1-6°C and

the plasma is removed. The plasma is frozen and then thawed slowly at 1-6°C.
The plasma is removed, leaving the precipitate containing AHF. The precipitate
is then refrozen for storage. (Vengelen-Tyler, p. 724)

9. A 60-year-old woman arrives at the donor center to provide a directed dona-

tion for a family member. The donor history questions reveal that she had
breast cancer 20 years earlier, was treated by mastectomy and chemother-
apy and has not had a recurrence. Which of the following is the appropriate
course of action for the clinical laboratory scientist?

A. Deny the donor

B. Accept the donor
C. Consult the collection facility’s physician
D. Refer the woman to her physician for a letter of permission to donate
 CLS Review Questions 91

The answer is C. Individuals with a prior history of cancer should be evaluated

for their suitability as donors by the collection facility’s physician. In general,
whenever the CLS has a question about the suitability of a donor, the facility’s
physician may be consulted to determine whether the donation may be harmful
to either the donor or the recipient. (Vengelen-Tyler, p. 103)

10. Which of the following cells would be the best choice to use in titration of
only anti-Jk* in a serum containing both anti-Jk? and anti-Jk>?

Anti-Jk? Anti-Jk®
A. Cell 1 0 0
B. Cell 2 + 0
Cy-Cell 3 + “
D. Cell4 0 +
>
fo)]
The answer is B. The cell used for the titration must have on its surface the anti- &
°
gen corresponding to the antibody to be titered and lack the antigen(s) corre- ~
©
sponding to antibody(ies) in the same serum that are not to be titered. (Venge- E
Vv
len-Tyler, pp. 677-680) is
3°
c
=]
E
11. Which of the following best reflects the discrepancy seen in a sample E
demonstrating the acquired—B-like phenomenon?

A. Forward group appears to be B, but reverse group seems to be O

B. Forward group appears to be AB, but reverse group seems to be A
C. Forward group appears to be O, but reverse group seems to be B
D. Forward group appears to be B, but reverse group seems to be AB

The answer is B. Some group A, individuals, such as those with carcinoma of

the colon, massive infection with gram-negative organisms or intestinal obstruc-
tion, have been observed to acquire a B-like antigen. This results from the action
of bacterial deacetylase, which converts the primary A-antigen determinant, N-
acetyl-galactosamine, to N-galactosamine; this is similar to the primary D-galac-
tose determinant of B antigen. Interestingly, the natural anti-B in the patient’s
serum does not react with the B-like antigens on his or her own cells, whereas
many other examples of anti-B, such as anti-B—typing sera, react with the
patient’s cells. (Vengelen-Tyler, p. 282)

12. A patient whose blood is a subgroup of A gives the following red-cell reac-
tions when tested against various antisera:

Antisera Reactions of patient’s RBCs

Dolichos biflorus: negative
Anti-A: mixed-field agglutination
Anti-A,B: mixed-field agglutination
This patient has an anti-A, in the serum. The subgroup is most likely
Bagh
B. A,
oye
Dan
22 Si immunehematology

The answer is C. The mixed-field reactions with anti-A and anti-A,B are char-
acteristic of the A; subgroup. The negative reaction with Dolichos biflorus (anti-
A,) indicates that the A, antigen is missing. Occasionally, A; persons have anti-
A, in their serum. Mixed-field agglutination is not seen in any other subgroup of
A. (Vengelen-Tyler, p. 274)

13. Select the most likely cause for the ABO forward and reverse reactions
given below:

Cell grouping Serum grouping

Anti-A Anti-B Anti-A,B Acells Becells Ovcells Autocontrol
4+ 0 4+ 0 0 0 0
A. polyagglutinable cells
B. immunodeficiency
C. acquired A-like antigen
D. A subgroup

The answer is B. The strong reactions in the forward grouping indicate a group A
individual. However, no agglutination is seen in the reverse grouping, in which
the serum of a group A person possessing anti-B should react with B cells. One
would not expect reactions with A cells or O cells. The autocontrol is negative,
ruling out an autoantibody. The lack of agglutination in all of the serum group-
ings indicates that an immunodeficiency state should be suspected. Immunodefi-
cient persons do not produce antibodies demonstrable at 22°C (room tempera-
ture). Newborns also lack reverse typing antibodies. (Vengelen-Tyler, p. 284)

14. Below are the results of a type and screen on blood from a patient with lym-
phoma who is scheduled for surgery the following day. In this laboratory,
cells are not washed for routine typing.

Cell grouping Serum grouping

Anti-A: 4+ A cells: 2+
Anti-B: 1+ B cells: 4+
37°C LISS) AHG Check cells
Patient serum + screening cell I 2+ 0 2+
Patient serum + screening cell II 2+ 0 2+
AHG = antihuman globulin

Which of the following techniques would be most useful in resolving the

ABO discrepancy and obtaining reliable antibody screening results?

A. Autologous absorption
B. Saline-replacement technique
C. Antibody-identification panel
D. Use of polyspecific AHG rather than monospecific AHG

The answer is B. If the weaker grouping results are ignored, the patient forward
and reverse groups as an A. The weak cell reaction with anti-B and the serum
reaction with A cells suggest that these results are unreliable. Since patient cells
are not washed prior to grouping tests in this laboratory, patient serum is present
in all of the tubes; however, patient cells are present only in the cell-grouping
 CLS Review Questions 93

tubes. Therefore, the problem is most likely to be with the patient’s serum. The
antibody-screening results also indicate a serum problem. An antibody detected
at 37°C in LISS would most often react with even greater strength in the AHG
phase of testing. In this case, the reactions disappear at AHG. Before AHG is
added to the test system, the cells are thoroughly washed, removing all patient
serum. Since this seems to have eliminated the reactions, rouleaux is suspected.
Rouleaux is typically seen in patients with multiple myeloma but may also be
observed in association with lymphocytic leukemias or lymphomas. Saline-
replacement technique is used when rouleaux is present. In this technique,
patient serum is allowed to react with the reagent cells. The tubes are then cen-
trifuged but are not resuspended for reading. The serum is removed, an equal
amount of saline is added, and the tubes are recentrifuged and read for aggluti-
nation. True agglutination will not be dispersed, but rouleaux will. (Vengelen-
Tyler, p. 285)

>
15. The ABO-grouping and Rh-typing results on a donor are given below. High- ro)
£
protein anti-D reagent was used. 0
od
6
E
Cell grouping Serum grouping o
rs
Anti-A: A cells: 4+ )
¢
Anti-B: B cells: 3+ 5
E
Anti-D (IS):
Rh control (IS):
E
Anti-D (AHG): +

Rh control (AHG): +
=>
See)
ww

The most appropriate next step is

A. label the unit O, Rh-negative, weak D-positive

B. label the unit O, Rh-positive
C. perform a DAT on the donor cells
D. wash the donor cells to remove rouleaux and retype

The answer is C. The patient’s ABO grouping is unremarkable. In the test for
weak D at AHG, however, the Rh control is reacting. The Rh control should be
negative. The Rh control for a high-protein reagent contains the protein and
additives that are included in the anti-D reagent but lacks the exogenous anti-
body. High protein is added to reagents to reduce the zeta potential and allow
cells to come closer together. This enables IgG antibodies to cause visible agglu-
tination at room temperature, speeding the typing reaction. When cells coated
with endogenous antibody are tested in this environment, the antibodies already
present on the red cells may crosslink and cause agglutination without the addi-
tion of exogenous antibody in the anti-D reagent. When the test for weak D is
performed by adding AHG after 37°C incubation, the AHG will react with the
endogenous antibody on the cell in the Rh control tube. Since the presence of
endogenous antibody coating the red cells is often the cause of a reaction with
the Rh control, a DAT should be performed. The DAT will detect endogenous
antibody coating red cells and either confirm this as the cause of the problem or
suggest that further testing is necessary. (Vengelen-Tyler, pp. 308-309)

16. A patient has incompatible crossmatches and a positive antibody screen in

the antiglobulin phase. The patient’s serum is tested against a panel of
reagent red cells. Reactions are shown below:
2A Swiinchematclogy

Cell Saline LISS LISS Check Ficin Ficin Check

No. DC Ec eMN S_s_ Le? Le? Py K k_ Fy? Fy? Jk? Jk> RT 37°C AHG Cells 37°C AHG Cells

] OO = (et (eer eee = O + O & OW a Fw 0 0 0 2+ 0 0 2+

2 ee 80 0 OL ee Oe 0) Oe tee 0 + 3+ NEA 3+ NP
3 eee O° ts Oe OO ee Ole eet eer eet 0 0 1+ NP 0 0) Der
4 s Q@ = 48 7 © 8 OO = & © Ss © + O 2 OF 0 0 0 2+ 0 0 2+
5 2 O- eo fe ty ae es Se OY Se OM = oe O O = 0 0) 2+ NP 0 0 es
6 O° OC. ee SSO SO Ee OS OO FO Os 0 2+ 4+ NP 2+ 4+ NP
7 0 @ O00 =e + @ & 0 = 0 & © 0 F&F O & ee @ 0 0 2+ 0 0 2+
8 O © UW ss OW OC oe & OO 2 © te 0 0 0 2+ 0 0 2+
9 OR OO men Ee a Oe ae Oc) ee) tee et met: 0 2+ 4+ NP 2+ 4+ NP
10 QO) 0 es 0 Se Rare aR se ar 0 0 1+ NIRS 0) 2+
MCcoyad f fF FY [ke hf - SiS ORE ORE 20 ARISE Re Sane PERS! 0 a5 2+ IND es 2+ NP
Auto + + 0 +. + + 0 + <SOPOMEE 40 nRHILON Bee a70 0 0) 0 2+ 0 0 2+

AHG = antiglobulin test; LISS = low ionic strength salt solution;

NP = not performed; RT = room temperature

What are the most probable antibodies?

A. Anti-S and anti-k
B. Anti-S and anti-Fy*
C. Anti-K and anti-Fy*
D. Anti-s, anti-K, and anti-Fy*

The answer is C. The autocontrol is negative, indicating that these are alloanti-
bodies. Cells 1,4, 7, and 8 give negative reactions with the patient’s serum. Anti-
bodies that would have reacted with the antigens on these cells can then be elim-
inated. This leaves three possibilities: anti-S, anti-K, and anti-Fy*. All of these
antibodies react optimally in the antiglobulin phase of testing. The reactions
seen in LISS at 37°C coincide with the pattern shown for anti-K. K antigen is
present on cells 2, 6, and 9, and cells 6 and 9 are KK while cell 2 is Kk. The reac-
tions correspond to the dose of the antigen, with stronger reactions seen when
testing with the homozygous cells 6 and 9. The LISS-AHG phase of testing
increases the reaction with cells 2, 6, and 9; additionally, reactions are seen with
cells 3, 5, and 10. Cells 3, 5, 6, and 10 possess the Fy* antigen. Ficin treatment
destroys the Duffy antigens, and cells will no longer give reactions with anti-
Fy*. Following ficin treatment, only cells 2, 6, and 9 react (corresponding with
anti-K); this indicates that the antigen reacting on cells 3, 5, 6, and 10 has been
removed from the cells by the ficin treatment as would be the case with Fy?. The
antibodies identified by this panel are anti-K and anti-Fy*. Anti-S cannot be
ruled out, however, because the patient is S-antigen positive, it is unlikely that
anti-S is present in the patient’s serum. (Vengelen-Tyler, p. 394)

17. Anti-D and anti-Fy* have been tentatively identified in a serum. To provide
95% confidence in the proper identification of the antibodies, which set of
cells and serum results would be expected?

Patient
Anti-D = Anti-Fy? serum
Ay seoicells + 0 £3
3 cells 0 4 +
3 cells + + +
B. 3 cells + 0 4
3 cells 0 0 +
3 cells 0 + +
 CLS Review Questions 95

C. 3 cells + + 0
3 cells + 0 +
3 cells 0 0 0
D.. 3. cells + 0 +
3 cells 0 2 nt
3 cells 0 0 0

The answer is D. Whenever an antibody panel is used to identify antibodies, the

possibility exists that the patient’s serum is reacting against a low-incidence anti-
gen present on a panel cell that is unidentified, or that an additional antibody is
present but masked by reactions of other antibodies. The likelihood of the reac-
tion being due to an unsuspected antigen is reduced when the serum containing
the antibody reacts with three or more cells carrying the suspected antigen. Con-
fidence is further increased when the serum is negative with three or more cells
lacking the antigen. Therefore, to provide 95% confidence in the correct identi-
fication of the antibody, three cells carrying the antigen and three cells lacking >
3)
the antigen corresponding to the antibody identified should be tested against the 2
serum-containing antibody. The cells carrying the antigen should all react with fe}
=]
6
the serum, and the cells lacking the antigen should not react with the serum. £
When multiple antibodies are identified, three cells carrying antigen 1 but not vo
£
antigen 2, three cells carrying antigen 2 but not antigen 1, and three cells lack- fe)
‘=
=)
ing both antigens must be tested. All of the cells carrying either antigen 1 or anti-
E
gen 2 should react, but the cells lacking both antigens should not react with the
serum. (Vengelen-Tyler, p. 396)
5

18. Given the panel of reagent red cells below tested against patient serum at IS,
37°C with LISS, and AHG, which cells would show agglutination at some
phase of testing if the serum contained antibodies to M and Fy*?

Cellno. D C E ce K &k Fy? Fy?” M N

1 + fo Oona + + + + O + ‘+
2 + CoO 20) + 0 + 0 + + O
3 + QO +) + Oe 0 + + OF OF
4 + OF er ate Hed + 0 + O +
5 Opec e rin (re anther wee ee 0) + +> +
A. Cells 1, 2, 3, and 5
B. Cells 1 and 3
C. Cells 1, 2, and 5
D. Cell 4 only

The answer is A. The patient’s serum should react with each cell that carries M
antigen and each cell that carries Fy? antigen. It is likely that reactions with M-
positive cells would occur in the IS phase of testing and weaken or disappear on
warming, and the reactions with Fy*-positive cells would not appear until the
AHG phase. Cells that are homozygous for either antigen may demonstrate
stronger reactions. (Vengelen-Tyler, p. 391)

19. The results of an antibody screen are:

37°C LISS AHG Check cells

Patient serum + screening cell I 0 2+ NA

Patient serum + screening cells II I+ 3+ NA
 Assuming that the test has been performed correctly and the serum contains
only a single antibody, how can the difference in reaction between the two
cells be explained?

A. Dose
B. Larger drops of screening cell II were used
C. Prozone reaction with screening cell I
D. Rouleaux is present

The answer is A. Dose refers to the number of antigen sites on the cell surface
and is controlled by the number of genes coding for production of the antigen.
Possessing a single gene (i.e., being heterozygous) for a given antigen produces
fewer antigen sites on the cell, or one dose of antigen. Possessing two genes (i.e.,
being homozygous) for an antigen at one locus produces roughly twice the num-
ber of antigen sites on the cells, or a double dose. If the antibody concentration
in the two tubes is the same, as when a single serum is tested against two dif-
ferent screening cells, a stronger reaction can occur with a cell carrying a dou-
ble dose of the antigen. (Vengelen-Tyler, p. 210)

20. Below are the Rh phenotypes of 4 donor units. If a patient has anti-c in the
serum, which of the units of red cells may he or she receive without expect-
ing a reaction due to this antibody?

A. DCe
B: DGcE
G@ DGckEe
Dace

The answer is A. A person who has anti-c should receive blood that does not
carry the corresponding c antigen to prevent a transfusion reaction. Therefore,
the only unit that does not carry the c antigen is unit A. (Vengelen-Tyler, p. 386)

21. A donor’s cells give incompatible major crossmatches in the antiglobulin

phase of testing with sera from seven different recipients of the same ABO
group and Rh type as the donor, all of whom have negative antibody screens.
Based on these results, the donor sample might be expected to be positive in

A. anti-I testing
B. direct antiglobulin testing
C. indirect antiglobulin testing
D. k-antigen typing

The answer is B. The major crossmatch tests recipient serum against donor red
cells. Therefore, something on this donor’s cells must be reacting with all recip-
ient sera. The indirect antiglobulin test is eliminated, since donor serum (not
cells) is tested in that procedure. Similarly, since anti-I is present in serum, it
would not be the cause of the problem. Because most individuals are k positive,
anti-k is very rare. For the k antigen on the donor cells to be a problem, all
seven recipients would have to have anti-k in their serum, an extremely
unlikely event. The most likely cause of the problem is an unexpected antibody
coating the donor cells, which would give a positive direct-antiglobulin test.
Coated donor cells, since antibody is already present before addition of recipi-
ent serum, will react in the antiglobulin phase of all major crossmatches per-
 CLS Review Questions 97

formed regardless of the recipient serum added to the test system. (Vengelen-
Tyler, p. 384)

22. Which of the following differences between donors and recipients will the
major crossmatch performed at the IS, 37°C LISS, and AHG phases of test-
ing usually detect? In each situation, no unexpected antibodies are present
except those indicated.

A. Group O recipient mistyped as A; donor is A

B. Rh-negative recipient mistyped as Rh-positive but with no unexpected
antibodies; donor is Rh-positive
C. Recipient with AHG-reacting anti-Jk*; donor is Jk(a—b+)
D. Rh-positive recipient; donor is Rh-negative

The answer is A. Group O individuals have anti-A and anti-A,B in their serum,
>
which will react with the A antigen on the donor’s cells. An Rh-negative patient a
having no anti-D in the serum, as in option B, will not react with the D antigen 2
fe)
~
on the donor’s Rh-positive cells. In option C, the patient has an antibody, but the 6

donor lacks the corresponding antigen; therefore, no reaction will occur. In £

Vv
option D, the Rh-positive patient, having no unexpected antibodies in the serum, <=
fe)
c
would be expected to have a compatible crossmatch with the Rh-negative donor 5
cells. (Vengelen-Tyler, pp. 270, 406) 3
E
23. A patient is typed as group O, Rh-positive and crossmatched with five units
of red cells. The patient’s antibody screening test and one compatibility test
show agglutination in the antiglobulin phase. The autocontrol is negative. Of
those listed below, the most probable antibody causing the observations is

A. anti-I
B. anti-K
C. anti-M
D. anti-k

The answer is B. Anti-I and anti-M, which react best at room temperature and
below, are eliminated. Although anti-k is expected to react in the antiglobulin
phase, it is directed against a high-incidence antigen. If anti-k were present in
the patient’s serum, all donor units and screening cells would be expected to be
incompatible. The optimal phase for anti-K reactivity is the antiglobulin phase.
Although anti-K would be expected to give an incompatible crossmatch in one
of ten cases, the occurrence of one in five crossmatches in this instance is still
possible. (Vengelen-Tyler, pp. 317, 324)

24. A woman is diagnosed as having immune hemolytic anemia (IHA). Her

direct antiglobulin test is positive, but an indirect antiglobulin test is nega-
tive. Absorption-elution techniques are employed to help identify the
causative antibody. The eluate gives the following agglutination patterns
with group-O cells of the genotypes shown:
cDE/cDE: +
cdE/cDE: +
cde/cde: 4+
cDE/cde: 2+
CDe/cDE: 2+
38 3._Immunohematology

From these results, the specificity of the antibody appears to be

A. anti-C
B. anti-E
C. anti-c
D. anti-e

The answer is D. The logic applied to solving this is the same used in antibody
panel result interpretation. In this situation, the antibodies that could cause IHA
are assumed to be anti-C, -D, -E, -c, or -e. A spectrum of reactivities from + to
4+ is observed, indicating multiple antibodies or a dosing antibody. The data
may be rearranged as follows:
Antigens on cells Serum reaction
Cc D 12, c e
0 + + 0 an
0 + + 3 0 ae
0 0 0 + + 4+
0 + + + + 2+
+ + oF 0 + 2+

If the + reactions are treated as if they are negative, anti-c, anti-D, and anti-E
are unlikely, since only + results were obtained with cells cDE/cDE and
cdE/cDE. Anti-C is eliminated because a 2+ reaction is seen with cell cDE/cde,
which lacks the C antigen and thus could not cause the 2+ reaction. In contrast,
cell cde/cde carries the e antigen in the homozygous form, and a 4+ reaction is
seen. In addition, 2+ reactions are seen in cells cDE/cde and CDe/cDE, on which
e is carried in the heterozygous form. These results suggest a dosage effect.
Therefore, anti-e is the most logical antibody. Additional resolution of the +
reactions may be indicated depending on the policies of the individual blood
bank regarding the possible clinical importance of such reactions. (Vengelen-
Tyler, pp. 394, 427)

25. A Kleihauer-Betke acid-elution test is performed to determine the dosage of

Rh-immune globulin (RhIg). Once the cells have been counted, the per-
centage of fetal cells in the maternal circulation is determined to be 2.2%.
The procedure manual directs the use of the following formula to calculate
the Rh-immune globulin dosage:

% fetal cells X 50 ~ doses of Rhlg

30
How many doses of RhIg should this woman receive?
A. 2
B. 3
C. 4
|
Bets)

The answer is D. 2.2 X 50 divided by 30 equals 3.6. However, the method is

imprecise, and undertreatment must be avoided. Therefore, when the number to
the right of the decimal point is less than 5, round down and add 1 dose. When
the number to the right of the decimal point is greater than 5, round up and add
1 more vial. In this case, round up to 4 and then add 1 more dose; the correct
dosage would be 5 vials. (Vengelen-Tyler, pp. 507-508)
 CLS Review Questions 99

26. In which of the following situations would the administration of Rh-

immune globulin (RhIg) not be indicated? None of the women has received
antenatal Rhlg.
Mother Newborn
A. Rh-negative, weak D-negative; Rh-positive; DAT positive
no antibody detected
B. Rh-negative, weak D-negative; Rh-positive; DAT negative
no antibody detected
C. Rh-negative, weak D-negative; Rh-positive; DAT positive
anti-E in serum
D. Rh-negative, weak D-negative; Rh-positive; DAT positive
anti-D in serum

The answer is D. Administration of RhIg prevents the formation of anti-D by the

mother. If the mother has already been immunized to the D antigen and has pro- a>
duced anti-D, RhIg would not be of benefit. If anti-D is detected in maternal fo)
2
serum, however, the clinical laboratory scientist must determine whether the O°
~
woman received Rhlg antenatally. If so, she should receive additional immuno- ©
S
prophylaxis after delivery, because the anti-D in her serum is likely due to the RhIg Vv
dc
and does not represent immunization to the D antigen. (Vengelen-Tyler, p. 506) °
iS
S
E
27. The primary investigation of a transfusion reaction yields the following E
results. (The records show that the patient and donor are both group O, Rh-
positive.)
DAT _ Serum/plasma hemolysis
Pretransfusion recipient sample 0 absent
Posttransfusion recipient sample 0 present
Pretransfusion donor segment 0 absent
Sample from the donor unit 0 present
These results are consistent with

A. acute hemolytic transfusion reaction

B. allergic reaction
C. transfusion of hemolyzed blood
D. delayed transfusion reaction

The answer is C. The presence of hemolysis in the posttransfusion patient sam-

ple when it was not present in the pretransfusion sample suggests that the trans-
fusion caused the hemolysis. Immunologic causes such as ABO incompatibility
must be considered, but nonimmunologic causes must also be considered. Gen-
erally, nonimmunologic causes create hemolysis within the donor unit prior to
transfusion so that hemolyzed blood is being transfused into the recipient. The
recipient reacts to the free hemoglobin with fever and other symptoms as if the
hemolysis were happening in vivo. Nonimmunologic causes of hemolysis of the
unit include bacterial contamination, infusion of inappropriate fluids with the
blood, use of inappropriate infusion sets, use of improper devices to increase the
rate of infusion, improper warming of the unit, or improper storage of the unit.
These occur after the pretransfusion testing has been performed on the segment,
so it shows no hemolysis. However, a sample of blood taken directly from the
bag implicated in the transfusion reaction shows the presence of hemolysis and,
together with a negative DAT on the recipient’s posttransfusion sample, con-
firms the nonimmunologic cause. (Vengelen-Tyler, p. 584)
Job
ee Semalmmpunchematology

28. Which of the following matings has the potential to result in hemolytic dis-
ease of the newborn (HDN) due to antigens in any of the systems identified?

Mother’s phenotype Father’s phenotype

A-O;DGcEe O, DCe
B. A, DCcEe, Kk O, DcE, kk
CaBadce O, DCce
D. AB, Dee, Jk(a—b+) A, dce, Jk(a—b+)

The answer is C. HDN can occur when the fetus has antigens, inherited from the
father, that the mother lacks. In option A, the father has no antigens that the
mother lacks. In option B, the Rh and Kell system antigens are no problem,
because the mother has all of the antigens carried by the father. The ABO sys-
tem is also compatible, because the child of the mating would be either A or O.
In option C, the mother lacks both D and C antigens, which are carried by the
father and could be passed to the fetus. In option D, the father has no Rh or Kidd
system antigens not carried by the mother, and since the mother is AB, no ABO
incompatibility between mother and fetus is possible. (Vengelen-Tyler, p. 496)

29. A mother is group O, Rh-negative and has anti-K in her serum. Her baby is
group B, Rh-positive and requires an exchange transfusion. Assuming that
the exchange crossmatch is performed using the maternal serum, which of
the following units would be expected to be compatible?

A. O, Rh-negative, K-positive
B. B, Rh-positive, K-negative
C. O, Rh-positive, K-negative
D. B, Rh-negative, K-positive

The answer is C. The blood used for an exchange transfusion must lack the anti-
gen against which the maternal antibody is directed. In this case, the mother has
anti-K in her serum; hence, only K-negative units can be considered. Addition-
ally, the unit must be compatible with the baby’s blood group. In this case, group
B or O, Rh-negative or Rh-positive blood would be compatible with the baby.
However, since the maternal serum is being used for the crossmatch, type-B
cells cannot be used. Therefore, only group O cells lacking the K antigen, either
Rh-positive or Rh-negative, will be expected to be compatible. (Vengelen-Tyler,
p. 504)

30. What is the preferred hematocrit level in small-volume transfusions given to

neonates?

A. 45%
B. 50%
Cr55%
D. 65%

The answer is D. Hematocrits can be adjusted to any required percentage by col-

lecting the whole blood into a multipack system and expressing the plasma into
a satellite bag. The cells and plasma are then mixed in a second satellite bag to
the required level. When using 12-h settling, the resulting hematocrit is approx-
imately 65%, which is the preferred concentration when transfusing small vol-
umes to neonates. Since neonates do not compensate well for changes in blood
 CLS Review Questions 101

volume, a unit with a relatively high hematocrit, comparable to that of a healthy

neonate, is preferred. (Vengelen-Tyler, p. 519)

31. A unit of packed red cells was issued to the floor nurse for a patient trans-
fusion at 13:51 h. The patient was taken to radiology before the nurse could
start the infusion; the blood bag and all ports were unentered. The unit was
placed in the drug refrigerator on the floor. The temperature of this unmon-
itored refrigerator was reported as 10°C. At 15:12 h, the blood is returned to
the transfusion service. Can this unit be returned to inventory and reissued?

A. Yes, because it has been returned to the transfusion service within 2 h of

issue
B. Yes, because it has not been entered
C. No, because the unit was outside a monitored refrigerator for more than
30 min
>
D. No, because the temperature of the drug refrigerator was =10°C fo]
2
fe)
The answer is C. Packed red-cell units returned to the transfusion service intact ~
i)
less than 30 min after issuance (i.e., outside a monitored refrigerator for less than £
ov
30 min) are reissuable. After 30 min, regardless of storage away from the trans- =
3°
fusion service, units are considered to be warmed and cannot be reissued. The ¢
=]
only exception to this rule is when the unit is stored in a refrigerator monitored £
by the transfusion service in an alternate location, such as the surgical area or the E
emergency room. (Vengelen-Tyler, p. 186)

32. The clinical laboratory scientist has recently been promoted to a supervisory
position in the transfusion service of a small rural hospital. He feels that the
optimal blood inventory should be reviewed. The data for the previous 3 mo
of group A, Rh-positive blood usage are given below.
Week Usage
1
2 —

B)
4
5
6
7
8
9
10
11
12 W
AND
BRWWANWUNCNH

Assuming that these data are representative of a 6-month period, what

should the optimal inventory of A-positive units be for this institution if cal-
culated by average weekly use?
A. 3
B. 4
GS
D. 8

The answer is A. In calculating the optimal inventory, any weeks with unusually
high usage should not be included in the calculation, so week 2 is not included.
2
e Seeimmunohematologe
y e

The usage in each of the remaining weeks is averaged (33/11 = 3). This provides
an average usage across several weeks, which is the optimal inventory. (Venge-
len-Tyler, p. 78)

33. While inspecting the donor units in the blood-bank refrigerator, the clinical
laboratory scientist notes a greenish appearance in the plasma of one unit.
What course of action should be taken?

A. Ignore this appearance and leave the unit in the available inventory
B. Remove the unit from the inventory pending completion of a bacterial
culture on the unit
C. Discard the unit following appropriate precautions
D. Return the unit to the donor center

The answer is A. On exposure to light, the yellow of bilirubin pigments in the

plasma can be converted to green. This is not a cause for concern. However,
other colors, such as purple, brown, or red, can indicate contamination or other
harmful changes in the unit, and it should be removed from inventory. Clots or
cloudiness in the plasma are also causes for removing the unit from the inven-
tory. (Vengelen-Tyler, p. 184)

34. A request for a transfusion was sent to the Transfusion Service with the fol-
lowing information:

Request: 2 units of packed cells

Patient: Mary Jones, Room 136A
Which of the following pieces of information is needed in order to comply
with AABB Standards for positive recipient identification?
A. Date of request
B. Name of requesting physician
C. Patient’s unique identification number
D. Age of patient

The answer is C. Two unique and independent identifiers are required on

requests for transfusion. Blood requests that lack the required information
should not be accepted. (Venegelen-Tyler, p. 376)

35. When preparing small-volume red blood cell units for infants from a quad
pack unit, the individual small volume packs carry an outdate

A. consistent with that of the original unit

B. of the day the quad pack was prepared
C. of the day the small-volume unit is separated from the original unit
D. 24 hours from the time the small-volume unit was prepared

The answer is A. As long as the small-volume units are prepared from a quad
pack where each is integrally connected to the original unit and the unit remains
unentered, the aliquots will outdate with the original unit. If aliquots are pre-
pared in a manner that enters the unit, then the outdate is 24 hours with refrig-
eration. (Vengelen-Tyler, p. 519)
 CLS Review Questions 103

36. In urgent situations when a crossmatch cannot be completed and the recipi-
ent’s blood type is unknown, which of the following components may be
given?

A. Group O plasma
B. Group AB plasma
C. Group A red blood cells
D. Group AB red blood cells

The answer is B. Transfused plasma must be ABO compatible with the recipient
and free of clinically significant unexpected antibodies. The testing performed
by the collection facility confirms the latter, but the former is the responsibility
of the transfusion service. To insure ABO compatibility with any recipient, AB
plasma is used since it lacks anti-A and anti-B. (Vengelen-Tyler, pp. 270, 525)

>
37. Platelet units differ from other blood products like red blood cells in that oy]
2
ie)
=)
A. multiple units of platelets are combined and transfused together 6
B. there are no compatibility concerns with platelet units £
vu
C. platelets cannot be frozen <=
°
D. platelets cannot be collected by hemapheresis ¢
=]
£
The answer is A. Platelets are often pooled to create a single unit of larger vol- E
ume that is easier to transfuse. Platelets can be collected by hemapheresis and
frozen. Compatibility concerns lie not with the platelets themselves, but with red
blood cells that may be present in platelet units. (Vengelen-Tyler, pp. 174-175)

38. Platelet units may be pooled together for ease of transfusion only if they are

A. all of the same ABO group

B. ABO group specific for the recipient
C. ABO group compatible with the recipient
D. ABO group compatible with each other

The answer is C. Platelet units of different ABO groups may be pooled, how-
ever, plasma antibodies must be compatible with any red cells that may be pres-
ent in the units. This is most easily achieved by using platelets of a single ABO
type, but that is not required. (Vengelen-Tyler, p.174)

References
Harmening DM. Modern Blood Banking and Transfusion Practices. Philadel-
phia: FA Davis, 1999.

Vengelen-Tyler V (ed). Technical Manual of the American Association of Blood

Banks (13th ed). Bethesda: American Association of Blood Banks, 1999.
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Microbiology
Chapter Author Connie R. Mahon

CLT Review Questions Contributor

1. Which of the following characteristics is not used to characterize Staphylo- Terri L. Murphy-Sanchez
coccus aureus?

A. “Pitting” on sheep-blood agar’

B. Fermentation of mannitol
C. Positive catalase test
D. Positive coagulase test

The answer is A. Pitting on sheep-blood agar is a characteristic typical of organ-

isms such as Ejikenella corrodens; it is not observed in Staphylococcus aureus.
S. aureus, which is the most important pathogenic staphylococcus, generally fer-
ments mannitol and produces catalase and coagulase enzymes. Mannitol salt >
agar is a selective and differential agar used for the primary isolation of staphy- oy)
lococci. Although S. aureus ferments mannitol to produce acid in the medium
2
2
surrounding the colonies, this ability is shared by other staphylococci. Definitive i}
fe)
identification of S. aureus usually involves characterization of the isolate as a
=

gram-positive cocci in clusters that are catalase-positive and coagulase-positive. =

(Murray et al., pp. 271-273)

2. To differentiate between a coagulase-negative staphylococcus species and a

micrococcus species, which of the following tests can be used?

A. Furazolidone (100 wg/disk) susceptibility

B. Catalase
C. Novobiocin susceptibility
D. Urease

The answer is A. Differentiation between staphylococci and micrococci can be

made using the furazolidone-disk test. Staphylococci and Stomatococcus sp. are
susceptible to furazolidone (100 xg disk) whereas Micrococcus sp. are resistant.
A catalase-positive reaction is expected from both staphylococci and micrococcus.
Novobiocin and urease tests may be used to assist in differentiating Staphylococ-
cus sp. All members of the family Micrococcaceae are resistant to (show no-zone
or up to 9-mm zone around) the 100 wg furazolidone disk; all other clinically sig-
nificant cocci are susceptible (zones of > 15 mm). (Forbes et al., pp. 612-613)

3. A pustule drainage submitted for culture is plated onto primary media. After
an 18-h incubation, the sheep-blood agar plate reveals a predominance of

105
 beta-hemolytic, white, porcelain-like colonies. Gram stain shows gram-pos-
itive cocci. The colonies test catalase-positive. The most appropriate test for
additional identification of the isolate is

A. bacitracin
B. bile esculin
C. bile solubility
D. coagulase

The answer is D. Facultatively anaerobic gram-positive cocci that are beta-

hemolytic on sheep-blood agar can presumptively be considered to be of the
Micrococcaceae or Streptococcaceae family. Most members of the Micrococ-
caceae family are strongly catalase-positive, whereas the Streptococcaceae are
catalase-negative or weakly positive. The coagulase test will definitively iden-
tify Staphylococcus aureus, the most likely causative agent from this specimen
source. Bacitracin, bile esculin, and bile solubility are tests used in the identifi-
cation of streptococci that are ruled out by a positive catalase result. (Murray et
al., pp. 287-289)

4. A 43-year-old female patient complains of a very sore throat. The throat

swab that is submitted for routine culture grows a variety of diphtheroids:
alpha, beta, and nonhemolytic streptococci; staphylococci; and Neisseria.
The next step is to

A. report it as normal throat flora

B. ask for a repeat collection to get a better specimen
C. identify the beta-hemolytic streptococcus species
D. identify the Neisseria species

The answer is C. Routine throat cultures on persons over approximately 10 years

of age are taken primarily to detect the presence of Streptococcus pyogenes or
Group A streptococci. S. pyogenes or Group A streptococci produce beta-
hemolyis on blood containing medium. Any amount of group-A, beta-hemolytic
streptococci isolated from throat cultures should be considered significant
because of the possibility of subsequent rheumatic fever or acute glomerular
nephritis. In this patient, therefore, the beta-hemolytic streptococcus species
should be identified. All the other organisms enumerated in this specimen may
be encountered in the usual oropharyngeal flora, including nongroup-A, beta-
hemolytic streptococci. (Mahon et al., pp. 879-880)

5. A nasopharyngeal culture grows a predominance of a beta-hemolytic

colony-type on sheep-blood agar at 18 h. The isolate is susceptible to a 0.04
unit of bacitracin. The most likely identification is beta-hemolytic strepto-
coccus,

A. group A
B. group B
C. group D
D. not group A, B, or D

The answer is A. Streptococcus pyogenes or Group A streptococci is beta-

hemolytic and is the most common cause of acute bacterial pharyngitis. It is
presumptively identified by demonstration of susceptibility to bacitracin or its
ability to hydrolyze the substrate L-pyrrolidonyl-beta-napthylamide (PYR).
 CLT Review Questions 107

Group A streptococci are bile-esculin—-negative and hippurate-hydrolysis—neg-

ative. Group B streptococci are resistant to 0.04 units bacitracin, hydrolyze hip-
purate, and PYR negative. Group D streptococci hydrolyze esculin in the pres-
ence of 40% bile, are resistant to 0.04 units bacitracin, and PYR negative.
Enterococci are PYR positive but hydrolize bile esculin. Other beta-hemolytic
streptococci that are not in group A, B, or D are generally resistant to bacitracin
and negative to the other reactions given in this problem. (Mahon et al., pp.
352-361)

6. Which of the following characteristics is not consistent with Streptococcus

pneumoniae?

A. Alpha hemolysis on sheep-blood agar

B. Bile-solubility—positive
C. Gram-positive, oval-shaped cocci in pairs
D. Positive catalase test —

The answer is D. S. pneumoniae is a catalase negative, gram-positive, oval, or

lancet-shaped coccus that is seen microscopically in pairs and chains. On sheep-
blood agar, colonies produce alpha hemolysis. S. pneumoniae is soluble in bile
and susceptible to ethylhydrocupreine hydrochloride (optochin). These two tests
differentiate it from viridans streptococci, which are insoluble in bile and resist-
ant to optochin. (Murray et al., p. 288)

7. Neisseria species can be identified and differentiated by

Pa)
A. bile-esculin hydrolysis a
<
B. carbohydrate utilization / =
C. nitrate test }
‘2
h
°
D. oxidase test ~
=
The answer is B. Members of the genus Neisseria are identified by demonstrat-
ing acid production from the degradation of carbohydrates. The standard basal
medium is cystine trypticase agar (CTA) into which 1% filtered sterilized car-
bohydrate is added. Conventional carbohydrate testing includes the utilization of
glucose, lactose, maltose, sucrose, and fructose. Nitrate reduction differentiates
Moraxella catarrhalis from members of the genus Neisseria. Since all Neisseria
are oxidase-positive, the oxidase test is not useful in their differentiation. Bile-
esculin hydrolysis is not used for testing this group of bacteria. (Murray et al.,
pp. 595-597)

8. A small gram-positive rod that causes neonatal meningitis and septicemia is

A. Escherichia coli
B. Corynebacterium diphtheriae
C. Listeria monocytogenes
D. Streptococcus agalactiae

The answer is C. L. monocytogenes is a small gram-positive rod that causes

meningitis and septicemia in neonates, the elderly, and immunocompromised
patients. E. coli is a gram-negative rod. C. diphtheriae is a small gram-positive
rod that can cause diphtheria in nonimmunized hosts. S. agalactiae is a gram-
positive coccus. (Murray et al., p. 346; Mahon et al., pp. 382-383)
 9. The X and V factors required for growth of Haemophilus influenzae are
contained in

A. brain/heart infusion broth

B. chocolate agar
C. sheep-blood agar
D. thioglycollate broth

The answer is B. Chocolate agar is enriched with hemin (or X factor) and NAD
coenzyme (or V factor). Among the more fastidious organisms, both Haemophilus
and Neisseria species will grow on chocolate agar. (Murray et al., p. 1693)

10. On a sheep-blood agar plate, Haemophilus influenzae satellites around

colonies of

A. diphtheroids
B. Streptococcus pyogenes
C. Haemophilus parainfluenzae
D. Staphylococcus aureus

The answer is D. H. influenzae has two growth requirements. The X factor,

hemin, is a heat-stable substance associated with hemoglobin and directly avail-
able in sufficient quantity in routine sheep-blood agar. The V factor (NAD) is a
heat-labile coenzyme that can be supplied by adding yeast or potato extract to
routine media. Alternately, certain bacteria such as staphylococci, Neisseria,
pneumococci, and some other microorganisms synthesize the required NAD that
enables H. influenzae to grow around the colonies of these organisms (satel-
litism). (Murray et al., p. 607)

11. The specimen of choice for the isolation of Bordetella pertussis from a sus-
pected case of whooping cough is

A. blood
B. cerebrospinal fluid
C. nasopharyngeal swab
D. throat swab

The answer is C. Whooping cough is an upper respiratory infection. Whereas a

throat swab is sufficient for the recovery of some agents of upper respiratory
infections, optimal recovery of B. pertussis is achieved by culture of a nasopha-
ryngeal swab or aspirate. (Murray et al., p. 616)

12. Family characteristics of the Enterobacteriaceae include

A. fermentation of glucose
B. fermentation of lactose
C. production of indophenol oxidase
D. failure to reduce nitrates

The answer is A. All species of the family Enterobacteriaceae are gram-nega-

tive rods that ferment glucose. Indophenol oxidase is not produced. Most species
are capable of reducing nitrates to nitrites, but not all species ferment lactose.
(Murray et al., p. 451)
 CLT Review Questions 109

13. Twenty patients on a surgical ward develop urinary tract infections after
catheterization. In each instance, the isolated organism grows on sheep-
blood agar as a large, gray colony, and on MacConkey agar as a large, flat,
pink colony. The oxidase-negative, gram-negative rod produces the same
biotype and is resistant only to tetracycline. Additional biochemical results
are as follows:
Phenylalanine deaminase (PAD): negative
Urease: negative
Hydrogen sulfide (H,S): negative
Lysine decarboxylase: positive
Ornithine decarboxylase: positive
Indole: positive
Citrate: negative
The most probable identity of this organism is
A. Escherichia coli
B. Enterobacter cloacae
C. Enterobacter aerogenes
D. Proteus vulgaris

The answer is A. E. coli, the cause of this nosocomial outbreak, is one of the most
frequent causes of hospital-acquired bacteriuria. Definitive identification of E. coli
is confirmed by the PAD-negative, H,S-negative, citrate-negative, indole-positive,
urease-negative results. Both Enterobacter species are indole-negative and citrate-
positive. Proteus species are PAD-positive and H,S-positive and would be non-
pink colonies on MacConkey agar. (Murray et al., pp. 443-446)
>
a
2
14. A mucoid, lactose-positive colony type on MacConkey agar that is indole- 2
negative and citrate-positive, and non-motile is 2
°=
-
A. Escherichia coli 2
B. Klebsiella pneumoniae
C. Enterobacter cloacae
D. Enterobacter aerogenes
The answer is B. K. pneumoniae is a gram-negative rod that produces lactose-
positive colonies on MacConkey agar. The IMViC (Indole, Methyl red, Voges-
Prosakeur, Citrate) reactions are §8++. Typical strains produce copious
amounts of capsular polysaccharide that render the colony macroscopically
mucoid; however, Enterobacter species may also produce similar colonial mor-
phology. E. cloacae and E. aerogenes produce similar IMViC reactions, but they
are motile. E. coli has a positive indole and a negative citrate; IMViC reactions
are ++00. (Murray et al., pp. 444)

15. Escherichia, Klebsiella, and Proteus species are common flora of the

A. gastrointestinal tract
B. respiratory tract
C. superficial skin surfaces
D. urinary tract

The answer is A. The gastrointestinal tract flora consists of members of the

Enterobacteriaceae, which includes Escherichia, Klebsiella, and Proteus
species. When isolated from fecal samples, these species are therefore consid-
110
ee 4. Microbiology EEE

ered “normal fecal flora.” While they may be isolated from superficial skin sur-
faces, the respiratory or urinary tracts, they are not considered as normal
microflora from these sites. (Mahon et al., p. 473, 477)

16. A discharge from an infected ear grows a colorless colony type on Mac-
Conkey agar that swarms on sheep-blood agar. This oxidase-negative,
gram-negative rod gives the following biochemical reactions:
Phenylalanine deaminase (PAD): positive Ornithine: positive
Hydrogen sulfide (H,S): positive Indole: negative
Urease: positive Citrate: positive
Lysine: negative
The organism described is
A. Citrobacter freundii
B. Morganella morganii
C. Proteus mirabilis
D. Proteus vulgaris

The answer is C. Chronic otitis externa is usually associated with infection of

pseudomonads or Proteus species. Here, the biochemical results confirm the
presence of P. mirabilis. C. freundii, although it produces H,S, is PAD-negative;
M. morganii is H,S-negative and indole-positive; and P. vulgaris is ornithine-
negative and indole-positive. (Murray et al., p. 445)

17. A gram-negative rod biochemically compatible with the genus Salmonella

fails to agglutinate in the polyvalent somatic antisera for Salmonella
serotyping. What is the next step in the definitive identification of this
organism?

A. Report the organism as a Salmonella polyvalent O-positive species and

send the isolate elsewhere for additional identification
B. Wash a suspension of the isolate in saline and retest it in the Salmonella
polyvalent antiserum
C. Boil a saline suspension of the organism for 15 min, cool, and retype in
Salmonella polyvalent antiserum
D. Retest the isolate using the individual somatic antisera from each
serogroup, A through E

The answer is C. Occasional strains of Salmonella fail to agglutinate in polyva-

lent O antiserum. Some Salmonella species possess K antigens that render them
nonagglutinable in the live, unheated form. These antigens can be inactivated by
heating a saline suspension of the isolate at 100°C for at least 15 min. Upon
retesting with the cooled saline suspension and the Salmonella polyvalent anti-
serum, agglutination may occur. If agglutination occurs and group-specific anti-
sera are available, individual grouping may then be performed. Boiled suspen-
sions that do not react in the polyvalent test may be Salmonella strains that
belong to groups other than those represented in the typical polyvalent antiserum
that includes groups A through E. (Forbes et al., p. 517)

18. A gram-negative rod is isolated from a patient with second- and third-degree
burns. The isolate produces a bluish green pigment and a characteristic
fruity odor. Other characteristic observations are:
 CLT Review Questions 111

Triple sugar iron: K/K

Motility: positive
Oxidase: positive
Oxidative/fermentation glucose: oxidative utilization only
The most probable genus of this isolate is
A. Acinetobacter
B. Alcaligenes
C. Moraxella
D. Pseudomonas

The answer is D. Pseudomonas aeruginosa is a probable infective agent in a

burn patient. This organism is the only one that produces both pyoverdin and
pyocyanin, water soluble pigments, giving the bright green characteristic color,
and a fruity, grapelike odor. Species in the genus Pseudomonas are nonfer-
menters, most can utilize glucose oxidatively, are motile, and produce indophe-
nol oxidase. Acinetobacter, although it degrades glucose oxidatively, is non-
motile and oxidase-negative. Alcaligenes and Moraxella are oxidase-positive
but are nonsaccharolytic. Moraxella is nonmotile, while Alcaligenes is motile.
(Mahon et al., pp. 547-549, 554-559)

19. After 48 h of incubation on anaerobic sheep-blood agar, Clostridium per-

fringens appears as a

A. large, flat colony with a double zone of hemolysis

B. white, butyrous, nonhemolytic colony with a glistening surface
C. gray, mucoid colony with a zone of alpha hemolysis >
3D
D. colony with a pearl-like surface and a single zone of beta hemolysis 2
2
2
The answer is A. A double zone of hemolysis is typical for C. perfringens. The 2
inner zone of complete hemolysis is distinct and surrounded by an indistinct =
=
zone of partial hemolysis. (Mahon et al., p. 598)

20. Isolation of Campylobacter jejuni from a patient with gastroenteritis is opti-

mized by

A. incubation at 35—37°C
B. selective enrichment in selenite broth
C. a microaerophilic environment
D. an anaerobic environment without CO,

The answer is C. C. jejuni is an oxidase-positive, gram-negative curved rod that is

a strict microaerophile. It grows best in an environment of less than 6% O, and
requires 5—10% CO). This atmosphere can be achieved easily by using microaer-
obic gas generator packs (for example the CampyPak generator envelope by BBL
Microbiology Systems, Cockeysville, Md.) in an incubator jar. Alternatively, evac-
uation and replacement of a jar with 5% O3, 5% CO , and 90% N, gas mixture will
achieve the desired environment. Incubation at 42°C is desirable since C. jejuni
thrives better at 42°C than at 35°C. This microbe is fastidious but grows on Skir-
row’s or supplemented Campy blood-agar medium. Broth enrichment of the spec-
imen can be set up in Campy thio. Selenite, a selective enrichment broth media, is
recommended especially for the recovery of Salmonella, it will not enhance the
recovery of Campylobacter species. (Mahon et al., pp. 532-533)
21. In the N-acetyl-L-cysteine—alkali method of processing sputum specimens
for mycobacterial culture, the N-acetyl-L-cysteine serves as a

A. buffer
B. decontaminant
C. digestant
D. pH stabilizer

The answer is C. N-acetyl-L-cysteine is a liquefying agent that digests tenacious

sputum specimens. Sodium hydroxide is a decontaminant. Phosphate buffer (pH
6.8) stabilizes the pH to stop the action of the N-acetyl-L-cysteine and sodium
hydroxide solution. (Mahon et al., p. 675)

22. A sputum specimen is submitted to the laboratory accompanied by a request

for an AFB culture. All of the following are standard protocol for process-
ing this specimen except

A. use of a refrigerated centrifuge with bucket covers and safety domes for
high-speed concentration
B. use of both liquid and solid media for setup of AFB culture
C. use of concentrated potassium hydroxide for decontamination procedure
D. use of a laminar-flow biological safety cabinet for processing the specimen

The answer is C. The decontaminant used in the processing of this specimen is

sodium hydroxide not potassium hydroxide, and it is a 4% solution, not a con-
centrated solution. A refrigerated centrifuge is needed because of the high speed
and length of time required to sediment the AFB organisms (which are more buoy-
ant than non-AFB organisms). The covers and safety domes as well as the use of
a laminar-flow biological safety cabinet are necessary during these steps to prevent
the formation of aerosols from the specimen, which potentially carries the infec-
tive AFB organisms. For optimal recovery of AFB organisms both liquid media
(BACTEC) and solid media are recommended. NALC (AN-acetyl-L-cysteine
sodium hydroxide) is the most common method for liquefaction and decontami-
nation of AFB specimens from nonsterile sites. (Forbes et al., pp. 725-726)

23. Routine sterilization of artificial culture media by autoclaving is recom-

mended at

A. 15 psi at 121°C for 15 min

B. 10 psi at 121°C for 10 min
C. 15 psi at 200°F for 15 min
D. 10 psi at 220°F for 10 min

The answer is A. Artificial culture media are routinely sterilized by moist heat
under pressure of 15 psi at 121°C for 12 to 15 min. These conditions are suffi-
cient to kill thermoresistant spore-forming bacilli commonly found in the labo-
ratory environment. Overheating the medium can result in degradation of some
of the basic nutrients in artificial media. Inadequate sterilization may result in
contamination of the medium. (Murray et al., p. 157)

24. When acetone-alcohol is inadvertently omitted from the gram-stain proce-

dure, streptococci and Neisseria will be stained, respectively,
 CLT Review Questions 113

A. purple and red

B. purple and purple
C. red and red
D. red and purple

The answer is B. Iodine is a mordant that complexes with crystal violet and the
cytoplasmic contents of bacteria. Therefore, all bacteria are initially stained pur-
ple. Gram-positive bacteria such as streptococci, because of the thick peptido-
glycan layer in their cell wall, retain the crystal-violet-iodine complex after
decolorization. On the other hand, the cell wall of gram-negative bacteria, in
addition to a thin peptidoglycan layer, contains an outer membrane that is made
up of phospholipids and lipopolysaccharide. When the decolorizer is applied to
a gram-negative cell wall, it damages the lipid walls and allows the initial stain
to wash out of the cell. If the decolorizer is omitted, therefore, gram-negative
bacteria such as Neisseria will remain purple. (Mahon et al., p. 67)

25. The color of a nonacid-fast bacillus following the acid-alcohol step and
before counterstaining in the acid-fast stain procedure is

A. blue
ib. red
C. colorless
D. green

The answer is C. Due to their high lipid content, acid-fast bacilli resist staining
with ordinary dyes. Alcoholic basic aniline dyes are usually used to penetrate the
cell. Depending on the method used, penetration may be augmented by the addi- >
a
tion of heat or a wetting agent. After the initial staining step with carbol-fuchsin, =
virtually all intact bacteria should appear red. Once stained, acid-fast bacilli 2
‘2
resist decolorization with acid-alcohol and remain red. Most other bacteria are °
he

readily decolorized with acid-alcohol and appear colorless until a counter-stain —

=
is applied. Methylene blue and malachite green are commonly used as counter-
stains. (Koneman et al., pp. 904—905)

26. MacConkey agar is used for the isolation of members of the family Enter-
obacteriaceae because the medium is

A. inhibitory and differential

B. differential and enriched
C. enriched and selective
D. selective and supplemented

The answer is A. MacConkey agar is an inhibitory medium because it contains

bile salts and crystal violet, which inhibit the growth of gram-positive bacteria
and some fastidious gram-negative bacilli. It then allows the growth of the
Enterobacteriaceae and most other gram-negative bacilli. Additionally, this
medium contains lactose and neutral red indicator, which allows differentiation
between species that ferment lactose and those that do not ferment lactose. This
is important in screening stool samples for enteric pathogens such as Salmonella
and Shigella species, which are non-lactose fermenters and differentiate them
from lactose fermenting members of the Enterobacteriaceae that are common
colon flora. (Forbes et al., p. 157)
27. Ethylhydrocupreine hydrochloride (optochin) is a chemical used to differ-
entiate

A. catalase-positive Streptococcus species from catalase-negative Staphylo-

coccus species
B. Streptococcus pneumoniae from alpha-hemolytic streptococci
C. Enterobacteriaceae from non-Enterobacteriaceae
D. group-D enterococci from group-D nonenterococci

The answer is B. Ethylhydrocupreine hydrochloride (optochin) is a quinine

derivative that selectively inhibits the growth of S. pneumoniae. Pneumococcal
cells exposed to this chemical are lysed due to changes in surface tension, and a
zone of inhibition of 14 mm or more around a 6 mm (Taxo A) disk results. Gen-
erally, the viridans streptococci are relatively resistant to optochin, resulting in
no zone of inhibition. (Koneman et al., p. 1369)

28. A lysine-iron agar (LIA) slant shows a red slant over a yellow butt. This
reaction indicates that the organism

A. deaminates lysine
B. decarboxylates lysine
C. ferments lactose
D. produces H,S

The answer is A. LIA tests for fermentation of glucose, lysine decarboxylase

(LDC), H,S production, and lysine deaminase. Lysine deaminase is evidenced
by a red-slant reaction and indicates the tribe Proteeae. A yellow butt reveals fer-
mentation of glucose with a negative LDC. Decarboxylation of lysine is evi-
denced by a purple-butt reaction. H,S formation results in the production of a
black precipitate in the butt of the tube. (Koneman et al., p. 187 & plate 44G)

29. Which of the following statements regarding Simmon’s citrate agar is incorrect?

A. Blue color is an alkaline reaction

B. Citrate is the only source of carbon in the medium
C. Glucose is the carbohydrate in the medium
D. Growth on the slant is interpreted as a positive reaction

The answer is C. Simmon’s citrate agar tests for the ability of an organism to uti-
lize citrate as a sole source of carbon. Growth on the slant indicates this ability.
Most organisms that grow will produce sufficient alkaline products to turn the
bromthymol blue indicator from green to blue. Since the principle of this test is
to determine the ability to utilize citrate as the only source of carbon, no other
carbon-containing compounds, such as glucose, are ingredients in this medium.
(Mahon et al., p. 501; Figure 16-17, p. 502)

30. The reagent(s) used to detect a positive phenylalanine-deaminase reaction is

(are)
A. sulfanilic acid and alpha-naphthylamine
B. p-aminodimethylbenzadehyde
C. alpha-naphthol and potassium hydroxide
D. ferric chloride
 CLT Review Questions 115

The answer is D. Phenylalanine deaminase deaminates the amino acid pheny-

lalanine to phenylpyruvic acid. This alpha-keto acid forms a visible green-col-
ored complex with 10% ferric chloride. Within the family Enterobacteriaceae,
only members of the tribe Proteeae possess the deaminase required to deaminate
phenylalanine. (Mahon et al., p. 501; Fig 16-20, p. 504)

31. To eliminate the antibacterial properties of blood and simultaneously intro-

duce an adequate volume of blood for recovery of microorganisms from
septicemia, the recommended blood-to-broth ratio in the blood-culture bot-
tle is approximately

Ate TED
Be 2:1
Coo)
Db, 10:1

The answer is C. A minimal blood dilution of 1:10 in blood-culture broth effi-

ciently eliminates the inhibitory effect of previous antimicrobial chemotherapy
on the recovery of microorganisms from the blood. Additionally, it dilutes the
antibacterial properties of the serum. (Koneman et al., p. 156)

32. Which of the following specimens is acceptable for the evaluation of clini-
cally important anaerobes?

A. Feces
B. Sputum
C. Peritoneal fluid ~
>
a
D. Superficial wound ©
~~
‘2
The answer is C. Only those specimens that are likely to be devoid of contami- °bh
nating organisms, such as peritoneal (or other aspirated body fluids) are accept- os
=
able for anaerobic evaluation. Feces, sputa, and superficial wounds are fre-
quently contaminated with anaerobic microflora of the gastrointestinal tract,
oropharyngeal area, and skin, respectively. (Koneman et al., pp. 717 & 720)

33. A urine is received in the laboratory for culture. If the specimen cannot be
plated immediately, it should be held

Ae in the freezer
B. in the refrigerator
C. at room temperature
D. in the 35°C incubator

The answer is B. Refrigeration is a practical and safe method to hold a urine

specimen until it can be plated. In this manner, a urine may be held for up to 24
h without significant alteration in bacterial population. It is paramount to refrig-
erate urine specimens immediately to avoid bacterial growth and significant
increase in numbers of organisms in the urine. (Forbes et al., pp. 14-15)

34. Standardized testing conditions for the Kirby-Bauer agar-disk diffusion

antimicrobial susceptibility test include all of the following except

A. use of Mueller-Hinton media

B. standard inoculum size
116 4. Microbiology

C. incubation at 35°C
D. incubation in 8-10% CO,

The answer is D. Because capneic incubation decreases the pH of the medium

and affects the properties of some antimicrobials, ambient air incubation (with-
out CO,) is required. Some testing variables that can affect the results of the
Kirby-Bauer antimicrobial susceptibility test include composition and pH of the
medium, inoculum size, and drug stability. Mueller-Hinton medium should be
tested to assure that the medium pH is 7.2 to 7.4 and the approximate depth is 4
mm. Inoculum turbidity should be standardized to equal that of a No. 0.5 McFar-
land barium-sulfate standard. Incubation of the plates at 35°C (without CO,) is
recommended, since methicillin results are not reliable at 37°C. Only antimicro-
bial susceptibility disks that are in-date and have been quality controlled are to
be used. (Murray et al., pp. 1537-1538)

35. The pair of organisms that would provide a good positive and negative con-
trol for phenylethyl-alcohol (PEA) blood agar is

A. Pseudomonas aeruginosa and Escherichia coli

B. Haemophilus influenzae and Streptococcus pyogenes
C. Enterococcus and E. coli
D. Staphylococcus aureus and S. pyogenes

The answer is C. An Enterococcus species tests the PEA for ability to support
growth, and E. coli tests for the inhibition of growth. Phenylethyl-alcohol agar
is a selective medium for the isolation of gram-positive cocci including staphy-
lococci and streptococci. This medium should inhibit the growth of gram-nega-
tive bacteria. Since E. coli and P. aeruginosa are two gram-negative organisms,
no positive growth control is included in option A. Similarly, no negative con-
trol is included in option D, since both organisms are gram-positive. Option B
could be correct since it includes both gram-negative and gram-positive organ-
isms; however, because the sheep-blood enrichment of PEA does not support the
growth of H. influenzae, it does not challenge the inhibitory characteristics of
this medium. (Forbes et al., p.156)

36. Which of the following organisms will give the appropriate positive and
negative reactions for quality control of the. test listed?

Positive Negative
A. Gram stain E. coli Neisseria meningitidis
B. Indole E. coli Proteus vulgaris
C. Catalase S. aureus S. epidermidis
D. Oxidase Pseudomonas aeruginosa E. coli

The answer is D. Quality control requires that the performance of stains, media,
and reagents be tested for the desired positive and negative reactions using stock
culture strains of known stability. The performance characteristics of the oxidase
reagent are tested adequately using P. aeruginosa as the positive control and E.
coli as the negative control. Both E. coli and N. meningitidis are gram-negative.
Both E. coli and P. vulgaris are indole-positive. Both S. aureus and S. epider-
midis are catalase-positive. (Koneman et al., p. 1372)
 CLT Review Questions 117

37. A fungal colony grows rapidly on Sabouraud’s dextrose agar as a white

colony type with a dense production of aerial, blue-green spores. On lac-
tophenol cotton blue preparation, swollen-tipped conidiophores bear sterig-
mata and conidia in chains. The most likely identification of this isolate is

A. Aspergillus
B. Paecilomyces
C. Penicillium
D. Scopulariopsis

The answer is A. Aspergillus species are rapid-growing fungi that produce densely
colored surfaces. Microscopically, septate, hyaline hyphae are seen with swollen-
tipped conidiophores. Sterigmata that radiate from the conidiophores bear chains
of spherical conidia. Penicillium and Scopulariopsis produce freely branching,
slender conidiophores of the penicillus type. (Koneman et al., pp. 1002-1006)

38. A saprobic yeast that inhabits airborne dust, skin, and mucosa grows rapidly
and produces an orange-to-red color. This isolate most likely belongs to the
genus

A. Cryptococcus
B. Geotrichum
C. Rhodotorula
D. Saccharomyces

The answer is C. Rhodotorula is a common yeast that is saprobic and found in

airborne dust, skin, and mucosa. Cultures grow within 24 to 48 h on Sabouraud’s >
a
dextrose agar with colonies that are small, shiny, rounded, and orange-to-red. =
The color is due to carotenoid pigments that are produced by the genus. (Kone- 2
‘2
man et al., p. 5153) °ih
=
2
39. The function of 10% potassium hydroxide in the direct examination of skin,
hair, and nail scrapings is to

A. preserve fungal elements

B. kill contaminating bacteria
C. clear and dissolve debris
D. fix preparation for subsequent staining

The answer is C. Direct examination of specimens submitted for fungal analysis

can be crucial to early initiation of antifungal therapy. Ten-percent potassium
hydroxide mounting fluid is recommended for the examination of skin, hair, and
nail scrapings to clear and dissolve keratinous material that would render the
preparation difficult to evaluate for fungal elements. (Koneman et al., p. 85)

40. A potentially pathogenic yeast that is normal flora in the oropharyngeal cav-
ity and may produce thrush is

A. Trichosporon beigelii
B. Candida albicans
C. Cryptococcus neoformans
D. Geotrichum
118 4. Microbiology

The answer is B. Although Candida albicans may be part of the normal oropha-
ryngeal flora, it causes oral candidiasis, commonly called thrush, in immuno-
suppressed individuals. Cryptococcus neoformans is another yeast that may
rarely be part of the oropharyngeal flora, but it does not cause thrush. (Koneman
et al., p. 1046)

41. In an iodine preparation of feces, an amoebic cyst appears to have a single

nucleus with a large karyosome and chromatin bodies do not appear along
the nuclear membrane. A large glycogen mass that stains reddish brown
occupies the cytoplasm. The most probable identity of the cyst is

A. Entamoeba histolytica
B. lodamoeba biitschlii
C. Entamoeba coli
D. Entamoeba hartmanni

The answer is B. A cyst with the large, well-defined glycogen mass describes J.
biitschlii. Entamoeba cysts may have such glycogen masses when very immature;
however, these cysts have one to four nuclei, small karyosomes and chromatoid
bars, which are not present in Jodamoeba cysts. (Markell et al., pp. 51-53)

42. The infective stage of this parasite consists of an egg with a thin hyaline
shell, with one flattened side and, usually, a fully developed larva within.
The parasite is

A. Enterobius vermicularis
B. hookworm
C. Ascaris lumbricoides
D. Trichuris trichiura

The answer is A. E. vermicularis fits the description given in this item. Hook-
worm eggs are thin-shelled with an internal four- to eight-cell stage, which pulls
away from the shell, resulting in an empty peripheral space. Ascaris has a thick
shell with an albuminous coat that may be mamillated. T. trichiura has an oval
egg with polar mucous plugs at each end. (Markell et al., pp. 276-278)

43. The direct iodine preparation is best used to detect protozoan

A. eggs
B. trophozoites
C. cysts
D. larvae

The answer is C. Protozoan cysts stained with a weak iodine solution are refrac-
tile and show yellow-gold cytoplasm and brown glycogen. Although tropho-
zoites also may be visible in iodine preparations, they are more easily detected
by permanent stained slide or by their motility in unstained direct wet prepara-
tions. (Mahon et al., p. 759)

44. Parasites that are detected by direct visualization in a peripheral blood

smear are

A. Ascaris
B. Entamoeba
 CLT Review Questions 119

C. Giardia
D. Plasmodium

The answer is D. Plasmodium species are the causative agents of malaria. Lab-
oratory diagnosis of those blood-borne parasites involves preparing thick- and
thin-film blood smears. Wright’s or Giemsa stain may be used. Ascaris, Enta-
moeba, and Giardia are generally intestinal tract parasites. (Koneman et al., p.
1079)

45. Chlamydiae differ from viruses in that chlamydiae

A. are true bacteria

B. are obligate intracellular organisms
C. produce intracellular inclusions
D. are isolated in tissue-culture systems

The answer is A. Chlamydiae have some characteristics in common with bacte-

ria and some characteristics of viruses. Chlamydiae are bacteria that possess
bacteria-like cell walls and are gram-negative, although they usually cannot be
visualized by Gram’s stain. Like viruses, chlamydiae are obligate intracellular
organisms that can be visualized as intracellular inclusions using a Giemsa or
immunofluorescent stain. Similar to viruses, tissue-culture techniques are
required for growth and isolation. Unlike viruses that possess either RNA or
DNA, chlamydiae contain both. (Murray et al., p. 795)

46. A specimen for viral culture is collected on a Friday and must be held for >
a
processing until the next day. In general, the optimal temperature for hold- £
ing this specimen is -
‘2
°
—_
|e ea @ =
B. 4°C =
C.D
|B re (©

The answer is B. Specimens for viral isolation should be collected as soon as pos-
sible after the onset of the illness, preferably within 3 days, and refrigerated
promptly using viral transport media. If processing will be performed within 2
days, the specimen may continue to be held at 4°C or on ice. To hold for long peri-
ods, the specimen should be frozen at —70°C. Freezing at —20°C is not recom-
mended since some viruses are labile at this temperature. (Murray et al., p. 80)

47. A procedure that directly determines beta-lactamase production by a

microorganism is based on detection of a(n)

A. zone of susceptibility around an ampicillin disk

B. zone of inhibition around an oxacillin disk
C. increased acidity due to the release of penicilloic acid
D. increase in pH due to the reduction of iodine

The answer is C. The direct detection of beta-lactamase production is most com-

monly performed by demonstrating the ability of the microbe to convert peni-
cillin to penicilloic acid. The rapid acidimetric method uses a pH indicator to
detect the decrease in pH in response to cleavage of the beta-lactam ring to form
120 4. Microbiology a

penicilloic acid. The iodometric method centers on the ability of penicilloic acid
to reduce iodine and, therein, decolorize a starch-iodine solution. Neither of the
screening tests using ampicillin or oxacillin disks tests directly for beta-lacta-
mase production. (Mahon et al., p. 89)

48. In a broth-dilution method of antimicrobial susceptibility testing, the tube

with the lowest concentration of antimicrobial in which there is no visible
growth is the minimal

A. antimicrobial concentration
B. bacteriocidal concentration
C. inhibitory concentration
D. lethal concentration

The answer is C. The minimal inhibitory concentration (MIC) of an antimicro-

bial is the lowest concentration of the drug that inhibits the growth of the organ-
ism as compared to a negative growth control. The minimal bacteriocidal con-
centration (MBC) is the lowest concentration of the drug that kills the
organism. The MBC is also known as the minimal lethal concentration (MLC).
The minimal antimicrobial concentration has no meaning per se. (Koneman et
al., p. 805)

49. The intestinal parasite shown in the image below, which is recovered from
steatorrheic stool, will produce which of the following?

. Malabsorption syndrome
Iron deficiency anemia
. Intestinal obstruction
. Extraintestinal infection
moaw>
Vitamin B,, deficiency anemia

The answer is A. The image shown is Giardia lamblia trophozoites, the most
commonly reported intestinal protozoan in the United States. In most patients,
infections are self-limiting, producing a mild diarrheal illness. However, patients
who suffer from secretory IgA deficiency or achlorhydria may eventually suffer
from a malabsorption-like syndrome. Patients produce steatorrheic stool with
large amounts of gas. (Mahon et al., p. 777)

50. This fungal species shown below that is isolated from the blood of bone
marrow transplant patient is
 CLS Review Questions 121

A. Aspergillus
B. Penicillium
C. Rhizopus sp.
D. Mucor sp.
E. Blastomyces

The answer is A. Aspergillus species is the most commonly encountered fungal

species in the clinical laboratory. Aspergillus shows an erect condiophore that
terminates in a vesicle on which phialides are borne. Phialides produce chains of
phialoconidia. Species are differentiated by the conidial arrangement. Like other
saprobes, Aspergillus such as A. fumigatus and A. flavus have become clinically
significant opportunistic fungi among immunosuppressed hosts such as those
who have undergone organ transplantation and chemotherapy. (Mahon et al., pp. >
3)
742-743) 2
=
2
fe)
=
=
=
CLS Review Questions

1. An early morning clean-catch, midstream urine specimen yields these

results on urinalysis:

Appearance: yellow, cloudy Protein: 1+

Specific gravity: 1.025 Blood: negative
pH: 8.0 Ketones: negative
Glucose: negative Bilirubin: negative
Nitrite: positive
Microscopic: no casts, 15 to 25 WBCs per high-power field; many bacteria
present
The results of this urinalysis indicate that
A. the bacteria present are the result of collection into a nonsterile container
and correlate to a probable original count of less than 10* CFU/ml
B. the bacteria present are the result of a delay of several hours in process-
ing and correlate to a probable original count of less than 10* CFU/ml
C. significant urinary-tract infection that correlates to a probable original
count of greater than 10° CFU/ml should be suspected
D. nephrotic syndrome should be considered, and the bacteria are merely
coincidental
122
Bic:4. Microbiology
a cl Pl a

The answer is C. The combination of a cloudy, concentrated (specific gravity =

1.024), alkaline urine that is positive for nitrite and protein, and in which WBCs
are found on microscopic examination indicates probable urinary-tract infection.
Urine specimens that are not examined while fresh may deteriorate, and small
numbers of contaminating bacteria can multiply, splitting urea, producing nitrite,
and increasing the pH. However, large numbers of WBCs would not be found in
that instance. The classic findings in nephrotic syndrome include lipiduria and
proteinuria. (Murray et al., p. 75)

2. This adult disease results from preformed neurotoxin that is ingested and
causes the symptoms of neuromuscular flacid paralysis. The agent that pro-
duces the toxin is

A. Bacillus cereus
B. Clostridium botulinum
C. Clostridium tetani
D. Staphylococcus aureus

The answer is B. The spores of C. botulinum occur in the soil ubiquitously.

Intoxication in adults results from consumption of inadequately preserved foods
in which spores of C. botulinum germinate and produce the neurotoxin botulin.
This toxin inhibits the release of the neurotransmitter acetylcholine. In this coun-
try, the incriminated foods are usually canned vegetables. Infant botulism is a
special case resulting from ingestion of the spores with subsequent colonization
of the intestinal tract and production of the toxin in situ. Ingestion of B. cereus-
contaminated food results in a profuse, watery diarrhea. S. aureus food poison-
ing results from ingestion of preformed enterotoxin and causes severe vomiting
and diarrhea. C. tetani causes tetanus or lockjaw. It produces the neurotoxin
tetanospasmin, which prevents the release of inhibitory transmitters resulting in
neuromuscular spasms. Infection with C. tetani is acquired when a deep-tissue
wound becomes contaminated with soil-containing spores. (Mahon et al., pp.
595-596)

3. Two siblings arrive at the emergency room. Both had antecedent sore
throats about 2 to 3 weeks earlier that grew beta-hemolytic streptococci;
now they present with different clinical symptoms. The brother displays
edema and hypertension, and RBC casts are seen in the urine. The sister
complains of fever and joint pains and has carditis. The diseases that these
siblings have are most likely

A. erysipelas and glomerulonephritis

B. glomerulonephritis and rheumatic fever
C. rheumatic fever and scarlet fever
D. scarlet fever and erysipelas

The answer is B. Although beta-hemolytic streptococcus group A can cause sev-

eral types of disease, it most commonly causes an infection of the pharynx and
adjacent areas. Symptoms from Streptococcus pyogenes arise initially from an
acute upper respiratory infection. If inadequately treated, delayed complications
can result, such as the two cardinal sequelae described in these siblings. The sister
exhibits rheumatic fever, in which carditis and arthritic joints are major features.
The brother displays acute glomerulonephritis indicated by the edema, hyperten-
sion, and RBC casts in his urine. Erysipelas and scarlet fever are skin manifesta-
 CLS Review Questions 123

tions of S. pyogenes. Erysipelas is a form of cellulitis also caused by S. pyogenes.

Scarlet fever is a superficial skin rash resulting from the host’s hypersensitivity to
an erythrogenic toxin produced by S. pyogenes. (Mahon et al., p. 360)

4. Purulent material is obtained from a carbuncle and submitted for bacterial

culture. The direct smear reveals many gram-positive cocci and WBCs. The
culture shows growth in the primary broth and on the sheep-blood agar plate
and no growth on the MacConkey agar plate. The colonies on the blood-
agar plate are butyrous, white, and beta-hemolytic. The catalase test is pos-
itive and modified oxidase test is negative. Although the slide coagulase test
is negative, the tube coagulase test is positive. The most probable identity
of this isolate is

A. Micrococcus sp.
B. Staphylococcus aureus
C. Staphylococcus epidermidis
D. Staphylococcus saprophyticus

The answer is B. S. aureus is a catalase positive, coagulase-producing staphylo-

cocci frequently isolated from this site. Staphylococci and micrococci are cata-
lase positive, gram positive cocci. The modified oxidase test differentiates
staphylococci (negative) from micrococci (positive). The positive coagulase
tube test, which demonstrates the presence of “free” coagulase, is the best test to
identify S. aureus definitively. Not all strains of S. aureus possess “bound” coag-
ulase; as evidenced in the data from the negative slide coagulase test, Micro-
coccus sp., S. epidermidis, and S. saprophyticus do not produce coagulase.
>
(Mahon et al., pp. 330-331) a
<
<
2
5. Which of the following is unique to Pseudomonas aeruginosa? °
_
ss
A. Growth at 30°C =
B. Production of pyocyanin, a blue or blue-green pigment
C. Beta-hemolysis on both sheep- and horse-blood agar
D. Oxidation of O-F glucose medium

The answer is B. Unique to Pseudomonas aeruginosa is pyocyanin, a blue-green

pigment, that when produced is sufficient for the identification of this organism.
Pseudomonas aeruginosa grows at 42°C; this ability is also shared by several
other Pseudomonas species. Pseudomonas aeruginosa is beta-hemolytic on
sheep-blood agar, and it oxidizes O-F glucose medium; however, these are not
unique features of this organism. Other gram-negative bacilli in the nonfer-
menter group may also exhibit these characteristics. (Mahon et al., pp. 544-549)

6. On thiosulfate-citrate—bile-salts—sucrose (TCBS) agar, colonies of Vibrio

cholerae appear

A. yellow
B. colorless
C. olive green
D. black

The answer is A. Vibrio cholerae appears yellow on TCBS because it ferments

sucrose. Yellow colonies appear on TCBS when organisms such as V. cholerae
124 4. Microbiology EE

and V. alginolyticus ferment sucrose. Non-sucrose fermenting Vibrio species

such as V. parahemolyticus and most of V. vulnificus produce green colonies.
Vibrio species do not produce colorless or black colonies on TCBS. (Mahon et
aly ps522)

7. A gram-negative coccobacillary organism that is isolated from synovial

fluid on chocolate agar resembles either a Moraxella species or Neisseria
gonorrhoeae. The single best test to distinguish between these organisms 1s

A. beta hemolysis
B. glucose degradation
C. motility
D. oxidase production

The answer is B. The single best test for distinguishing N. gonorrhoeae from a
Moraxella species is carbohydrate degradation. N. gonorrhoeae forms acid from
glucose, whereas Moraxella species are metabolically inactive in carbohydrate-
utilization tests. Moraxella species and N. gonorrhoeae can be isolated from
similar specimen sources such as the genitourinary tract, blood, and synovial
fluid. The microscopic morphology of Moraxella is coccobacillary, but some-
times resembles a gonococcus. Both Neisseria and Moraxella produce indophe-
nol oxidase and are nonmotile. Moraxella species are nonhemolytic on sheep-
blood agar. Because N. gonorrhoeae does not routinely grow on sheep-blood
agar, beta hemolysis is irrelevant. (Forbes et al., pp. 359-360)

8. A lumbar puncture is performed on an 82-year-old woman who is receiving

immunosuppressive therapy. The direct Gram’s stain of the CSF reveals
small gram-positive rods and numerous WBCs. At 18 h, small translucent
colonies with narrow zone of beta hemolysis grow on sheep-blood agar. The
isolate produces catalase. Identification of this isolate could be made by
demonstration of

A. tumbling motility
B. metachromatic granulation
C. hippurate hydrolysis
D. H,S production on TSI agar

The answer is A. On wet-mount or hanging drop preparations, Listeria monocyto-

genes appears as small rods with tumbling motility. On Gram-stained smears, it
appears as a small gram-positive rod. The organism is an opportunistic pathogen
often associated with meningitis in infants and elderly adults with predisposing
conditions such as malignancies and blood disorders, and, as in this instance, in
patients receiving immunosuppressive therapy. Growth on sheep-blood agar yields
small, round translucent colonies with a faintly detectable narrow zone of beta
hemolysis. Key characteristics for the identification of L. monocytogenes include
blackening of routine bile-esculin agar, tumbling motility at 25°C, production of
catalase, and development of an umbrella-like area of motility in a semisolid
medium incubated at 25°C. Metachromatic granulation is a characteristic attribute
of Corynebacterium diphtheriae. The ability to hydrolyze hippurate is a charac-
teristic of Streptococcus agalactiae, which are catalase-negative, gram-positive
cocci. Erysipelothrix rhusiopathiae is a gram-positive nonspore-forming rod that
produces H,S on TSI agar. This organism is usually associated with a cutaneous
infection referred to as erysipeloid. (Mahon et al., pp. 374-387)
 CLS Review Questions 125

9. In an overcrowded poverty-stricken central core of a United States-Mexico

border town, a 15-month-old baby girl is admitted to the city hospital. Phys-
ical examination of this child reveals fever, repetitive coughing spells that
make the child gasp for air, and a cyanotic appearance. Laboratory findings
show lymphocytosis. The probable diagnosis is

A. diphtheria
B. epiglottitis
C. pertussis
D. trench mouth

The answer is C. The infectious disease described is consistent with pertussis.

Pertussis is one of the most communicable childhood diseases especially in non-
immunized populations. Infections follow after exposure to Bordetella pertussis,
a gram-negative minute coccobacilli. The initial symptoms are similar to those of
a common cold, but later the disease progresses to a severe episode of repetitive
coughing followed by the characteristic “whoop” when the patient gasps for air.
Pertussis toxin or lymphocyte-promoting factor is responsible for lymphocytosis
that occurs in pertussis infections. (Mahon et al., p. 458; Koneman et al., p. 424)

10. A dairy farmer who has an intermittent fever, progressive weakness, and
night sweats is suspected of having undulant fever. Blood cultures from this
patient yield an organism that shows the following characteristics: requires
an atmosphere of 10% COs, urease-positive in 1 to 2 h, grows in the pres-
ence of thionine dye but not in the presence of fuchsin. Which of the fol-
lowing is described here?
>
a
A. Bacillus anthracis 2
B. Brucella suis 2
2
C. Brucella abortus fe)
=
D. Brucella melitensis 2
=
The answer is C. Brucella species cause brucellosis or undulant fever, a zoonotic
infection that humans acquire from infected animals or animal products. Bru-
cellosis in cattle causes contagious abortion, or Bang’s disease, and commonly
results from infection with Brucella abortus. Typical clinical manifestations
include recurring fever that fluctuates consistently as described above. B. abor-
tus is the only Brucella species that requires up to 10% CO, for primary isola-
tion. It is also urease-positive in 1 to 2 h. Brucella melitensis is most often found
in sheep and goats, does not require CO, for growth, and varies in its ability to
split urea. Bacillus anthracis is the etiologic agent of anthrax in cattle and, sec-
ondarily, in humans. Brucella suis is a rapid urease producer and is inhibited by
thionine and not by fuchsin. (Mahon et al., p. 444)

11. A patient is admitted to the hospital with symptoms of appendicitis. A stool

specimen for culture reveals a gram-negative bacillus that is oxidase-negative,
catalase-positive, urease-positive, and weakly fermentative. The slant of
Kligler’s iron agar (KIA) is orange-yellow but the triple sugar iron agar (TSI)
shows yellow slant and yellow butt. These reactions suggest the possibility of

A. Yersinia enterocolitica
B. Escherichia coli
C. Plesiomonas shigelloides
D. Pasteurella multocida
126 4. Microbiology

The answer is A. Y. enterocolitica and Yersinia pseudotuberculosis are zoonotic

organisms capable of causing a mesenteric lymphadenitis that clinically simu-
lates appendicitis. The genus Yersinia belongs to the family Enterobacteriaceae.
Yersinia is cytochrome oxidase-negative and weakly ferments carbohydrates;
hence, an orange-yellow color reaction on KIA slant. ¥. enterocolitica, however,
ferments sucrose, which allows a more visible color change on TSI . Pasteurella
and Plesiomonas are oxidase-positive. The positive urease reaction differenti-
ates Yersinia from E. coli. Sucrose fermentation distinguishes the two species of
Yersinia. Y. enterocolitica ferments sucrose and Y. pseudotuberculosis does not.
(Mahon, pp. 486-488, 494, 495)

12. A stool culture from an adult appears to have two lactose-negative colony
types on Hektoen and xylose-lysine-deoxycholate (XLD) agar. One colony
type retains the original color of each medium and the other has black cen-
ters. Stool screen data are as follows:
Medium Isolate 1 Isolate 2
TSI alkaline/acid, no gas, acid/acid, gas,
H,S-negative H,S-positive
LIA purple slant/yellow butt red slant/yellow butt,
H,S-negative H,S-positive
Urease negative positive
Based on these data, an important step is to
A. set up confirmatory tests for Campylobacter sp.
B. set up Shigella serogrouping
C. set up Salmonella serogrouping
D. report the culture as negative for enteropathogens

The answer is B. The stool-screen reactions for isolate 1 are typical of those
expected for a Shigella species. However, they are also consistent with a possible
lysine-negative E. coli or Aeromonas hydrophila; therefore, biochemical confir-
mation and Shigella serogrouping should be performed for this isolate. Campy-
lobacter sp. would be isolated on selective media incubated at 42°C. Testing on
those isolated includes Gram stain, motility, catalase and oxidase; not TSI and LIA
reactions. LIA reaction on isolate 2 shows deamination (red slant), and a positive
urease reaction, which are characteristic features of Proteus species; there is no ad-
ditional work-up necessary for this isolate. (Mahon et al., pp. 484, 485, 494, 495)

13. Both blood and urine cultures are positive for an oxidase-negative, gram-
negative rod that is colorless on MacConkey agar. Biochemical reactions
include the following:
TSI Acid/Acid, gas + H,S-negative
Phenylalanine deaminase: negative DNase: positive
HS: negative Arabinose: alkaline
Indole: negative Lysine decarboxylase: positive
Citrate: positive Ornithine decarboxylase: positive
Motility: positive
The opportunistic pathogen that shows these reactions is
A. Escherichia coli
B. Serratia marcescens
 CLS Review Questions 127

C. Enterobacter aerogenes
D. Klebsiella pneumoniae

The answer is B. This patient’s blood and urine cultures are positive for the
opportunist Serratia marcescens. S. marcescens is a slow-lactose fermenting
organism, hence, the colorless appearance on MacConkey agar. Most strains fer-
ment sucrose, producing an acid slant/acid butt on TSI agar. E. coli, K. pneumo-
niae, and E. aerogenes ferment lactose efficiently and will show fermentation on
MacConkey agar after 18 hours of incubation. E. coli has a typical IMViC reac-
tion of ++66, while S. marcescens, K. pneumoniae, and E. aerogenes all produce
a §6++ IMViC reaction. K. pneumoniae is non-motile and ornithine decarboxy-
lase negative, while S. marcescens and E. aerogenes are both motile and
ornithine decarboxylase positive. The DNase test differentiates S. marcescens
from E. aerogenes. (Mahon et al., pp. 476, 494-497)

14. The metabolism of glucose by the Klebsiella-Enterobacter-Serratia group is

as follows:
Glucose > 2,3-butanediol + 2 CO, + H,
The reaction is the basis for the

A. glucose oxidase reaction

B. methyl-red test
C. oxidative/fermentation (O-F) glucose test
D. Voges-Proskauer test

The answer is D. All members of the family Enterobacteriaceae metabolize glu- a

a
cose to pyruvate via the Embden-Meyerhof pathway. The subsequent metabo- 2
lism of pyruvate results in either mixed organic acid end products or the forma- 2
‘2
tion of neutral 2,3-butanediol end product. In the methyl-red test mixed acid end °be
products decrease the acidity of the medium to approximately pH 4.4, where the An
methyl-red indicator in the medium is red. In the Voges-Proskauer test, the neu-
=
tral 2,3-butanediol end product is detected by a colorimetric reaction. The Kleb-
sielleae utilize the butylene-glycol pathway, which results in a negative methyl-
red test and a positive Voges-Proskauer test. (Mahon et al., pp. 498, 501)

15. A stool specimen is submitted for culture from a patient with gastroenteri-
tis, nausea, and vomiting. A gram-negative rod grows on TCBS agar as a
large green colony type. Additional screening characteristics include:

Triple-sugar iron (TSI): alk/acid Catalase: positive

HS: negative Nitrate: positive
Oxidase: positive Lysine: positive
Nutrient broth with 0% NaCl: no growth
Nutrient broth with 3% NaCl: growth
The most probable presumptive identification of this isolate is
A. Aeromonas hydrophila
B. Shigella flexneri
C. Vibrio parahaemolyticus
D. Yersinia enterocolitica

The answer is C. Vibrio parahaemolyticus produces large, blue-green colonies on

TCBS agar at 24 h of incubation. Vibrio species are oxidase-positive, gram-nega-
128 4. Microbiology iS,
ES

tive curved rods that metabolize carbohydrates fermentatively. TCBS is an excel-

lent selective and differential medium for the isolation and initial differentiation of
vibrios. This medium is selective because most fecal flora and gastrointestinal
pathogens are inhibited. Non-sucrose fermenting vibrios such as V. para-
haemolyticus and V. vulnificus produce blue-green colonies while sucrose-fer-
menting species such as V. cholerae and V. alginolyticus produce yellow colonies.
Halophilic vibrios, such as V. parahaemolyticus, also require salt for growth, while
Aeromonas, which is also an oxidase-positive fermenting species, does not require
salt for growth. Shigella and Yersinia are oxidase-negative, do not require salt, and
are lysine decarboxylase-negative. (Mahon et al., pp. 518-527)

16. Respiratory secretions from a patient receiving inhalation therapy reveals a

nonmotile gram-negative coccobacillary rod that grows on MacConkey agar
as a lactose-negative colony at 24 h. It is a nonfermentative organism. A
large battery of conventional biochemical tests yields the following reac-
tions:

O-F glucose (aerobic): acid Lactose: alkaline

O-F glucose (anaerobic): alkaline Maltose: alkaline
Oxidase: negative Mannitol: alkaline
TSI: alkaline/no change Sucrose: alkaline
Orthonitropheny] galactoside (ONPG): negative Xylose: acid
This isolate also produces acid from a 10% lactose agar slant. The identifi-
cation of this isolate is
A. Acinetobacter baumannii
B. Alcaligenes faecalis
C. Moraxella osloensis
D. Burkholderias cepacia

The answer is A. This isolate is Acinetobacter baumannii, which is a nonmotile

coccobacillary gram-negative nonfermentative microbe. Its key reactions using
the King criteria are glucose oxidizer, growth on MacConkey, and oxidase-neg-
ative. Typical reactions include the production of acid from O-F xylose and a
10% lactose slant. Alcaligenes faecalis is non-saccharolytic and motile with per-
itrichous flagellation. M. osloensis is non-saccharrolytic and nonmotile.
Although B. cepacia is an oxidizer, it is motile with polar flagellation and
ONPG-positive. (Mahon et al., pp. 549, 551, 554, 558, 559)

17. Which result is not consistent with the identification of Mycobacterium for-
tuitum?

A. Arylsulfatase positive
B. Nitrate reduction negative
C. Growth on MacConkey agar
D. Growth in 5% NaCl

The answer is B. M. fortuitum may be differentiated from the other rapid-grow-

ing mycobacteria by its positive arylsulfatase reaction within 3 to 5 days and its
growth on MacConkey agar within 5 days. This saprobe also grows in 5% NaCl
in 3 to 5 days. Nitrate reduction is a major characteristic used in distinguishing
between M. fortuitum and M. chelonei; M fortuitum is nitrate reduction positive,
while M. chelonei is negative. (Mahon et al., pp. 698-699)
 CLS Review Questions 129

18. An acid-fast bacillus (AFB) has been isolated from the sputum of a patient sus-
pected to have a mycobacterial pulmonary disease. The organism is a slow-
growing isolate that produces cream- to tan-colored colonies when grown in
the dark in the incubator and turns bright yellow upon exposure to light. Which
of the following is the most likely identification of this organism?

A. Mycobacterium avium
B. Mycobacterium chelonei
C. Mycobacterium kansasii
D. Mycobacterium scrofulaceum

The answer is C. Mycobacterium kansasii is a slow-growing photochromogen

capable of causing serious pulmonary disease similar to tuberculosis. M. avium,
a nonphotochromogenic mycobacterium, also causes serious systemic infections
especially among the immunosuppressed patients. M. chelonei is a Runyon
group-IV rapid grower, while M. scrofulaceum is a slow-growing species that is
scotochromogenic. (Mahon et al., p. 697)

19. Nocardia species that cause nocardiosis often are

A. obligate anaerobes
B. gram-variable
C. partially acid-fast
D. spore-forming rods

The answer is C. Nocardia species are nonspore-forming, branching, gram-pos-

itive bacilli. They are characterized as being partially acid-fast; i.e., they retain >
a
the carbolfuchsin when decolorized with a diluted acid-alcohol solution. Nocar- =
dia species are generally aerobic, although they tend toward microaerophilic or A
‘2
capnophilic requirements. (Forbes et al., pp. 676-677) °
ww
=
20. A direct Gram’s stain of a pelvic mass from a patient with an IUD shows
numerous pus cells and branching, beaded gram-positive rods. Heaped,
lobate colonies grow anaerobically and develop a molar-tooth appearance
after several days of incubation. The most probable identity is

A. Actinomyces israelii
B. Streptomyces sp.
C. Nocardia asteroides
D. Fusobacterium nucleatum

The answer is A. The description of the anaerobic, branched, gram-positive rods

is typical of Actinomyces. A israelii, which develops mature molar-tooth-type
colonies, has been shown to be present in the cervix of approximately 5 to 25%
of women using IUDs and has been implicated in pelvic infections complicated
by IUDs. Streptomyces species and Nocardia asteroides are obligate aerobes.
Fusobacterium nucleatum is an anaerobic gram-negative bacilli. (Forbes et al.,
pp. 689, 697)

21. A lung abscess is cultured. At 24 h of capneic incubation, no growth is

detected on any of the primary agar plates. Gram-negative rods are seen in
the thioglycollate broth. After 48 h, the growth includes:
130 4. Microbiology ee

Anaerobic sheep blood agar: 3+ gram-negative rods

Anaerobic laked-blood agar with kanamycin-vancomycin (K-V): 3+ gram-
negative rods
The isolate fluoresces a brick-red color under long-wave ultraviolet expo-
sure. If allowed to incubate several more days, the colonies would be vis-
ibly
A. black-pigmented
B. yellow-pigmented
C. orange-pigmented
D. blue-pigmented

The answer is A. Anaerobic gram-negative rods that are initially nonpigmented

on laked-blood agar with K-V and fluoresce brick-red when exposed to ultravi-
olet light (365 nm) are of the Prevotella melaninogenica. With age, the fluores-
cence disappears and a brown-black pigment is produced. These bacteria are
important pathogens in respiratory infections and are seen in other infections as
well. (Mahon et al., pp. 609-610)

22. Two organisms that are thought to act synergistically to produce an ulcera-
tive infection of the gums, commonly called trench mouth, are

A. streptococci and staphylococci

B. yeast and fusiforms
C. fusiforms and treponemes
D. spirochetes and treponemes

The answer is C. This ulcerative or pseudomembranous infection of the gums is

thought to be a fusospirochetal disease related to Borrelia vincentii and
Fusobacterium species. Demonstration of Vincent’s infection can be made by
staining smears with Gram’s crystal violet for 1 min and examining them for the
presence of numerous white cells, fusiform bacilli, and spirochete organisms.
Culture of mouth lesions or pseudomembrane is of no value. (Forbes et al., p.
323)

23. A physician inquires about repeated sputum specimens, negative on routine

bacterial culture, that are reported to contain only normal oropharyngeal flora
on routine bacterial culture. The patient is a 67-year-old man who smokes 15
to 20 cigarettes a day and has persistent cough, malaise, and a fever of
102—105°F. Empiric antimicrobial therapy has not been effective; the cough
and fever persist. The most recent direct Gram’s stain of sputum shows 3+
PMNs, mucus present, and rare epithelial cells. A likely etiologic agent is

A. Haemophilus influenzae
B. Legionella pneumophila
C. Pseudomonas aeruginosa
D. Streptococcus pneumoniae

The answer is B. Repeatedly negative sputum cultures from an elderly patient

who smokes, has pneumonia with persistent cough and high fever, and does not
respond to routine drug therapy are suggestive of legionellosis. Culture on a spe-
cial medium, such as buffered charcoal yeast extract agar, or a rapid immunodi-
agnostic approach have been used to confirm clinical diagnosis. Acid treatment
of samples before inoculating the selective media may enhance the recovery of
 CLS Review Questions 131

Legionella species. The Legionella antigens are also detectable in urine as early
as day 3 of the infection and remain detectable for up to a year. Erythromycin is
the drug of choice. H. influenzae would be detected on Gram’s stain and grow
on chocolate agar on routine sputum culture. Both P. aeruginosa and S. pneu-
moniae can be recovered from routine sputum cultures. (Mahon et al., pp.
453-454)

24. Which of the following descriptions does not pertain to Pasteurella multo-
cida?

A. Gram-negative coccoid bacillus

B. Growth on MacConkey agar
C. Nonhemolytic on sheep-blood agar
D. Oxidase-positive

The answer is B. P. multocida is a small coccobacillary gram-negative rod, oxi-

dase-positive, facultative anaerobe. It grows on sheep-blood agar as a small
translucent colony type that is nonhemolytic and fails to grow on MacConkey
agar. Among the Pasteurella, P. haemolytica is beta-hemolytic on blood agar and
grows on MacConkey agar, and P. aerogenes grows on MacConkey agar.
(Mahon et al., pp. 441-442)

25. Which of the following media has a high protein content and requires ster-
ilization by inspissation?

A. Lowenstein-Jensen egg >

a
B. Sheep-blood agar =
C. Thioglycollate 2
‘2
D. Christensen’s urease °
2
The answer is A. Inspissation is a moist-heat method of sterilization in which the =
medium thickens by coagulation and evaporation when exposed to a tempera-
ture of 75°C on 3 consecutive days for 2 h each day. This sterilization method is
generally used to avoid altering the appearance of media that contain high
amounts of protein, egg, or serum. Thioglycollate is autoclaved routinely; ster-
ile sheep blood is added to basal agar after autoclaving; and urea must be filter-
sterilized for incorporation into Christensen’s urease. (Murray et al., pp. 1, 259)

26. All of the following describe the orthonitrophenyl galactoside (ONPG) test
except

A. it detects the presence or absence of the enzyme beta-galactosidase in an

organism
B. it is positive for organisms that produce both beta galactosidase and
galactoside permease
C. it is positive for isolates that are capable of fermenting lactose but lack
the permease
D. it detects the decarboxylation of ONPG to ornithine and galactose

The answer is D. Rapid lactose-fermenting bacteria possess two enzymes: lac-

tose permease enhances transport of lactose across the cell wall, and beta-galac-
tosidase cleaves the galactoside bond of lactose, producing glucose and galac-
tose. The glucose is then degraded by the Embden-Meyerhof pathway,
132 4. Microbiology ———— SS

producing mixed-acid fermentation. In conventional lactose-fermentation tests,

such as that using MacConkey agar, both enzymes must be present to evidence
a rapid positive test. Some species appear to be nonlactose fermenters at 18 to
24 h because they lack the permease activity, even though they possess beta-
galactosidase. Because ONPG readily permeates the cell and is structurally sim-
ilar to lactose, the ONPG test detects only beta-galactosidase activity. By cir-
cumventing the need for permease, ONPG rapidly identifies these late
lactose-fermenting bacteria. (Mahon et al., pp. 498-499)

27. Bacteria that are glucose oxidizers in Hugh-Leifson (H-L) O-F medium pro-
duce an alkaline/no change reaction in Kligler iron agar (KIA) because

A. these organisms produce insufficient amounts of acid to be detected on

KIA
B. the lactose component in KIA inhibits glucose oxidation in this medium
C. the concentration of glucose in KIA is higher than in the O-F medium
D. KIA detects only fermentation of lactose

The answer is A. Fermentation media such as KIA contain 2% peptone and 0.1%
glucose. In contrast, Hugh-Leifson O-F medium contains 0.2% peptone and 1%
glucose or other carbohydrate. The decrease in peptone reduces the formation of
alkaline end products from oxidation of amino acids. The increase in carbohy-
drate enhances production of acids. Consequently, Hugh-Leifson O-F medium is
a more sensitive medium for detecting weak-acid production. Nonfermentative
bacteria, such as Pseudomonas aeruginosa, which utilize glucose oxidatively,
produce small amounts of acid in Hugh-Leifson O-F medium exposed to air.
Because KIA contains a low concentration of glucose, these organisms resort to
oxidative utilization of peptone to form amines that result in an alkaline/no
change reaction on KIA. (Mahon et al., pp. 541-542)

28. Physical examination of a 20-year-old man seen in the emergency room

reveals nuchal rigidity and a temperature of 102°F. Direct Gram’s stain of
the CSF reveals numerous WBCs and a few gram-negative diplococci. The
isolate grows on sheep-blood agar and is oxidase-positive. Acid production
occurs in the cystine trypticase agar (CTA) carbohydrates as follows:

Glucose: acid
Lactose: acid
Maltose: acid
Sucrose: acid

The most appropriate action to take is

A. identify the organism as meningococcus and report it

B. identify the organism as Moraxella and set up additional tests to deter-
mine the species
C. Gram’s stain and subculture the CTA sugars to check them for purity
D. perform an antimicrobial-susceptibility test as a confirmation of the
identification

The answer is C. This situation represents a classic presentation of meningococ-

cal meningitis, diagnosed on the basis of clinical symptoms and preliminary cul-
ture results. Because meningococci ferment glucose and maltose exclusively,
and Moraxella species are unable to attack carbohydrates, it appears that the
 CLS Review Questions 133

CTA sugars are contaminated. The possibility that the sugars contain more than
the patient’s isolate could be established by Gram’s stain and subculture. Antimi-
crobial susceptibility testing does not aid identification when the carbohydrate
reactions are discrepant. (Koneman et al., p. 5100)

29. Special handling or methods are required when blood cultures are requested
on a patient to recover any of the following organisms except

A. nutritionally-deficient streptococci
B. Candida albicans
C. Mycobacterium tuberculosis
D. Salmonella serotype typhi

The answer is D. Routine blood cultures will become positive for Salmonella sp.
organisms (agent of typhoid) within the first few days of incubation. Nutrition-
ally-deficient streptococci require the addition of 0.001% pyridoxal hydrochlo-
ride (also known as Vitamin B,) to multiply. Human blood contains enough pyri-
doxal to support the growth of the organisms in blood culture medium; however,
when subcultured onto agar plates such as 5% sheep-blood agar, a source for
pyridoxal is required. A pyridoxal disk or a Staphylococcus aureus streak may
provide this requirement. With candidemia and fungemia, the organisms often
do not grow rapidly in routine blood culture media and may require up to 2
weeks’ incubation. M. tuberculosis 1s optimally cultured in special media such
as Middlebrook 7H9 broth, in special biphasic media; prolonged incubation (>
5 days) may be required for positive cultures. (Forbes et al., pp. 300-302)
>
ro)
30. Safety precautions designed to minimize laboratory-acquired infections i)
when working with Mycobacterium tuberculosis in a clinical laboratory 2
2
would prevent spreading of these organisms by °o
=
pe
. aerosol production
=
. ingestion
. superficial contact
VaAw>
contact with fomites

The answer is A. Tuberculosis is initiated by inhalation of droplet nuclei of less

than 5 ym. Inhalation of infectious aerosols is the major biohazard to microbi-
ology laboratory personnel. To minimize laboratory-acquired infection, safety
precautions are designed that prevent spread of aerosols and inhalation of
droplet nuclei. (Murray et al., p. 405)

31. To check for positive and negative reactions, select the appropriate set of
quality-control microorganisms for the following tests:

Bile esculin hydrolysis

Bacitracin susceptibility
6.5% NaCl tolerance
Hippurate hydrolysis

A. Streptococcus pyogenes, Viridans streptococci, enterococci

B. S. pyogenes, Streptococcus agalactiae, enterococci
134
e
eG 4. Microbiology Y Sa
es

C. Staphylococcus aureus, S. pyogenes, enterococci

D. S. agalactiae, Viridans streptococci, enterococci

The answer is B. An appropriate quality-control set of microorganisms

would be as follows:
Test Positive reaction Negative reaction
Bile esculin hydrolysis Enterococcus sp. S. pyogenes
Bacitracin susceptibility S. pyogenes S. agalactiae
6.5% NaCl tolerance Enterococcus sp. S. pyogenes
Hippurate hydrolysis S. agalactiae S. pyogenes
(Mahon et al., pp. 349-353)

32. From the dimorphic fungi and major identifying morphologic features
listed, select the species whose major characteristics are not described cor-
rectly.

A. Blastomyces dermatitidis: thick-walled yeast cells with single, broad-

based buds at 37°C
B. Coccidioides immitis: barrel-shaped arthrospores at 25°C
C. Histoplasma capsulatum: spherical, tuberculated macroaleuriospores at
PE ®
D. Sporothrix schenckii: thick-walled yeast cells with multiple buds at 25°C
The answer is D. The morphologic features of the dimorphic molds that cause
disease in humans are of major importance in determining the etiology of these
sometimes life-threatening illnesses. Pertinent criteria of the thermally dimor-
phic species are as follows:
Blastomyces dermatitidis: at 37°C tan- to cream-colored colonies with wrin-
kled surfaces and waxy sheen; microscopically, large, thick-walled yeast
cells that have single buds attached by a broad base
Coccidioides immitis: at room temperature, white-to-brown colonies with
cottony aerial mycelia; microscopically, septate hyphae dissociate and
fragment into barrel-shaped arthroconidia
Histoplasma capsulatum: at room temperature, silky-smooth, white-to-tan
colonies; microscopically, echinate, tuberculated, spherical macroconidia
Sporothrix schenckii: at room temperature, smooth cream-to-white colonies
that turn brown with age; microscopically, branched slender conidiophores
with small conidia arranged in flowerettes or in a sleeve arrangement
(Koneman et al., p. 1038)

53: Fusarium species have on occasion been associated with corneal ulcers,
ulcerated skin conditions, and mycetoma. Typical macromorphologic and
micromorphologic features are

A. rapid growers that usually produce a lavender pigment and crescent-

shaped, septate macroconidia
B. rapid growers that darken with age and produce aseptate hyphae with
rhizoids
C. slow growers that are velvety and light tan with a salmon-colored
reverse, and seldom produce macroconidia
D. slow growers that are gray-brown and produce multicellular macroconi-
dia with both transverse and longitudinal septa
 CLS Review Questions 135

The answer is A. Fusarium is a genus of fungi that is pathogenic to plants. Com-

monly considered a contaminant, it is known to cause keratomycosis and myce-
toma. Its colonies are cottony on Sabouraud’s dextrose agar, with a lavender pig-
ment at 4 days. Microscopically, it is a septate hyaline fungus that produces
crescent-shaped septate macroconidia. Option B describes the member of
Zygomycetes, Rhizopus. Option C describes the dermatophyte Microsporum
audouinii. Option D describes the dematiacious fungus Alternaria. (Koneman et
al., pp. 994, 1006)

34. An 8-year old child presents with tinea capitis, thought to be caused by
Microsporum canis. Characteristics of this fungi include

A. spindle-shaped, thick-walled macroconidia with an asymmetric terminal

knob
B. demonstration of endothrix invasion of hair
C. salmon-colored reverse of colony
D. production of abundant peg-shaped microconidia on Sabouraud’s dex-
trose agar

The answer is A. M. canis is a common agent of ringworm in domestic animals

and of tinea capitis in children in the United States. Most human infections are
acquired from cats and dogs. Hairs infected with a species of Microsporum flu-
oresce a bright yellow-green under ultraviolet examination. Most other der-
matophytes do not fluoresce. Many dermatophytes have a predilection for
ectothrix—infection of hair evidenced by conidia forming a sheath around the
surface of the hair shaft. Microsporum canis grows on Sabouraud’s dextrose
>
agar as a white, fluffy colony type with a chrome-yellow reverse. Microscopic ro)
examination of the colony reveals thick-walled, echinulate, spindle-shaped 2
4
macroconidia usually with an asymmetric terminal knob. (Mahon et al., p. 728) re)
°i=
=
=
35. Which of the following pairings of yeast species with identifying character-
istics is (are) correct?

. Cryptococcus neoformans: urease-negative, encapsulated

. Candida albicans: germ tube—positive, chlamydoconidia producer
. Torulopsis glabrata: urease-positive, arthroconidia producer
. Geotrichum species: hyphae-blastoconidia positive, arthroconidia pro-
QVUaAWS
ducer

The answer is B. There are several approaches to laboratory identification of

yeasts. Some key characteristics and preliminary tests are as follows:

Germ tube test: positive for Candida albicans in 2 h and negative for most
of the yeast species in this time limit
Urease test: positive for Cryptococcus and Rhodotorula and negative for
Torulopsis, Geotrichum, and Candida species, except for an occasional
strain of Candida krusei
India ink test: positive for encapsulated yeast such as Cryptococcus neofor-
mans and negative for nonencapsulated yeast species
Corn meal agar: detects formation of chlamydoconidia, arthroconidia, and
blastoconidia; Candida albicans forms chlamydoconidia, Geotrichum
forms hyphae and arthroconidia, and Torulopsis forms blastoconidia only
(Mahon et al., pp. 748-752)
36. Which of the following is characteristic of Dientamoeba fragilis?

A. Easily recognized by its rapid, jerky motility

B. No known cyst stage, trophozoite shaped like an amoeba
C. Two-to-four nuclei have a small pin-dot karyosome
D. The size is typically smaller than £. nana cysts

The answer is B. As its name suggests, D. fragilis usually has two nuclei in the
trophozoite form. In addition, it has no known cyst stage. D. fragilis moves like
an amoeba with a slow, progressive, gliding motion. The nuclei contain a
karyosome, which is often splintered into four parts. The size is typically larger
than E. nana cysts. (Markell et al., pp. 68-69)

37. A thick film has been prepared from a patient suspected of having malaria.
It is stained with Wright’s stain. Inclusions seen in the patient’s erythrocytes
are described as blue disks with red nuclei. The infected erythrocytes are
generally enlarged and some of them have granules of brownish pigment.
Many of the erythrocytes appear to have more than 15 nuclear masses in a
single cell. Identify the parasite described.

A. Plasmodium falciparum
B. Plasmodium malariae
C. Plasmodium ovale
D. Plasmodium vivax

The answer is D. P. vivax is a Plasmodium species that prefers young erythro-

cytes (reticulocytes), which may be slightly larger than the average red cell on
a peripheral smear. The typical appearance of the Plasmodium trophozoite on a
Wrights-stained smear is the “signet ring,” a blue ring with a red nuclear mass.
Reddish or brown granules known as Schiiffner’s dots may be seen in red cells
infected in either P. vivax or P. ovale. P. vivax commonly divides to produce a
total of 12 to 24 nuclear masses within a single erythrocyte. P. ovale usually
produces 4 to 12 merozoites during schizogony. (Markell et al., pp. 95-97)

38. The diagnostic stage of Strongyloides stercoralis infection is the

A. egg
B. cyst
C. larva
D. trophozoite

The answer is C. Strongyloides does not develop cyst or trophozoite stages. The
female lays her eggs in the patient’s intestinal mucosa. Ordinarily the eggs hatch
in the mucosa and mature into the rhabditiform larvae, which appear in the feces.
Strongyloides eggs do not appear in the stool except in very severe diarrhea.
These eggs resemble the hookworm egg in general size and shape. Hookworm
egg in the feces may hatch into the first stage rhabditiform larvae. The larvae of
hookworm must be differentiated from the S. stercoralis larvae. (Markell et al.,
p. 287)

39. Trematodes that mature in the lung and produce eggs that appear in the spu-
tum or stool are probably
 CLS Review Questions 137

A. Fasciolopsis buski
B. Schistosoma japonicum
C. Paragonimus westermani
D. Clonorchis sinensis

The answer is C. Although all the parasites listed are flukes capable of infecting
humans, only Paragonimus consistently invades the lung. F. buski, S. japon-
icum, and C. sinensis parasitize the intestine, blood vessels, and liver, respec-
tively. (Markell et al., p. 226)

40. A 15-year-old girl was admitted with severe headache and confusion. An
examination of her spinal fluid revealed many small, motile amebae. The
girl was visiting friends in Georgia and had been swimming and diving in a
freshwater pond. The most likely genus and species of the organism is

A. Entamoeba histolytica
B. Endolimax nana
C. lodamoeba biitschlii
D. Naegleria fowleri

The answer is D. The amoeba most frequently associated with primary amoe-
bic meningoencephalitis is Naegleria fowleri. Certain free-living water amoe-
bae can cause primary meningoencephalitis. Fatalities have been reported in the
United States, Belgium, Australia, England, and Czechoslovakia. Illness begins
with headaches and mild fever, and sometimes, sore throat and rhinitis. While
headache and fever increase over the next 3 days, vomiting and neck rigidity
develop. Soon the patient becomes disoriented and may lapse into a coma and >
a
die. Most case studies to date have occurred following swimming and diving in 2
warm ponds or pools containing water amoebae. It is postulated that the amoe-
=
‘2
bae gain entrance through the nasal passages, invade along the olfactory nerves, °
<
and spread via the subarachnoid space. Hartmannella and Acanthamoeba have =
also been reported, rarely, as causative agents. (Markell et al., pp. 175-180)

41. The causative agent of Q fever is

A. Coxiella burnetii
B. Rickettsia typhi (mooseri)
C. Rickettsia rickettsii
D. Rickettsia tsutsugamushi

The answer is A. C. burnetii causes Q fever, one of the three important rickettsial
diseases in the United States. R. mooseri is the agent of murine typhus. R. rick-
ettsii causes Rocky Mountain spotted fever, and R. tsutsugamushi causes scrub
typhus. (Mahon et al., p. 1078)

42. Cerebrospinal fluid from a 24-year-old man reveals a high number of

mononuclear cells and a negative routine culture for bacteria. Spinal fluid,
glucose, and protein values are normal. In addition, the patient has vesicu-
lar genital lesions. The most likely etiologic agent is

A. Neisseria meningitidis
B. Streptococcus pneumoniae
138ne
Ried 4.RCLMicrobiology
SSC bedi) a

C. Chlamydia trachomatis
D. herpes simplex virus

The answer is D. Herpes simplex genital infection may rarely progress to menin-
gitis, which would result in a mononuclear infiltrate to the CSF but no change in
the CSF glucose levels. N. meningitidis and S. pneumoniae both cause meningi-
tis in young children and adults. However, neither organism causes vesicular
lesions, and usually produces an elevated white blood cell count, predominantly
neutrophils, and CSF protein level would be elevated while glucose levels would
be below normal. C. trachomatis genital lesions are characteristically non-vesic-
ular. (Koneman et al., p. 1210)

43. A 20-year-old man with urethritis who had been treated with penicillin
returns to the outpatient clinic the following week. A possible cause of his
symptoms is Chlamydia trachomatis, which may be confirmed by

A. inoculating the specimen onto selective media

B. demonstrating inclusion bodies in the cell culture
C. performing a direct Gram’s stain for gram-negative rods
D. performing a blind passage of cells

The answer is B. The “gold-standard” technique for in-vitro isolation of C. tra-

chomatis is tissue culture. Many laboratories use the McCoy cell line. After
incubation for 48 to 72 h, the cell monolayer is stained with iodine or an
immunofluorescent stain. C. trachomatis-infected cell cultures are detected by
iodine or fluorescent stained inclusions. C. trachomatis usually cannot be visu-
alized by direct Gram stain. More recently, nonculture methods such as enzyme
immunassays, nucleic acid probes, and amplification methods for detection of
Chlamydia trachomatis are more commonly used. (Mahon, pp. 646-648)

44. You suspect a yeast isolated from a urine sample of a 25-year-old female
patient is Candida albicans. Which of the following is the test when posi-
tive that will presumptively identify your isolate?

. Hair penetration test

. Urease test
. Germ tube test
. Nitrate reduction
. Arthroconidia production on corn meal agar
mMmOoOaAwWS

The answer is C. Germ tube test is the most simple test commonly used to iden-
tify yeasts. C. albicans produces germ tubes when colonies are placed in serum
and incubated for two hours. C. albicans is negative for urea, nitrate reduction,
and does not produce arthroconidia. Hair penetration test is used to differentiate
dermatophytes. Urease test and nitrate reduction will be positive for Cryptococ-
cus species. Urea and production of arthroconidia as well as blastoconidia are
characteristics of Trichosporon beigelii. (Mahon et al., pp. 749-750)

45. A recently FDA-approved direct antigen test to detect Group A streptococ-

cus in throat samples shows a 90% sensitivity and 98% specificity. In a pop-
ulation with an estimated prevalence of 5%, the calculated positive predic-
tive value for this test is 70.3%. This means that
 CLS Review Questions 139

. the test is at least 70% accurate

. there is a 30% chance an individual may not have the disease
. 30% of the population tested will give a false negative result
. the test is positive in 70% of the population
. 70% of the population tested will give a false positive result
mOoawep

The answer is B. The positive predictive value of a test means that the probabil-
ity that in a positive result, there is a 70.3% chance the disease is present. This
also means that there is about a 30% chance the patient may not have the dis-
ease. (Mahon, pp. 121-124)

46. Falsely decreased zone diameters on a Kirby-Bauer agar disk-diffusion test

would most likely result from

A. an inoculum that is less turbid than a 0.5 MacFarland standard

B. use of disks with a higher-than-recommended concentration of antimi-
crobial
C. a 2-h delay in placing the antimicrobial disks on the seeded plate
D. a 2-h delay in incubating the plates after the disks have been applied

The answer is C. A 2-h delay in placing antimicrobial-containing disks on the

seeded plate would allow the organism to multiply before the antimicrobial is
applied. This factor will result in falsely small zone sizes. Other factors that may
cause falsely decreased zone size include the use of Mueller-Hinton agar at a
depth of greater than 4 mm, use of deteriorated disks, and an increase in the con-
centration of calcium or magnesium ions in the agar when testing Pseudomonas
>
aeruginosa with the aminoglycosides. The use of a mixed culture may also cause a
falsely small zones in cases in which one organism is sensitive to a drug, and the <
2
other organism is resistant. If the inoculum is too sparse, fewer organisms will 2
°he
result in falsely increased zone diameters. Using antimicrobial disks with Y
higher-than-recommended concentrations of antimicrobials enhances diffusion 2
and allows more organisms to be inhibited. Delaying more than 15 min after
disks are applied before incubating plates allows excess pre-diffusion of antibi-
otics. These factors result in falsely increased zone diameters. Other factors that
may produce falsely large zones include use of Mueller-Hinton agar thinner than
4 mm and too light an inoculum. (Murray et al., p. 1541)

47. In interpreting a minimal inhibitory concentration (MIC) by the macro-

broth-dilution method, you determine that the first test tube that shows vis-
ible turbidity has a final dilution factor of 1:32. Since twofold serial dilu-
tions are made from the working stock of 0.256 mg/mL, the MIC for this
isolate is

A. 4 pg/mL
B. 8 pg/mL
C. 16 pg/mL
D. 32 pg/mL

The answer is C. Since the MIC end point is the lowest concentration of the
antimicrobial at which no visible growth can be detected, the end point in this
problem is the 1:16 dilution. To calculate the concentration of antimicrobial at
this dilution, divide the stock concentration of 256 wg/mL by the dilution factor
of 16. Thus, the MIC is 16 pg/mL. (Forbes et al., pp. 253-255)
48. In a synergy study, when drug A, drug B, and drug A + B act singly and in
combination on a single population of growing bacteria in vitro, the type of
killing action signified is

A. antagonism
B. indifference
C. synergism
D. not determinable from this representation

The answer is B. This synergy study shows an indifferent effect, that is, the effect
of the combined therapy does not exceed the sum of the independent effects. The
purpose of synergy studies, which test the effect of combinations of antimicro-
bials on the rate of killing of microbes, is to determine if the two drugs in com-
bination are synergistic (the effect of the two drugs together is greater than the
sum of the effects of either drug alone), antagonistic (the combined drugs are less
effective than one of the drugs alone), or indifferent. Examples of the three types
of interactions are depicted in the following figure. (Mahon et al., p. 102)

SYNERGISM ANTAGONISM INDIFFERENCE

Control (no drug) Control (no drug) Control (no drug)
| | I | I | | | | | I |
co foe) co

=
i

foes eneacs a
PAL ee,
wee.=o xt
Drug E+F

organisms
viable
of
number
Log = == - -
OSS
_

Hours

(Used with permission from Mahon CR, Manuselis G. Textbook of Diagnostic Microbiology (2nd ed).
Philadelphia: W B Saunders, 2000, p. 102.)

49. In the Kirby-Bauer agar-disk diffusion susceptibility test, a steady decrease

in zone diameter of the methicillin disks obtained with the control organism
Staphylococcus aureus, ATCC 25923, may be due to the fact that the

A. S. aureus control strain is too old

B. methicillin disks were not stored frozen
C. pH of the agar is less than 7.2
D. Mueller-Hinton agar is too thick

The answer is B. A decrease in zone size with the control strain of S. aureus and
the methicillin disks indicates that the disks are no longer fully potent. This may
be due to improper storage conditions. Antimicrobial disk cartridges should be
stored appropriately to ensure that the drugs maintain their potency. For long-
term storage, disks should be stored at — 14°C or lower in non-frost free-freez-
ers. Other factors that cause disk deterioration are humidity and contamination.
(Mahon, p. 75)
 CLS Review Questions 141

50. “Clue cells” seen in a malodorous vaginal discharge are associated with a
diagnosis of bacterial vaginosis; vaginal culture typically shows a predomi-
nance of

A. Gardnerella vaginalis
B. Haemophilus ducreyi
C. Lactobacillus species
D. Streptococcus agalactiae

The answer is A. G. vaginalis serves as one indicator organism of the bacterial

vaginosis. Bacterial vaginosis, a syndrome that presents with a copious, foul-
smelling vaginal discharge also involves mixed anaerobic organisms. Presump-
tive diagnosis can typically be made by demonstrating a discharge pH greater
than 4.5, a “fishy” amine-like odor from addition of 10% potassium hydroxide
to the discharge, and clue cells on direct wet mount or Gram’s stain of the dis-
charge. Clue cells are squamous epithelial cells coated with tiny gram-variable
bacilli. Gram stain (not culture) is viewed to be the most reliable diagnostic lab
test for bacterial vaginosis. H. ducreyi is the etiologic agent of chancroid, which
displays with necrotic lesions. Lactobacillus species are normal female genital-
tract microflora. S$. agalactiae is carried in the vagina by many healthy females.
(Murray et al., p. 340)

References
Forbes BA, Sahmn DF, Weissfeld A. Bailey and Scott’s Diagnostic Microbiol-
ogy (10th ed). St. Louis: Mosby, 1998. >
a
Koneman, E, et al. Color Atlas and Textbook of Diagnostic Microbiology (10th 2
ed). St. Louis: Mosby, 1998. =
2
°i=
Mahon CR, Manuselis G. Textbook of Diagnostic Microbiology (2nd ed). —
Philadelphia: WB Saunders, 2000. =

Markell EK, et al. Medical Parasitology (8th ed). Philadelphia: WB Saunders,

1999.
Murray PR, Baron E, et al. Manual of Clinical Microbiology (7th ed). Washing-
ton DC: American Society for Microbiology, 1999.
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Immunology
Chapter Author Michelle S. Wright-Kanuth

CLT Review Questions

1. A patient presented with symptoms of pneumonia and a cold agglutinin titer

was performed. Doubling dilutions of patient serum were tested against
group O human red blood cells at 4°C, resulting in a reported titer of 256.
This result should be interpreted as

A. not clinically significant

B. significant for Mycoplasma pneumoniae
C. diagnostic of Mycoplasma pneumoniae
D. significant for Streptococcus pneumoniae

The answer is B. Individuals infected with Mycoplasma pneumoniae produce an-

tibodies against the human I blood group antigen, present on all normal adult cells.
The minimum clinically significant titer is 64. The cold agglutinin titer is not spe-
cific for M. pneumoniae; therefore, it is not diagnostic and must be interpreted in
the context of patient symptoms and clinical presentation. (Sheehan, pp. 272-273)

2. In performing a Davidsohn differential test, serum was absorbed with guinea

pig kidney cells, then reacted against sheep red blood cells. No agglutination
was seen. Serum was also absorbed with beef erythrocytes and then reacted
against sheep red blood cells. No agglutination was seen. This is indicative of

A. Forssman antibody
B. infectious mononucleosis
C. serum sickness
D. Paul-Bunnell antibody

The answer is C. The heterophile antibody produced in serum sickness reacts

with both beef erythrocytes and guinea pig kidney cells. Therefore, the antibody
was adsorbed onto the guinea pig kidney cells and none remained in the serum
to react with the sheep erythrocytes. Similarly, the antibody was absorbed onto
the beef erythrocytes and none remained in the serum to react with the sheep
erythrocytes. (Sheehan, p. 242)

3. In the RPR card test, the reagin antibody in the patient serum will react with
the antigen component

A. cardiolipin
B. cholesterol

143
 C. lecithin
D. charcoal

The answer is A. Reagin is an antibody that is formed against the lipid compo-
nents of the Treponema pallidum membrane. These lipid components are also
found on cardiolipin, which is used as part of the antigen in non-treponemal
tests. (Stevens, p. 235)

4. An RPR card test performed on a spinal fluid sample was nonreactive. The
physician was skeptical and asked for a repeat test of the spinal fluid. The
RPR result was reactive 1:1 dilution. The result

A. should be reported as nonreactive

B. should be reported as reactive 1:1 dilution
C. is inconclusive, and should be repeated on a new spinal fluid sample
D. is unreportable; the RPR card test should not be performed on spinal fluid

The answer is D. The RPR card test is not recommended by the CDC to test
spinal fluid. The VDRL is the method of choice. (Stevens, p. 236)

5. The results of a quantitative VDRL test are as follows:

ilell |g? 1:4 1:8 1:16
WR R R WR NR
This result is reported as
A. reactive, titer 4
B. reactive, titer 8
C. weakly reactive
D. weakly reactive, titer 16

The answer is A. The titer is reported when dilutions are performed in the VDRL
test. The titer is defined as the greatest dilution to yield a reactive result. Weakly
reactive sera are titered to eliminate errors due to prozone reactions as shown in
this example; however, a weakly reactive result is not considered when deter-
mining the titer endpoint. (Turgeon, p. 205)

6. Acommon test kit for rheumatoid factor (RF) contains a saline diluent, pos-
itive and negative controls, and an IgG-coated latex particle reagent. In this
procedure, which of the following statements is true?

A. A positive reaction is indicated by agglutination of the latex particles

B. RF inhibits the agglutination of the latex particles
C. The RF in patient serum primarily represents IgG immunoglobulin
D. The test is specific for rheumatoid arthritis

The answer is A. Most tests for RF are passive agglutination procedures in

which antigen (IgG) is linked to latex particles or sheep RBCs. Serologically de-
tectable RF, an IgM anti-IgG, will react with this IgG-particle complex. Specif-
ically, the RF in the patient’s serum combines through its Fab region to the Fc
region of the IgG molecule of the IgG-coated latex particle reagent. Since the
IgG is passively attached to latex, the latex particles will agglutinate. The test is
not specific. False-positives are seen in syphilis, lupus erythematosus, and other
diseases. (Sheehan, p. 290)
 CLT Review Questions 145

7. The results of an agglutination test for antibody detection using dilutions of

patient serum are shown below. What do the results in tubes 1 through 5 rep-
resent?

Mubeno. 1 2 3 4 5) 6 7 8 9
Dilution 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 Antigen control
Patient Ue Oe Om 0 OR of sp + 0
+ = agglutination; 0 = no agglutination

. Agglutination was prevented by lack of complement activation

. Prozone due to antigen excess
. Prozone due to antibody excess
GVaAWLY
. Technical error; these results cannot occur when the procedure is cor-
rectly performed

The answer is C. These results represent the classic prozone phenomenon due to
antibody excess. It is thought that excess of antibody relative to antigen prevents
lattice formation. (Sheehan, pp. 117, 129)

8. Which of the following statements is true regarding C-reactive protein

(CRP)?

A. CRP is an immunoglobulin
B. It can be elevated in postoperative patients
C. It remains elevated in the serum after an inflammatory response has sub-
sided
D. It is diagnostic for active rheumatic fever

The answer is B. CRP is not an antibody but a protein produced by the liver. It is
elevated when tissue injury occurs. The presence of CRP is not diagnostic for any
specific disease but indicates necrosis and inflammation of numerous origins. Thus,
CRP may be elevated postoperatively until inflammation has subsided. Although
small amounts of CRP are seen in healthy persons, it is elevated only during the
acute injury and disappears rapidly following recovery. (Sheehan, pp. 47-48)

9. Which of the following is most likely to be associated with a false-negative

urine pregnancy test performed by latex-particle agglutination immunoassay?

A. Choriocarcinoma
B. Hydatidiform mole
C. Presence of increased TSH in the patient urine Immun
D. Very early gestation

The answer is D. Human chorionic gonadotropin (hCG) levels detected in this

assay increase during the first trimester of gestation, peaking at about 70 days
after the last menstrual period. In very early pregnancy, levels of hCG double ap-
proximately every 2 days. Dilute urine may also cause false-negatives. Hydatid-
iform mole and choriocarinomas are associated with extremely high levels of
hCG. When assays for whole hCG are used, the alpha subunit of TSH (which is
identical to the alpha subunit of hCG) may cross-react in the assay and cause a
false-positive result. (Sheehan, pp. 158-159)

10. A modified Davidsohn’s differential rapid-slide test is set up as follows:

146 ‘5. mmunology

Left side: patient serum + guinea pig kidney reagent + horse cells
Right side: patient serum + beef erythrocytes + horse cells

The reactions appear as follows:

2
eo
NICS

ges
INS
ES

pee
LEO

These findings indicate:

A. Forssman antibody
B. infectious mononucleosis
C. normal serum
D. serum sickness

The answer is B. On the left side of the slide, the antibody in the patient’s serum
is not absorbed by guinea pig kidney. Therefore, the patient’s heterophile anti-
bodies are not neutralized and are available to react with the horse cells to give
agglutination. On the right side of the slide, the antibody in the patient’s serum
is absorbed by beef erythrocytes. Therefore, no antibody is left to react with
horse cells, and no agglutination occurs. This is the expected reaction in infec-
tious mononucleosis. (Sheehan, p. 242)

11. A rubella antibody titer is to be performed. Doubling dilutions of the pa-

tient’s serum are made in saline, with the first tube containing 0.2 mL of
serum and 0.2 mL of saline, continuing through tube 10. Rubella antigen is
added in a constant amount, negligible to the serum dilution. At this point,
0.3 mL of a 2% suspension of RBCs is added to each tube. What is the final
serum dilution, after the addition of the red cells, in the third tube?

AS ls
Bees
(Or TEES)
D. 1:20

The answer is D. The initial dilution in the third tube is made by adding 0.2 mL
of saline to 0.2 mL of the 1:4 dilution from the second tube, for a 1:8 dilution.
Since the dilutions continue, 0.2 mL of the 0.4 mL in the third tube is removed,
leaving 0.2 mL of a 1:8 dilution in the tube. When 0.3 mL of RBCs are added,
the new total volume in the tube is 0.5 mL. Since we are determining the dilu-
tion of the serum, the volume of the serum (0.2 mL) is divided by the total vol-
ume (0.5 mL) and multiplied by the initial dilution in the tube. 0.2/0.5 or 2:5
times 1:8 equals 2:40 or 1:20. (Stevens, pp. 7-8)

12. A cold agglutination titer is performed. The results are as follows:

 CLS Review Questions 147

Dilution ito et 1:8 1:16 132. 1:64 1:128

Patient 4+ 4+ 3+ 1+ 1+ 0 0)
The patient’s titer is
A. 8
B. 16
Cc. 32
D. 64

The answer is C. The end point of the cold agglutinin titer is the greatest dilu-
tion to show agglutination. Cold agglutinin titers must be confirmed by reversal
of agglutination upon warming. (Sheehan, pp. 272-273)

CLS Review Questions

1, While reading a radial immunodiffusion (RID) plate, the CLS notices that
one well has an irregularly shaped area of precipitation around one side. The
most likely explanation for this result is

A. a high concentration of antigen in the sample

B. uneven distribution of monospecific antibody in the agarose
C. the well was not filled with sample
D. the well was nicked when filled with sample

The answer is D. If the well is nicked when filled, an irregulary shaped precip-
itin ring will form after incubation where the nick occurred. (Sheehan, p. 121)

2. In a serum immunoelectrophoresis, the precipitin arc formed for IgM is

close to the trough. This indicates

A. high concentration of IgM in the test serum

B. low concentration of IgM in the test serum
C. the presence of monoclonal IgM
D. the test should be repeated; the electric current was inadequate
>
The answer is A. The closer the arc is to the trough, the higher the concentration a
Le
of the immunoglobulin being measured in the test serum. Since the anti-IgM in )
<
the trough and the IgM in the electrophoresed sample are diffusing in all direc- |
tions, including toward one another, the precipitin arc will form at the zone of E
equivalent concentrations. The reactant of higher concentration, in this case the E
serum IgM, will diffuse farther before becoming dilute enough to equilibrate
with the anti-IgM and form a precipitin arc. Thus, the arc will form closer to the
trough containing the reactant of lesser concentration, the anti-IgM. (Turgeon,
pp. 141-143)

3. Which of the following is characteristic of the Laurell or rocket technique

of one-dimensional electroimmunoassay?

A. Antigen is moved by electrophoresis rather than by diffusion

B. Lines of identity and nonidentity can be distinguished easily
C. It is performed in test tubes and similar to the Oudin test
D. It is a qualitative rather than quantitative test
AS 3. Immunology

The answer is A. In rocket electroimmunoassay, the antigen is placed in a well,

and antibody is incorporated into the agar. Current is then applied, moving the
antigen by electrophoresis through the agar. Precipitation occurs along the edges
of the antigen trail, resembling a rocket. The length of the rocket is directly pro-
portional to the antigen concentration in the sample tested. (Sheehan, p. 124)

4. A Western-blot assay to detect HIV antibodies is performed according to es-

tablished laboratory procedure. All controls are acceptable. The patient sam-
ple exhibits a p24 band only. The result that should be reported is

A. positive for HIV

B. negative for HIV
C. indeterminate result; repeat assay
D. false-positive for HIV; investigate for anti-HLA antibodies

The answer is C. The CDC recommends that sera exhibiting antibody bands to
at least two of the following should be reported as positive: p24, gp41, gp120,
gp160. A negative report should only be made when no bands appear. If a single
band appears, the result is indeterminate, and the patient should be retested in 6
months to allow for the possibility that the patient was in an early stage of in-
fection. (Stevens, pp. 288-289)

5. A 25-year-old female suffering from systemic lupus erythematosus (SLE)

and an ear infection is tested for syphilis using the RPR card test. The result
is reactive; however, the patient denies any sexual activity. A repeat test 8
months later is still reactive although the ear infection has resolved. The
most likely explanation for these results is

A. chronic biological false-positive due to SLE

B. the patient has pinta or yaws
C. the syphilis is in the incubation period
D. transient biological false-positive due to the infection

The answer is A. Systemic lupus erythematosus, an autoimmune connective-tis-

sue disease, is known to commonly cause chronic biological false-positive re-
sults in reagin tests lasting 6 months or longer. It is possible that the ear infec-
tion could cause a transient false-positive; however, false-positives due to
infections rarely last more than 6 months. (Stevens, p. 237)

6. The results of a quantitative VDRL are reported to the physician as reactive,

undiluted only. The results were recorded in the laboratory as follows:
ei 12 1:4 1:8
WR NR NR NR
The supervisor checking the day’s results should
A. change the report to weakly reactive
B. change the report to nonreactive
C. confirm the report as stated
D. perform a qualitative RPR test

The answer is A. The results have been incorrectly reported. Specimens that ex-
hibit only weak flocculation are reported as weakly reactive unless a prozone re-
action has been demonstrated. (Turgeon, p. 203)
 CLS Review Questions 149

7. The results below represent a viral hemagglutination-inhibition test for

rubella. The titer of the first tube is 1:10; doubling dilutions are used there-
after. What interpretation of the results can be made?

Tube no. La 2a ere 5) 6 Ts 9 10

virus serum RBC
control control control
Result OPeOr OO. toe ee 0 0
+ = agglutination; 0 = no agglutination

The results are

A. invalid due to the virus control pattern and should not be reported
B. invalid due to the serum control pattern and should not be reported
C. valid; a titer of 160 should be reported
D. valid; a titer of 320 should be reported

The answer is C. For this hemagglutination-inhibition test, the serum is diluted

as 1:10, 1:20, 1:40, etc. A constant amount of virus preparation is added, fol-
lowed by indicator red cells. The cells settle, and the pattern of sedimented cells
is read. The end point is the highest dilution of serum that will inhibit hemag-
glutination by the virus. All controls are valid; the virus control (containing no
serum) shows hemagglutination; the serum control (containing no virus) shows
that the serum used had no antibodies to RBCs; the RBC control contains only
RBCs and shows no spontaneous agglutination. The end point of the test is tube
5, representing a titer of 160. (Sheehan, p. 233)

8. A latex-agglutination test is set up to titer rheumatoid factor. The positive

control is acceptable and the antigen control shows no agglutination. The
patient serum has been diluted 1:20 in the first tube and in doubling dilu-
tions thereafter. The patient’s results are shown below:

The results should be interpreted as

A. invalid and should not be reported

B. a titer of 320
 C. a titer of 640
D. a titer of 1,280

The answer is C. The controls are all acceptable and the end point is seen in tube
6 of the photograph. Since the dilution in tube 6 is 1:640, the titer is the recip-
rocal of that dilution, or 640. (Turgeon, pp. 119-120)

9. An antinuclear antibody screen exhibits diffuse, peripheral, and coarse-speck-

led fluorescence. All of the controls are acceptable. No other samples tested
in the same run exhibit multiple patterns of fluorescence. The CLS should

A. concentrate the sample exhibiting multiple patterns and reassay

B. dilute the sample in question and reassay
C. report the types of fluorescence seen; this is not unusual
D. run an LE prep to confirm

The answer is C. Multiple ANAs are not unusual in many patients with rheu-
matic conditions. An LE prep is a less sensitive test than the ANA and is not used
as a confirmatory procedure. (Sheehan, pp. 285-286)

10. An indirect fluorescent assay for Toxoplasma gondii is performed using

commercially prepared T: gondii slides as the substrate. The test serum
shows strong green peripheral staining under the fluorescent microscope.
This should be interpreted as

A. negative
B. 1+
C. 4+
D. inconclusive

The answer is C. Strong apple-green fluorescence along the edge of the substrate
organism is considered to be a 4+ result. No fluorescence is negative, and 1+ flu-
orescence would appear as a weak apple-green color around the edge of the or-
ganism. (Turgeon, p. 291)

11. A beta-subunit RIA test for human chorionic gonadotropin (hCG) yields a
result of 615 mIU/mL. The patient’s last menstrual period was 10 weeks
ago. This is indicative of

A. choriocarcinoma
B. ectopic pregnancy
C. hydatidiform mole
D. normal intrauterine pregnancy

The answer is B. Low levels of hCG during the first trimester are indicative of
ectopic pregnancy. Levels of hCG in normal pregnancy peak at 70 days after the
last menstrual period at a level of about 100,000 mIU/mL, then decline to levels
of between 10,000 and 20,000 mIU/mL at 15-16 weeks of gestation, remaining
at that level throughout the 2nd and 3rd trimesters. Choriocarcinoma and hyda-
tidiform mole are trophoblastic tumors that secrete large amounts of hCG, usu-
ally > 5,000 mIU/mL. (Sheehan, pp. 158-159)

12. A qualitative, enzyme-linked immunosorbent assay (ELISA) was performed

as follows:
 CLS Review Questions 151

. Add patient serum to an antigen-coated microtiter well

. Incubate
Wash
. Add horseradish peroxidase-labelled antihuman globulin
. Incubate
. Add peroxide and chromagen
WN
YANK
. Stop the reaction
The resulting color development was extremely intense because
A. incorrect substrate was added
B. the patient’s serum contained a large amount of antibody
C. the patient’s serum contained a small amount of antibody
D. a step in the procedure was not performed

The answer is D. In ELISA procedures, a washing step must follow each reagent
addition to remove unbound reagent. Failure to wash after step 5 results in no
separation of bound from free reagent; therefore, falsely elevated values are ob-
tained. Since the color development is directly proportional to the amount of
bound reagent, intense color would be seen in this case. (Sheehan, pp. 151-154)

13. An anti-DNase-B neutralization test was performed on the serum of an

acutely ill 24-year-old female. The titer was 120. Two weeks later, a conva-
lescent serum was obtained and tested by the same method in parallel with
the acute specimen. The convalescent titer was 240; the titer on the acute
specimen was again 120. These results indicate that the patient

A. has not had a recent infection with group A streptococcus

B. has had a recent group A streptococcal infection
C. is at risk for severe poststreptococcal glomerulonephritis
D. suffers from streptococcal pyoderma

The answer is A. The patient has exhibited less than a fourfold rise in titer be-
tween the acute and convalescent specimens; a fourfold rise in titer is indicative
of a recent infection with group A streptococcus. A fourfold increase is needed
to detect a significant change in the antibody level. A twofold increase is a one
tube difference and can be expected to be within the error of the method. (Shee-
han, p. 211)

14. In an ASO test, the streptolysin-O control tube demonstrates no lysis. What
might be the effect on the results of the test?
Immu
A. Falsely elevated values
B. Falsely decreased values
C. No effect, since the end point is read as the highest dilution demonstrat-
ing hemolysis
D. No effect, since all tubes would be equally affected

The answer is A. The principle of the ASO test is as follows: streptolysin-O

causes the lysis of erythrocytes. In the presence of a neutralizing antibody
(ASO), however, hemolysis of cells is inhibited. The end point of the test is read
as the greatest serum dilution showing no hemolysis. The absence of hemolysis
in the streptolysin control tube indicates inactivation of the reagent. Thus, a
falsely elevated value will be obtained, since the reagent streptolysin-O is not ef-
fective in hemolyzing erythrocytes. (Sheehan, pp. 209-210)
492 2-_Immunology

15. A heterophile differential-absorption test was performed on serum from a

patient suspected of having infectious mononucleosis. The patient serum re-
acted with horse RBCs initially and after absorption with beef erythrocytes,
but not after absorption with guinea pig kidney cells. This result is consis-
tent with the presence of

A. Forssman antibodies
B. infectious mononucleosis antibodies
C. Mycoplasma-associated cold agglutinins
D. serum-sickness antibodies

The answer is A. The heterophile antibody known as the Forssman antibody re-
acts with beef erythrocytes and horse erythrocytes. Therefore, when the serum
is absorbed with beef erythrocytes, the Forssman antibody attaches to these cells
and is not available in the serum to react with the horse erythrocytes. (Sheehan,
pp. 241-242)

16. One mL of patient serum is added to 2 mL of saline in a test tube labeled

tube 1. A total of 5 tubes are set up, with 1.5 mL of saline added to tubes 2
through 5. Next, 0.5 mL of the serum dilution from tube | is transferred to
tube 2, mixed, and 0.5 mL is serially transferred to the remaining tubes.
What is the dilution in tube 3?

Aw:3
Balai?
Cale 24.
D. 1:48

The answer is D. The volume of the serum in tube | is divided by the total vol-
ume in tube 1, so the initial dilution is 1 divided by 3, or 1:3. Since 0.5 mL is
then added to tube 2, the new dilution in tube 2 is 0.5 divided by the total vol-
ume in tube 2, which is now 2 mL (0.5 mL + 1.5 mL). The new dilution in tube
2 is 1:4. The new dilution must then be multiplied by the initial dilution, because
we now have a 1:4 dilution of the 1:3 dilution in tube 1; so, 1/3 X 1/4 = 1/12,
or 1:12. We again make a new 1:4 dilution in tube 3 (0.5 mL from tube 2 + the
1.5 mL saline). Since we have made a 1:4 dilution of the 1:12 dilution in tube 2,
our dilution in tube 3 is 1/4 X1/12 = 1/48, or 1:48. (Stevens, pp. 7-8)

17. The following results are seen in an antistreptolysin-O (ASO) test on serum
from a 35-year-old male. The red cell control shows no lysis, and the strep-
tolysin control shows total hemolysis. The positive serum control is ex-
pected to be 333 Todd units.

Tube no. 1 Dy 3 4 5) 6 7 8 9
Positive contol NH NH NH NH NH TH TH TH _ TH
Patient Wish Iie INdsl INSEL Sue NEL SE EL = TET
Todd units LOQY 123.5 ¢lGG) 2250 3335 2500 e625) 83s) ele)
NH = no hemolysis; SH = slight hemolysis; TH = total hemolysis

What conclusion can be drawn from this result?

A. The patient’s ASO titer is within the normal range for an adult
B. The patient’s ASO titer is elevated, suggesting a recent group A strepto-
coccal infection
 CLS Review Questions 153

C. The results are invalid due to partial hemolysis in some tubes

D. The results are invalid due to the control results

The answer is B. The titer is the unit of the highest dilution (last tube) showing
no hemolysis, or 250. Low ASO titers are seen in the majority of the population,
but the normal level varies widely with age and geographic locale. Levels for
preschool youngsters and mature adults are generally less than 100 Todd units,
whereas school-age children, teenagers, college students, and members of the
armed services have slightly higher levels (e.g., 166 Todd units). It is important
to remember that a low titer may be normal and that regional and hospital norms
exist. Acute and convalescent ASO titers are desirable for good diagnostic
workups. Significant elevations of titer (250 Todd units or greater) are indicative
of recent group A streptococcal infection. The control results are acceptable, and
slight hemolysis can occur in some tubes (i.e., tubes that are between those
showing no hemolysis and those showing total hemolysis). (Sheehan, pp.
209-210)

18. A fluorescent label commonly used in flow cytometric analysis is

A. auramine
B. Giemsa
C. phycoerythrin
D. Romanowsky

The answer is C. The commonly used fluorescent labels in flow cytometry in-
clude fluorescein isothiocyanate, phycoerythrin, and rhodamine. (Sheehan, p.
164)

19. In a radial immunodiffusion test for IgG, the results on the standards tested
were as follows:

Standard IgG concentration (mg/dL) Ring diameter (mm)

1 2,300 10
2 1,000 6
3) 250 2
>
If a patient sample was tested on the same plate and had a ring diameter of a
2
12, the CLT should °
¢
3
. dilute the patient serum with saline and run it again E
. extrapolate from the highest standard and report the result g
. report the IgG concentration of the patient as > 2,300 mg/dL
S . divide the ring diameter of 12 by 2 (resulting in 6 mm), read the con-
GaAs
centration from the standard curve and double the result, and report the
patient result as 2,000 mg/dL

The answer is A. When the patient sample yields a precipitin ring with a diam-
eter greater than that of the highest standard tested, the patient sample should be
diluted 1:2 with normal saline and reassayed. The result in mg/dL must then be
multiplied by the dilution factor (e.g., 2) and reported. (Sheehan, p. 121)

20. A serum immunoelectrophoresis shows a dense, circular, sharply peaked arc

when reacted with IgG antiserum. This indicates
154 5. Immunology

. an incorrect antigen/antibody ratio in the test system

. increased polyclonal IgG in the patient serum
. amonoclonal IgG in the patient serum
SYS
Daw. the presence of kappa light chains

The answer is C. Normal polyclonal IgG produces a rounded elliptical arc. Mon-
oclonal proteins, in this case IgG, produce circular, sharply peaked arcs. The in-
tensity of the band indicates the concentration of protein, not the clonality. (Tur-
geon, pp. 142-143; Sheehan, pp. 122-123)

21. A patient’s serum sample is reactive at the 1:8 dilution when tested with the
RPR card test. An FTA-ABS was subsequently performed according to the
established laboratory protocol, which required heat inactivation of the
serum and adsorption with the sorbent, yielding a 1:5 patient-serum dilution.
The patient sample was nonreactive at the 1:5 sorbent dilution, and controls
were satisfactory. The most likely explanation for this discrepancy is

A. a biological false-positive reaction in the RPR

B. a false-negative reaction in the FTA-ABS due to increased sensitivity
C. the patient serum should also be run undiluted in the FTA-ABS
D. the patient serum was not inactivated before performing the RPR

The answer is A. The FTA-ABS is a more specific confirmatory test, most often
run when a positive RPR screening test result is obtained. There are many causes
of biologically false-positive RPRs. The 1:5 dilution of the sorbent is correct,
and undiluted serum is not tested in the FTA-ABS. The protocol for the RPR
card test does not include heat inactivation of the patient serum, since the addi-
tion of choline chloride replaces this step. (Sheehan, pp. 217-219)

22. A 32-year-old white female presents with signs suggestive of systemic lupus
erythematosus (SLE). The antinuclear antibody (ANA) screen by indirect
immunofluorescence shows many evenly distributed spots of fluorescence
over the entire nucleus. Which antibody is most likely present in the pa-
tient’s serum?

A. Anti-dsDNA
B. Anti-DNP
C. Anti-histone
D. Anti-Sm

The answer is D. Anti-Sm is the only antibody listed that fluoresces in a speck-
led pattern. Anti-histone fluoresces in a homogeneous pattern. Anti-DNA and
anti-DNP yield either homogeneous or peripheral fluorescence patterns. (Shee-
han, pp. 285-289)

23. In an immunoassay, serum is added to a microtiter well coated with specific

antibody. After incubation and washing, enzyme-labelled specific antibody
is added. This procedure is

. a competitive-binding immunoassay
. an enzyme-multiplied immunoassay
. a homogeneous immunoassay
. a sandwich immunoassay
DaAmS
 CLS Review Questions 155

The answer is D. The specific antibody that coats the well is used to capture any
corresponding antigen in the serum. Unreacted serum components are washed
away. Then the enzyme-labelled specific antibody will bind to the captured anti-
gen, sandwiching it between unlabelled and labelled antibody. The enzyme ac-
tivity is then measured and is directly proportional to the amount of captured
antigen. (Sheehan, pp. 150-151)

24. In an enzyme-multiplied immunoassay (EMIT), the patient sample showed

high levels of enzyme activity. This indicates the presence in the patient
serum of a

A. high concentration of the antigen being measured

B. high concentration of the antibody being measured
C. low concentration of the antigen being measured
D. low concentration of the antibody being measured

The answer is A. The concentration of the antigen being measured in the test is
directly proportional to the level of enzyme activity measured in the test system.
(Sheehan, p. 154)

25. On an Ouchterlony double diffusion plate, 2 wells are filled with antigen
and one well is filled with antibody. If the antibody reacts with both anti-
gens and the antigens are identical, the precipitin line will be

A. smooth and continuous between the antigen wells and the antibody well
B. crossed, forming a double spur
C. a Y-shaped single spur
D. straight across above the antibody well

The answer is A. A line of identity is a smooth continuous line between the an-
tibody well and the antigen wells, forming an arc around the antibody well.
(Sheehan, p. 119)

26. A latex agglutination test for C-reactive protein is performed. The patient
>
serum is tested undiluted and at a 1:5 dilution. The undiluted sample shows a
no agglutination. The 1:5 diluted sample is agglutinated strongly. This dis- 2
re)
crepancy is most likely due to c
3
E
A. bacterial contamination of the sample cS
B. reaction time longer than 2 minutes
C. prozone reaction
D. improper dilution technique

The answer is C. False-negative results may be seen in undiluted serum samples

when the patient has very high levels of CRP, resulting in antigen excess in the
test system and causing the prozone phenomenon. The 1:5 dilution is routinely
tested to detect this problem. (Stevens, pp. 53-55)

27. A complement fixation assay for cryptococcal antibody is performed. The

antigen control, patient control, and complement control all show hemoly-
sis. The cell control is not hemolyzed. Patient results are as follows:
156 5. Immunology ee

Dilution i129) 1:4 1:8 1:16 1232 1:64

Patient NH NH NH NH SH H
NH = no hemolysis; SH = slight hemolysis; H = hemolysis

The results should be reported as

A. titer = 16
B. titer = 32
C. titer = 64
D. invalid; the cell control should have been hemolyzed

The answer is A. The endpoint of complement fixation tests is the highest dilu-
tion showing no hemolysis. All controls are reacting as expected. (Stevens, p.
103)

28. An HIV patient is to be tested for total T cells, CD4 cells and CD8 cells by
flow cytometry. The gating tube would be prepared by staining cells with
fluorescent-labelled antibodies detecting

A. CD 45 and CD16
B. CD4 and CD8
C. CD14 and CD45
D. CD3 and CD5

The answer is C. CD14 is a monocyte marker and CD45 is a pan-leukocyte

marker. These markers are used to find the monocyte and lymphocyte popula-
tions in the patient cell preparation. Gating is used to determine where the ma-
jority of cells of each population occur in the dot display on the cytometer grid,
based on size and granularity. (Sheehan, pp. 180-183)

29. A polymerase chain reaction is to be performed to amplify Borrelia burgdor-

feri DNA in a sample. The CLS adds the DNA polymerase, ATP, GTP, CTP, and
TTP to the test system and begins the cycling. When the sample is analyzed, no
B. burgdorferi DNA is found. This can be explained by the fact that

A. no B. burgdorferi DNA was present in the original sample

B. no DNA primers were added to the test system
C. no reverse transcriptase was added to the test system
D. uracil triphosphate was missing from the test system

The answer is B. DNA primers are required for DNA polymerase to elongate
DNA during the replication process. The target DNA may have been present but
could not be replicated for detection without the primers. (Sheehan, p. 194)

30. A patient serum was tested for HbsAg, anti-HBc, and anti-HBs by compet-
itive binding ELISA assays. The patient was negative for HbsAg and posi-
tive repeatedly for anti-HBc and anti-HBs. These results indicate that the
patient is

. immune to HBV
. actively infected with HBV
. infected with both HBV and HCV
a . a chronic HBV carrier
wen
 CLS Review Questions 157

The answer is A. The presence of both anti-HBc and anti-HBs in the serum in-
dicate immunity to HBV. Active infection is indicated by the presence of HbsAg
in the serum. Anti-HBc in the serum in the absence of anti-HBs indicates a
chronic carrier state or the late stage of active infection. (Sheehan, pp. 251-252)

References
Sheehan C. Clinical Immunology: Principles and Laboratory Diagnosis (2nd
ed). Philadelphia: Lippincott Williams & Wilkins, 1997.

Stevens CD. Clinical Immunology and Serology. A Laboratory Perspective.

Philadelphia: FA Davis, 1996.

Turgeon ML. Immunology and Serology in Laboratory Medicine (2nd ed). St.
Louis: Mosby, 1996.
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Laboratory Practice
Chapter Author Scott E. Aikey

CLT Review Questions Contributors

Kathleen Beach
1. How should hydrochloric acid burns of the skin be treated? Jimmy L. Boyd

A. Flush with copious amounts of water Virginia Emmons

B. Flush with 10% sodium hydroxide and copious amounts of water Brenda N. Galloway
C. Flush with 5% ammonium hydroxide and copious amounts of water Mary M. Gourley
D. Rush the victim to the nearest emergency facility William H. Hunt
The answer is A. For chemical burns of the skin, wash away the chemical with Mary Ann McLane
large amounts of water, using a shower or hose as quickly as possible and for at Stacey Pastore
least 5 min. Remove the victim’s clothing from the areas involved. (Linne et al.,
p. 34)

2. Which of the following procedures is most basic and effective in preventing

the spread of infectious diseases in the hospital environment?

A. Wearing face masks and gloves in the presence of patients

B. Wearing laboratory coats in patient rooms
C. Wearing laboratory coats in the laboratory
D. Washing hands between each patient contact

The answer is D. It has been said that soap, water, and common sense are the
best disinfectants. Although laboratory coats, masks, and gloves have their place
and are important in certain situations, the single most effective means of re-
ducing nosocomial infections is frequent and thorough hand washing between
patient contacts. (Garza et al., pp. 112-113)

3. Which of the following has the highest incidence of infectious risk in the
clinical laboratory?
c)
iEe)
A. Hepatitis U
Le}
B. Infectious mononucleosis .
he

C. Acquired immunodeficiency syndrome (AIDS) Pa]

i“
D. Rubella fe)
rw)
6
hen

The answer is A. Viral hepatitis is the leading cause of laboratory-acquired in- °

Re}
fections. Human blood can transmit a number of infectious diseases such as hep- Li}
|

atitis and AIDS and should be treated as a potentially infectious material. The
risk of infection is directly related to the degree of contact with contaminated

159
160 6. Laboratory Practice

blood. Infection with the AIDS virus, HIV, has grave consequences, but the oc-
currence of hepatitis B is more common and hence the leading infectious risk in
the clinical laboratory. (Linne et al., p. 27)

4. Which of the following do: s the most to minimize aerosol production dur-
ing centrifugation?

A. Using a refrigerated centrifuge

B. Using centrifuge tubes with tapered bottoms
C. Selecting centrifuge tube sizes that will fit securely into the centrifuge rack
D. Using stoppered centrifuge tubes or a cover over the rotar chamber

The answer is D. Specimen-collection tubes should be left stoppered for cen-

trifugation; if need arises to centrifuge an unstoppered tube, it should be covered
with Parafilm or fitted snugly with a stopper. Alternately, a centrifuge with a
rotar-chamber cover will contain any aerosols. (Burtis et al., pp. 18-19, 54)

5. A laboratory fire ignited by faulty wiring in a chemistry analyzer and par-

tially fueled by surrounding paper products is classified as

A. Class B
B. Class C
C. Class A and B
D. Class A and C

The answer is D. Paper and other ordinary combustibles constitute a class-A fire
when ignited, and the burning-energized electric equipment characterizes a
class-C fire. The situation described above is a combination class-A and -C fire.
(Burtis et al., p. 38)

6. Which of the following has been prohibited from use on anything other than
a temporary basis in the clinical laboratory?

A. Power strips
B. Portable floor fans
C. Extension cords
D. Multi-outlet boxes

The answer is C. In 1980, the National Committee for Clinical Laboratory Stan-
dards (NCCLS) standard on power requirements for clinical laboratories pro-
hibited the use of extension cords except under certain temporary conditions. In
such cases, cords must be less than 12 feet long, single-outlet, at least 16 AWG
wire, and UL-approved. (Burtis et al., p. 38)

7. The coefficient of variation is the

A. square root of the variance from the mean

B. standard deviation expressed as a percentage of the mean
C. sum of the squared differences from the mean
D. confidence interval of the mean

The answer is B. The coefficient of variation (CV), or relative standard devia-

tion, is a statistical tool used to compare variability in nonidentical data sets. To
 CLT Review Questions 161

do this, the variability in each data set must be expressed as a relative rather than
absolute measure. This is accomplished for each data set by expressing the stan-
dard deviation as a percentage of the mean:

CV = SD/ Mean

The CV of each data set allows comparison of two or more test methods, labo-
ratories, or specimen sets. (Burtis et al., p. 390)

8. The term that means reproducibility among replicate determinations of a

sample is

A. accuracy
B. precision
C. reliability
D. standard deviation

The answer is B. Precision refers to the magnitude of the random errors and the
reproducibility of the measurements. The precision of a clinical method is meas-
ured by its variance or standard deviation. The smaller the variance, the greater
the precision; if two methods are being compared, the method with the smaller
variance is more precise. (Burtis et al., p. 511)

9. Which of the following statements is a description of a reference interval?

A. 95% of the quality control specimens for an albumin method are ex-
pected to give a value from 2.6—3.7 mg/dL
B. Two methods for sodium, when compared, have a correlation coefficient
of 0.976
C. Analysis for creatine kinase from 95% of patients without muscle cell
damage will show results from 15-160 U/L
D. The predictive value of the assay for prostate specific antigen is 59.4%
when sensitivity is 79%, specificity is 46%, and disease prevalence is
0.5%

The answer is C. “Reference interval” is the term used to describe that range of
values for an analyte obtained in a healthy population. It is obtained by analyz-
ing specimens from at least 40 healthy individuals and calculating the result’s
mean and 2 SD values. Each laboratory must establish reference intervals for
each analyte tested, based on the population served by the facility. It may also
be necessary to establish ranges specific for certain age groups and for males/fe-
males. (Bishop et al., p. 68)

x7)
10. Which of the following would be included as a pre-analytical factor of lab- 2
he
U
oratory testing? 6
ih
a.
Pa)
A. Centrifuge speed and time used to prepare patient sera Be
ie)
B. Frequency of calibration of micropipets ~~
©
C. Storage temperature of reagent packs used for instrument
“
°
2
D. Establishment of 95% confidence limits for quality control decisions ©
al

The answer is A. Pre-analytical factors include all aspects of patient sample col-
lection, transport, separation, aliquotting, and storage. Any deviation from es-
tablished protocols may render a patient specimen less than optimal for analyti-
cal testing. Considerations for the actual testing method (including instrumenta-
tion and reagents) are analytical factors, consisting of the recording and report-
ing of patient data to the healthcare provider. (Bishop et al., pp. 79-81)

11. Which of the following statistics is determined by the formula shown

below?

/X (X — X)?
n-1
A. Mean
B. Standard deviation
C. Variance
D. Confidence limits

The answer is B. The standard deviation is an attempt to represent a true or re-

producible measure of dispersion in quantitative determinations. The first step is
to note the amount by which the individual measurements differ from the mean
and to calculate the average of these deviations. The deviations are squared to
eliminate negative signs. The result to this point is called the variance, or the
square of deviations. We then take the square root of the variance to convert the
statistic to a workable form. The positive square root of the variance is known
as the standard deviation. (Campbell, p. 307)

12. A control has a mean of 5.5 with a standard deviation of 0.5. If the labora-
tory is using a 95% confidence interval, the control values must fall between

A. 4.5 to 6.5
B. 5.0 to 6.0
C. 4.0 to 7.0
D.25.0:10,6.5

The answer is A. A confidence limit or confidence interval of 95% is equal to the

mean plus or minus 2 SDs. In this case it is equal to 5.5 + 1 or 4.5 to 6.5. (Linne
et al., p. 198)

13. Storage of computer data may be done

A. with magnetic disc or tape

B. on a cathode ray tube (CRT)
C. in the central processing unit (CPU)
D. on a video display terminal (VDT)

The answer is A. Both a CRT and a VDT allow the operator to visualize the data
as they are entered. A CPU is the computer chip through which all data flow be-
fore they are stored. The principal means of storing data is on magnetic disc or
tape. Data retrieval is faster from disc than it is from tape. (Snyder et al., p. 332)

14. The term computer software consists of

A. the program and operating system

B. memory, program, and printout
 CLT Review Questions 163

C. CPU and program

D. all the data stored in volatile memory

The answer is A. Software is the part of the computer system you cannot touch.
Software gives the computer instructions as to how to carry out different tasks.
It consists of programs and the operating system. (Snyder et al., pp. 328-329)

15. An example of a post-analytical function of a laboratory information system

is which of the following?

A. Delta checking
B. Laboratory report production
C. Order entry of tests
D. Patient identification

The answer is B. The end product of the work performed in the laboratory is the
laboratory report—a post-analytical function. Delta checking is an example of
an analytical function; order entry of tests and patient identification are exam-
ples of pre-analytical functions. (Linne et al., pp. 220-221)

16. The Clinical Laboratory Improvement Amendments of 1988 require that

personnel be assessed

A. quarterly
B. semi-annually
C. annually
D. bi-annually

The answer is C. CLIA 88 requires that employers assess the competency of em-
ployees at least annually. (Snyder et al., p. 30)

17. A clinical laboratory technician determines that a minimum of 85 mL of

working reagent is needed for a procedure. To prepare a 1:5 dilution of
reagent from a stock solution, one should measure

A. 15 mL of stock solution and dilute to 85 mL

B. 20 mL of stock solution and dilute to 100 mL
C. 25 mL of stock solution and dilute with 125 mL
D. 30 mL of stock solution and dilute with 125 mL

The answer is B. Dilution usually refers to the volume of concentrate in the total
volume of final solution. If 20 mL of the stock are diluted to a total volume of
100 mL, then 20 mL/100 mL = 1/5. (Campbell, p. 91)
v
=r=)
18. 11.0 mg/dL of serum calcium is equivalent to which of the following? VU

(Atomic weight of Ca = 40.) ©

h
a
Pal
A. 2.6 mmol/L
tJ
ie)
~
B. 2.75 mmol/L 6
h
ie)
C. 2.9 mEq/L 2
Dy 3s) mba L ©
al

The answer is B. Convert the weight per volume to weight per liter of solution.
The weight per liter is divided by the atomic weight of the ion being calculated.
 11 mg/dL = 110 mg/L
.040 g/L = 1 mmol Ca
110/.040 = 2.75 mmol/L

(Campbell, p. 136)

19. What is the correct formula to convert degrees Fahrenheit to degrees centi-
grade?

A. 5/o °F + 32)
B. */y (°F — 32)
CH CE 4892)
D. %/; CF — 32)
The answer is B. The centigrade scale is divided into 100 degrees and is the unit
in which most scientific study is expressed. (Campbell, p. 75)

20. To properly use a volumetric pipet calibrated “to deliver” (TD), one should

A. wipe the outside following delivery of the contents

B. drain the contents but do not blow out
C. rinse out the contents several times
D. drain the contents to the lowest etched mark on the volumetric pipet

The answer is B. The volumetric pipet is designed to deliver a fixed volume of

liquid with the greatest accuracy and precision. The tip of the pipet is tapered to
slow the flow of liquid to reduce drainage error. When the liquid has ceased to
flow, the tip of the pipet is touched to the inner surface of the container and the
residual fluid is allowed to flow out by capillary action. Any remaining liquid
should not be blown out. (Linne et al., pp. 123-124)

21. Chemicals such as sodium hydroxide and sulfuric acid should be labeled

A. poison
B. corrosive
C. biohazard
D. irritant

The answer is B. Corrosives used in the laboratory are defined as acids or bases
that can etch flesh with first-, second-, or third-degree burns 24 h after contact.
Some corrosives destroy live tissue immediately; others cause damage after they
have penetrated into deeper tissues. Inhalation of corrosive vapors or ingestion
of corrosives causes severe edema and extensive burning of the respiratory tract
or mouth and throat. All containers of corrosive acids and bases should be la-
beled with a CORROSIVE label. Eye, respiratory, and skin protection should be
worn when working with corrosives. (Snyder et al., p. 368)

22. A4.0-mg/dL creatinine standard is needed. To prepare 100 mL of the work-

ing standard, how much stock standard of 1 mg/mL creatinine is needed?

A. 0.1 mL
B. 0.4 mL
Crank
D. 40 mL
 CLT Review Questions 165

The answer is C. To solve this problem, use the following formula:

Volume, X concentration, = Volume, X concentration,
where volume, and concentration, represent the stock standard and vol-
ume, and concentration, represent the working standard. Units of concen-
tration must be the same between the stock and working standards, so 1
mg/mL should be expressed as 100 mg/dL to be consistent with the work-
ing standard.
V, X 100 mg/dL = 100 mL X 4 mg/dL
V, = 4mL
(Campbell, pp. 121-124)

23. Various blanks may be run during spectrophotometric analysis to correct for
absorbance contributed by entities of the test system other than the actual
color reaction. Which of the following blanks is used to compensate for ab-
sorption of the color of the test sample before reagents are added?

A. Reagent blank
B. Water blank
C. Alcohol blank
D. Sample blank

The answer is D. A water blank is used when no interfering absorbance is con-

tributed by any part of the test system. A reagent blank is used if there is appre-
ciable absorbance contributed by one or more reagents in the system. Alcohol
can be a type of reagent blank. In this instance, a sample blank should be run if
the color of the sample itself causes absorption at the wavelength being used.
(Burtis et al., p. 326)

24. What is the total magnification produced when using a 10X ocular lens and
a 40X objective lens on a light microscope?

A. 4,000X
B. 800X
C. 400X
D. Cannot be determined without additional information

The answer is C. Magnification power of a microscope is the product of the en-

larging ability of the objective lens and that of the ocular lens. The resolving
power of the microscope is provided by the objective lens, and the ocular lens
magnifies the image coming from the objectives lens. (Linne et al., pp.
141-142)
i)
~
de
U
25. If a technician performing routine microscopic analysis on unstained urine A}
rs
sediment is to have sufficient contrast and resolution to identify important a
P.)
elements, the microscope must be adjusted by +S
fe)
~
6
rs
. lowering the condenser and reducing the light fe)
2
. lowering the condenser and increasing the light 6
=
. raising the condenser and reducing the light
a
i . raising the condenser and increasing the light
weno
166 6. Laboratory Practice

The answer is A. To have the appropriate black-white contrast and sufficient res-
olution to identify important urine-sediment structures in unstained preparations,
especially casts, the amount of light must be reduced. For most microscopes this
can be done effectively by both lowering the condenser and decreasing the set-
ting on the rheostat. (Linne et al., p. 140)

26. If a ground circuit in an instrument wire is not complete

A. the instrument will not work

B. current leakage may cause a shock to the operator
C. the fuse or circuit breaker will blow
D. a fire will result

The answer is B. To avoid shocks, all instruments must be grounded. The third
wire is provided to drain leakage currents harmlessly to ground. A ground prong
should never be cut off because the old receptacle only has two slots. If it is nec-
essary to connect a three-prong plug to a two-slot receptacle, an adapter should be
used and the ground wire of the adapter must be securely attached to the retaining
screw of the receptacle coverplate to avoid shock. (Linne et al., pp. 34-35)

27. Which of the following instruments is used to measure the speed of a cen-
trifuge?

A. Volt-ohm-meter (VOM)
B. Refractometer
C. Tachometer
D. Potentiometer

The answer is C. An external tachometer of known accuracy should be used to

calibrate the speed of a centrifuge; the tachometer should be used to check the
speed of the centrifuge at least every 3 months for all speeds at which the cen-
trifuge is routinely used. (Burtis et al., p. 19)

28. The wavelengths in the ultraviolet region are

A. 620 to 700 nm
B. over 700 nm
C. 400 to 450 nm
D. below 380 nm

The answer is D. Wavelengths visible to the unaided eye occur at approximately

380 to 750 nm. Ultraviolet light is not visible and occurs at wavelengths below
380 nm. Infrared wavelengths occur above 750 nm. (Linne et al., p. 159)

29. One nanometer is equal to

A. 1072 meter
B. 10-6 meter
C. 10-9 meter
D. 107-12 meter

The answer is C. Wavelength of light is the distance between peaks as the light
travels in a wavelike manner. This distance is expressed in nanometers (nm). 1
nm = 10-9 m. (Campbell, p. 47)
 CLT Review Questions 167

30. Which of the following should be performed to determine the optimal wave-
length at which to measure the absorbance of a colored solution?

A. Calibration curve
B. Wavelength calibration
C. Spectral transmittance curve
D. Molar absorptivity calculation

The answer is C. When various wavelengths are plotted vs. % T, a spectral trans-
mittance curve will result, which will peak at the wavelength where greatest ab-
sorbance or least transmittance occurs. This process can be used to determine the
optimal wavelength of light to use for the analysis. This results in improved
specificity, sensitivity, and linearity of spectrophotometric measurement. (Burtis
et al., pp. 81-87)

31. From the following data, calculate the concentration of the analyte in a
serum sample read at 560 nm.

Absorbance of the unknown sample = 0.325

Absorbance of a 200-mg/dL standard = 0.460

A. 283 mg/dL
B. 141 mg/dL
C. 130 mg/dL
D. 14.1 mg/dL

The answer is B. Beer’s law states that concentration (conc) is directly propor-
tional to absorbance (abs) if the analysis is linear. The calculation is as follows:
abs unknown __ abs standard
conc unknown — conc standard

0.325 rh 0.460 yn oD
x 200
(Campbell, p. 210)

32. Polystyrene containers are unsuitable for specimen transport offsite because
they

A. cannot be completely sealed

B. are not inert and may interact with the specimen
C. allow too much light exposure to the sample
D. may crack when exposed to freezing temperatures
oY
The answer is D. Polypropylene and polyethylene are usually suitable for spec- SY
eo)
imen transport. (Burtis et al., p. 56) U
6
he
a
~
33. A whole blood sample arrives at a laboratory with the following handwrit-
~
fe}
ea)
ten information. Which information is incorrectly included on the sample? 6
he
°
2
A. Sally Doe—604A, 253-01-0001 Li}
ml

B. Isolation
C. 07/16/94—Dr. McLane
D. Call results ASAP 09:30 LLS
168 6. Laboratory Practice

The answer is B. No specific labeling should be attached to patients with infec-

tious diseases to suggest that these samples should be handled with special care.
All samples should be handled with appropriate blood and body-fluid precau-
tions. (Garza et al., pp. 101-108, 255-256)

34. Testing for occult blood in feces should be done on aliquots of excreted
stools rather than on material obtained on the glove of a physician doing a
rectal exam because

A. the exam procedure may cause enough bleeding to produce a positive re-
sult
B. glove powder has been shown to cause false-positive results
C. glove powder has been shown to cause false-negative results
D. there is a greater chance of urine contamination of the rectal exam spec-
imen

The answer is A. Glove powder has no effect on occult blood testing. There is
also a chance that the volume of stool on a glove may not be truly representative
of the whole feces, possibly resulting in a false-negative. (Burtis et al., p. 51)

35. Which gauge needle would be most appropriate for blood collection if the
vein tends to be thready or collapse easily?

Bris
(G34)
Deel

The answer is D. In such instances, choosing the smallest bore needle possible
is advisable: the larger the gauge, the smaller the bore size. (Garza et al., p. 201)

36. Which of the following phlebotomy equipment is not used in an arterial

puncture?

A. Tourniquet
B. Glass syringe
C. 18-20 gauge needle
D. Heparin solution

The answer is A. No tourniquet is required since the artery has a strong blood
pressure of its own. (Garza et al., pp. 327-330)

37. Blood to be collected from a patient with an intravenous line in the right
hand should be taken from which of the following sites?

A. Left wrist
B. Right wrist
C. Left arm antecubital
D. Right arm antecubital

The answer is C. Sampling should not be taken from the arm containing the IV.
Whenever possible, use the antecubital vein rather than wrist veins. (Garza et al.,
p. 278)
 CLS Review Questions 169

38. Application of a tourniquet for longer than 3 min during venipuncture will
result in

A. decreased hemoconcentration around the puncture site

B. no changes in blood composition if fist pumping is avoided
C. significant decrease in total protein
D. increased filtration pressure across capillary walls

The answer is D. Three-min stasis can lead to hemoconcentration, regardless of

whether fist pumping is used, and up to 15% increase in the concentration of
protein and protein-bound constituents. (Burtis et al., pp. 43-44)

39. If a timed urine specimen is required for analysis, the patient should be in-
structed to complete which of the following for the first voided specimen?

. Collect and save the sample

. Discard the first and the last sample
. Discard the first specimen and begin the timing of the urine collection
VAS
. It doesn’t matter if the first specimen is collected as long as the timing
is accurate

The answer is C. The first voided sample should be discarded and the timing of
the urine collection begun. At the completion of the required time, the patient
should void and add the last specimen to the collection container. (Burtis et al.,
p. 50)

40. Following collection of a fingerstick blood sample and tube centrifugation,

hemolysis of the serum is noted. The most likely cause is

A. the presence of alcohol at the site of puncture

B. failure to clean the finger before collection
C. the use of nonsterile collection materials
D. “milking” the finger prior to collection

The answer is A. Alcohol must be allowed to evaporate from the skin so that he-
molysis does not occur. Massage of the finger to stimulate blood flow may cause
the sample to be contaminated with excess tissue fluid. (Burtis et al., p. 46)

CLS Review Questions

1. Which of the following statements does not apply to dry chemical fire ex-
ov
tinguishers? Me
fe)
UU
i}
A. They can be used on flammable liquid fires involving live electric equip- b=
a
ment >
h=

B. They can be used on class A, B, and C fires =

fe)
i}
C. They can be used on fires in which a re-ignition source is present thn
te)
D. They contain ingredients that are nontoxic 2
Li}
ad

The answer is C. Dry chemical fire extinguishers can be used on flammable liq-
uid fires and fires involving live electricity (classes B and C) because the chem-
ical does not conduct electricity. Because it rapidly extinguishes fire, dry chem-
170 6. Laboratory Practice

ical is also often used on fires involving combustible materials (class A). How-
ever, because the use of a dry chemical does not produce a permanently inert at-
mosphere above the fire surface, if there is any possibility of re-ignition, such as
from hot surfaces or smoldering embers, additional appropriate extinguishing
agents such as foam must be used. (Burtis et al., p. 38)

2. It is the employer’s responsibility to ensure that employees are exposed to

levels of radioactive substances that are

A. as low as reasonably achievable

B. minimal so as to not be hazardous to general health
C. as non-existent as possible
D. below 50 REMs/year

The answer is A. According to NRC Regulations, employers must ensure that ra-
dioactive levels are as low as reasonably achievable (ALARA). (Burtis et al., p.
130)

3. The most environmentally acceptable method for disposal of most chemical

waste products is

A. burial
B. disposal to a sewer system
C. incineration
D. listed in the appropriate Material Safety Data Sheet (MSDS)

The answer is D. For each chemical product, the appropriate manner in which to
dispose of unused chemical is listed on the MSDS provided by the manufacturer.
The MSDS sheet also contains other important information such as flammabil-
ity, health concerns, and stability, among others. (Snyder et al., p. 357)

4. The term “contaminated sharps” means

A. any contaminated object that can penetrate the skin

B. needles only
C. needles and lancets only
D. dirty broken glass only

The answer is A. The OSHA bloodborne-pathogen standard defines a contami-

nated sharp as any contaminated object that can penetrate the skin, including, but
not limited to, needles, scalpels, broken glass, broken capillary tubes, and ex-
posed ends of dental wires. (Federal Register, pp. 64,004—64,182)

5. OSHA requires employers to have policies and procedures regarding precau-

tions to take when working with blood and body fluids. This is called a(n)

A. universal precautions plan

B. chemical hygiene plan
C. exposure control plan
D. infectious disease plan

The answer is C. The 1991 rule issued by OSHA requires that an employer have
an exposure control plan available to all employees at risk of infection from
 CLS Review Questions 171

blood and body fluids. The rule requires that an employer supply personal pro-
tective equipment to the employee free of charge. It also requires the safe dis-
posal of sharps and other biohazardous waste and requires that HBV vaccine and
postexposure treatment be made available free of charge to all employees at risk
of exposure. Annual training is also required that provides information on the
risks of exposure, transmission, and necessary precautions to avoid exposure.
The rule also addresses hand washing, specimen transport, use of pipet devices,
spill cleanup, waste disposal, and decontamination of equipment. (Federal Reg-
ister, pp. 64,004—64, 182)

6. With regard to the National Fire Protection Agency (NFPA) system of la-
belling hazardous chemicals, the number contained in the blue section of the
diamond label represents which of the following hazards

A. health
B. flammability
C. reactivity
D. chemical specific hazards

The answer is A. The NFPA label consists of a diamond shape label with 4 sec-
tions representing four different types of hazards. The blue section represents
health hazards; red, flammability; yellow, reactivity; and the white section de-
tails chemical hazards specific to the particular chemical. (Snyder et al., p. 356)

7. Ensuring reliability of all steps of a laboratory procedure requires

A. use of a serum standard

B. incorporation of pre-analyzed control material
C. duplicate patient testing
D. use of a primary standard

The answer is B. The reliability of laboratory procedures is best ensured by in-

corporating a pre-analyzed control in the run of patient specimens. In this way,
all steps of the procedure and all variations therein are monitored through ac-
ceptance or rejection of the value of the pre-analyzed control for the test. Stan-
dards may not be subject to all of the same test conditions as the unknowns,
whereas the control material would be treated as an unknown. If the test result
for the control falls within the pre-established acceptable limits of variation
around the mean, the accuracy and precision, and consequently the reliability, of
the entire test procedure is ensured. (Burtis et al., p. 393)

8. A hematology laboratory in a hospital has determined that the abnormal low

RBC control has a mean value of 3.12 million red cells per mm?. The 95% Vv
=~
confidence limits include red cell count values from 3.06 X 10°/mm? to 3.18 iw)
a}
xX 10°/mm°. One standard deviation for this control is equal to te
a
>
ht
A. 0.01 X 10°/mm? fe)
~
B. 0.02 < 10°/mm? 6
h
O°
C. 0.03 X 10°/mm? He}
6
D. 0.04 < 10°/mm? ad

The answer is C. Random errors occur in all laboratory measurements, creating

the need for establishing acceptable ranges. When sufficient determinations are
made, the distribution of values should follow the gaussian curve of normal dis-
tribution. Approximately 68% of the results should fall within 1 SD and 95%
within 2 SDs. In the above situation, the laboratory personnel are confident that
they can expect their low abnormal RBC control to fall between 3.06 x 10°/mm?
and 3.18 X 10°/mm?, 95% of the time. One SD is determined by subtracting the
mean, 3.12, from the upper confidence limit, 3.18, and dividing by 2 to equal
0.03. (Burtis et al., p. 273)

9. If a test has a specificity of 98%, it results in approximately

A. 98% false-positives
B. 98% false-negatives
C. 2% false-positives
D. 2% false-negatives

The answer is C. A highly specific test produces a low incidence of false-posi-

tive and a high incidence of true-positive results. A test with low specificity pro-
duces a high incidence of false-positive and a low incidence of true-positive re-
sults. (Burtis et al., p. 312)

10. Which federal law removed the exemption of nonprofit hospitals from en-
gaging in collective bargaining with employees?

A. Occupational Safety and Health Act of 1970

B. Clinical Laboratory Improvement Act of 1967
C. Amendment to National Labor Relations Act, 1974
D. Amendment to Federal Labor Standards Act, 1963

The answer is C. Amendments in 1974 to the National Labor Relations Act

(NLRA) removed the previous exemption of nonprofit hospitals that prevented
employees from engaging in collective-bargaining activities. Employees in in-
dependent and physicians’ office laboratories also have the right to engage in
collective-bargaining activities if the laboratory brings in a certain amount of
revenue. The Fair Labor Standards Act (FLSA) establishes minimum wages,
maximum hours, and certain working conditions. The 1963 amendment to the
FLSA eliminated sex-biased wage differentials. (Snyder et al., p. 272)

11. The regulations from the Clinical Laboratory Improvement Act of 1988
apply to

A. all clinical laboratories in the United States

B. hospital laboratories only
C. laboratories engaged in interstate commerce only
D. independent laboratories only

The answer is A. The Clinical Laboratory Improvement Act of 1988 applies to

all laboratories performing testing on human samples. The regulations require
specific personnel, quality-control standards, participation in approved profi-
ciency testing programs, and site inspections. (Snyder et al., p. 17)

12. When there are five or six consecutive values that continue to increase or
decrease on a Levey-Jennings chart, it is called a
 CLS Review Questions 173

. shift
. normal occurrence
. trend
SY. reliable measurement
VAw

The answer is C. A trend is a steadily increasing or decreasing control value. It

occurs when the analytic method suffers a progressively developing problem.
(Campbell, p. 316)

13. A device that allows computers to communicate via phone lines is a

A. modem
BaACPU
C. RAM
D. ROM

The answer is A. A modem (short for modulating-demodulating) is a device that

is wired into the telephone line. The speed at which a computer communicates
over the phone lines is measured in bauds (bits audio). (Snyder et al., p. 328)

14. The device used for capturing data from instruments and processing them
without delay is

A. modem
B. interface
C. CPU
D. printer

The answer is B. Instrument interfaces allow for the transmission of data from
instruments to the laboratory’s computer system. (Snyder et al., p. 328)

15. A “dumb” computer terminal can be used to

A. run programs to perform specific tasks at the work station

B. accept data entry only if the main computer is operating
C. download programs from the main terminal
D. store data if the main computer is not operational

The answer is B. A dumb terminal requires that the main computer be opera-
tional at the time of use and is used for data entry only. In contrast, an “‘intelli-
gent” terminal is capable of running programs independent of the main com-
puter, downloading programs from a local network to perform tasks, and storing
data until the main computer is operational. (Burtis et al., p. 360)
Vv
iw
uu
16. When developing a clinical teaching module, the instructor must a)
Se
a
a>
A. provide the student with the opportunity to practice the procedure +e
fe}
=)
B. prepare a slide series to reinforce the technique (e}
fe
C. plan to use at least three types of audiovisual techniques fe)
2
D. plan to limit the activity to less than one hour i}
a!

The answer is A. As soon as possible after the clinical teaching activity, the stu-
dent should be given the opportunity to practice the procedure. Ample time should
be given to allow the student to become proficient and confident in the procedure.
A more complex task will require more time to master. Each teaching event should
be evaluated to include or exclude audiovisual materials. In the clinical teaching
arena, the procedure manual, instrument, pipet, reagent, and sample all become the
audiovisual material to reinforce the learning event. (Beck et al., p. 122)

17. Statements of observable learning outcomes are called

A. goal statements
B. performance standards
C. objectives
D. test questions

The answer is C. Educational objectives are statements of learning outcomes

stated in terms of observable learner behaviors. Statements of general purposes
are termed goals. Achievement of objectives can be measured by construction of
test questions that relate back to them. Objectives can be classified into three do-
mains: cognitive, psychomotor, and affective. (Beck et al., p. 34)

18. A test that is used to evaluate an individual’s abilities against a predeter-

mined standard is

A. norm-referenced
B. criterion-referenced
C. not valid
D. not reliable

The answer is B. A criterion-referenced test has a predetermined minimal-com-

petence level set for passing. A norm-referenced test sets a passing score based
on the performance of all the examinees taking the test at that time. A frequently
calculated passing score for a norm-referenced examination is | SD below the
mean. (Beck et al., p. 90)

19. Given the following objective, determine the best audiovisual aid to aug-
ment learning:

“Following instruction, the student will be able to correctly interpret a Gram-

stain slide on a sputum specimen.”
A. Chalkboard
B. Overhead projector
C. Videotape
D. 35-mm slides

The answer is D. The chalkboard and overhead will not provide the color and
discrimination the student will need to appropriately interpret a Gram’s stain. A
videotape may provide the color; however, the 35-mm slide is the best answer,
since the slide is still and allows the student to determine the amount of time
needed on each example. (Beck et al., pp. 65-70)

20. Chemicals exist in varying degrees of purity. For quantitative measurements

and preparation of accurate standard solutions, it is important to use pure
chemicals labeled as
 CLS Review Questions 175

. technical grade
. reagent grade
. purified
GVaAwS
. United States Pharmacopeia (USP)

The answer is B. For quantitative measurements and preparation of accurate

standard solutions, it is important to use pure chemicals and to identify exact
amounts of compounds or elements desired, as well as amount of contaminants.
The use of reagent-grade chemicals, although more expensive than using less
pure grades of chemicals, is essential to accuracy. Because several grades of
chemicals are available, an awareness of the terms used widely is necessary. For
the most highly purified chemicals, either reagent grade, analytical grade, or
ACS (for having met standards of purity established by the American Chemical
Society) should appear on the label or in the catalogue. Less pure chemicals are
referred to as purified and technical. (Burtis et al., pp. 5-6)

21. A 200-mg/dL solution was diluted 1:10. This diluted solution was then ad-
ditionally diluted 1:5. What is the concentration of the final solution?

A. 2 mg/dL
B. 4 mg/dL
C. 20 mg/dL
D. 40 mg/dL

The answer is B. To calculate final dilutions, multiply the original concentration

by the dilution, expressed as a fraction.

200 mg X "ig X 1/5 = 4 mg/dL

(Campbell, p. 109)

22. What is the molarity of an unknown HCI solution that has a specific grav-
ity of 1.10 and an assay percentage of 18.5%? (Atomic weight: HCl = 36.5)

A. 5.6 mol/L
B. 6.0 mol/L
C. 6.3 mol/L
D. 6.6 mol/L

The answer is A. To solve this problem, it is necessary to convert the density and
percentage strength of the strong acid to grams per liter (g/L) and then to mo-
larity:
Density < 10 X percentage = g/L
oY
Molarity = No. of grams of solute per liter of solution
7)
uu
therefore, 6
bes
-¥
£1010 < 18.5 = 203.5 g/L < 1 mole/36.5 g = 5.6 mol/L Pa]
]

~
fe}
(Campbell, pp. 138-150) 6
&
fe)
fe}
6
|
23. A method requires the use of an 8% (weight per volume) solution of NaOH.
The available solutions are labeled IN, 2N, 2.5N, and 10N. Which solution
is equivalent to 8% NaOH? (Atomic weights: Na = 23; O = 16; H = 1)
 A. IN
Bae
Ce IN
D. 10N

The answer is B. The normality of a solution is equal to the number of gram

equivalents of solute per liter of solution or the number of milligram equivalents
(mEq) of solute per milliliter of solution.

mEq/L = (mg/100 mL) x 10 X valence/atomic mass

8% (w/v) = 8 g/100 mL or 8,000 mg/100 mL
mEq/L = (8,000 mg) X 10 X valence/40 = 80,000/40 = 2,000
N = 2,000 mEq/L/1,000 mL = 2N

(Campbell, pp. 143-146)

24. Which of the following statements concerning type-I reagent grade water is
true?

A. It is not covered by NCCLS specifications for reagent grade water

B. It is recommended for use in procedures requiring minimal interference
and maximal precision and accuracy
C. It may be used for washing glassware if followed by a rinse of higher
reagent grade
D. It may be stored for extended periods of time after production without
affecting its reagent grade

The answer is B. The term reagent grade water is accompanied by a type I, II,
or IL designation. Type I has rigid specifications of purity established by the
NCCLS and is recommended for those procedures requiring minimal interfer-
ence and maximal precision and accuracy. These procedures include preparation
of standards, as well as enzyme and electrolyte analyses. (Burtis et al., pp. 3-5)

25. Quartz or plastic cuvettes of optical quality should be used when perform-
ing spectrophotometric assays in the ultraviolet (UV) region (i.e., less than
340 nm of the spectrum) because the usual borosilicate glass

A. refracts light at 340 nm

B. contributes to light scatter at 340 nm
C. absorbs light at 340 nm
D. emits light of a different wavelength

The answer is C. Regular glass cuvettes made of borosilicate glass should not be
used for UV determinations because this material absorbs some of the incident
light at these wavelengths, resulting in optical densities that are falsely elevated.
(Henry, p. 56)

26. Which of the following best describes the relation of nephelometry to tur-
bidimetry?

A. Nephelometry measures the amount of light absorbed by particles in so-

lution, and turbidimetry measures the amount of light transmitted
through a solution
 CLS Review Questions 177

B. Nephelometry directly measures the amount of light scattered by parti-

cles in solution, and turbidimetry measures the decrease in incident-light
intensity
C. Nephelometry measures the amount of light emitted by particles in so-
lution, and turbidimetry measures the amount of light reflected by parti-
cles in solution
D. Nephelometry measures the amount of light transmitted, and turbidime-
try measures the amount of light absorbed

The answer is B. Turbidimetry is the measurement of the cloudiness of a solution

due to the number of particles suspended in solution. It is the decrease in the
amount of incident light that is transmitted through the sample that is actually
measured. Nephelometry measures directly the amount of light that is scattered or
reflected, rather than absorbed, by the particles in suspension. (Burtis et al., p. 110)

27. Which of the following statements best describes the principle of dark-field
microscopy?

A. Transparent objects are rendered visible by changing the amplitudes of

light waves as they pass through the objects under study
B. Selective absorption produces a visible image because specimen detail
appears as differences in color to which the eye is sensitive
C. Light passes through the specimen at an angle, is diffracted, and enters
the objective lens, producing a bright image
D. A visible image is produced by the use of magnetic fields, making pos-
sible greater magnification and resolution

The answer is C. In dark-field microscopy an opaque disk built into the con-
denser allows only peripheral rays of light to enter the condenser. These rays
pass through the specimen at an angle such that the field appears unilluminated.
Any particles in the field will diffract the light and appear bright against a dark-
ened background. Dark-field microscopy is useful in visualizing bacterial fla-
gella and spirochetes, which are poorly defined by bright-field and phase-con-
trast microscopy. (Linne et al., p. 153)

28. To obtain better separation of liquid and solid components by centrifugation

A. increase the speed of the head

B. decrease the radius of the circle inscribed by the revolving head
C. increase the length of the tube containing the specimen
D. reduce the number of specimens in the centrifuge

The answer is A. The relative centrifugal force (rcf) is calculated using the fol-
lowing formula: ov
<~
UU
Ref = 0.00001118 x r x N? Ww)
he
r = radius of centrifuge head in centimeters a
Pa]
N = speed in rpm =
fe}
~
Thus, rcf can be increased by increasing the speed or the radius of the head. ©
S&S
fe)
(Henry, p. 24) 2
Li}
a

29. Which of the following is essential in stating the conditions of centrifuga-

tion in a procedure?
 A. Revolutions per minute (rpm)
B. Voltage output of centrifuge
C. Relative centrifugal force (rcf)
D. Angle of centrifuge head

The answer is C. Conditions for centrifugation should specify both the time and
the rcf. The rcf is a function of the radius between the axis of rotation and the
center of the centrifuge tube and the number of revolutions per minute.
ref = 0.00001118 X radius X rpm?
(Burtis et al., p. 18)

30. Calibration of micropipets

A. must be verified each day of use

B. should be performed gravimetrically with mercury
C. is unnecessary if the pipet is certified by the manufacturer
D. can be verified spectrophotometrically on a predetermined schedule

The answer is D. Accurate calibration of micropipets must be verified on a regu-

lar schedule. Verification should not be performed with mercury because of envi-
ronmental and safety hazards. Although calibration verification can be done
gravimetrically using water with a density correction, another alternative is to use
a colored compound and spectrophotometric verification. (Burtis et al., pp. 15-16)

31. An automated system that is used for many different analyte applications
most frequently has a sample delivery system equipped with a

A. fixed pipet
B. variable pipet
C. selectable pipet
D. air-displacement pipet

The answer is B. A fixed pipet delivers only one set sample size and is used for
limited applications. A variable pipet can usually deliver samples in volumes
from 1 wL to 100 wL and may be adjusted based on the application required. A
selectable pipet has a predetermined selection of sample sizes it can deliver;
therefore, it widens the menu of applications. It is still not as versatile as a vari-
able pipet. An air-displacement pipet is not generally used to pipet sample
aliquots in an automated system, since the measure is affected by viscosity of the
sample. Positive-displacement pipettes provide high reproducibility and in-
creased accuracy compared to air-displacement pipettes. (Burtis et al., p. 236)

32. The aperture diaphragm of a microscope

A. reduces stray light

B. gathers and focuses the illumination light onto the specimen
C. provides the secondary-image magnification of the specimen
D. regulates the angle of light presented to the specimen

The answer is D. The aperture diaphragm is located at the base of the condenser
and regulates the angle of light presented to the specimen. The condenser gath-
ers and focuses the illumination light onto the specimen for viewing. The ocular
 CLS Review Questions 179

provides the secondary-image magnification of the specimen, and the field di-
aphragm reduces stray light. (Linne et al., p. 140)

33. When collecting a blood sample by means of a syringe, hemolysis can be

avoided by

A. using multiple syringes to permit small-volume collection

B. keeping the needle on the syringe during transfer to other tubes
C. using a small-bore needle for collection of the sample
D. precooling the needle and syringe before collection

The answer is C. There is less turbulence of the blood when a small-bore needle
rather than a larger bore needle is used. (Burtis et al., p. 44)

34. Collection of a 24-h urine includes which of the following procedural steps?

A. Inclusion of urine specimens at the beginning and end of the timed pe-
riod
B. Discarding any urine specimen that is collected at the same time as a
bowel movement
C. Collecting each void in a separate container without preservative and
then emptying it into the larger container
D. Removal of aliquots for analysis before collection is complete as long as
the volume removed is noted and corrected in the final total volume

The answer is C. The first urine during the collection period is discarded, and the
final urine is collected. Precautions should be taken to prevent fecal contamina-
tion by a bowel movement, but such urines still need to be included. Aliquots are
not permitted, because excretion of most compounds varies throughout the day.
(Burtis et al., p. 50)

35. A physician requests the following tests on an EDTA-vacutainer sample: he-

moglobin, hematocrit, BUN, sodium chloride, glucose, calcium, creatine ki-
nase, and iron. Of the requested tests, which of the following combinations
cannot be accurately analyzed on the EDTA specimens?

A. Hemoglobin, hematocrit
B. BUN, glucose
C. Hematocrit, sodium chloride
D. Creatine kinase, calcium

The answer is D. EDTA (ethylenediaminetetraacetic acid) containing vacutainers

are generally drawn for hematology testing because EDTA preserves the cellular
cc)
components of blood. EDTA chelates calcium to prevent coagulation. As an anti- se
Eo)
coagulant, it has little effect on most chemistries except calcium, iron, alkaline VU
11]
phosphatase, creatine kinase, and leucine aminopeptidase. (Burtis et al., p. 48)
&
a
~
~
fe}
P=)
36. What is the proper sequencing of steps for cleansing the venipuncture site 6
he
3°
when collecting a blood culture? Ke}
6
od
1. Scrub with alcohol
2. Scrub with iodine swab
3. Allow to dry for 1 minute
 Ww
WH
NR WO
bd
Wr

The answer is D. Less than 3% of blood cultures should contain contaminating

microorganisms from the skin. Therefore, the venipuncture site should be pre-
pared as follows: 1) Scrub with alcohol; 2) apply 1-2% tincture of iodine or
povidone-iodine; 3) allow to dry 1 min. The iodine and alcohol must be used to
disinfect the venipuncture site unless povidone-iodine is used; then, the 70% al-
cohol wash is omitted. (Garza et al., pp. 334-338)

37. A substance-of-abuse specimen has been sent to the laboratory for cocaine
analysis. If there is a possibility that this result will be used in a medical
legal investigation, which of the following procedures should be used?

A. The phlebotomist draws the blood and takes the specimen to the nurses’
station for delivery to the laboratory
B. A chain-of-custody form is completed and the specimen is sent to the
laboratory with the other specimens from the floor
C. A chain-of-custody form is signed for each stage of specimen transfer,
analysis, and reporting of the result
D. No special procedure is needed as long as the specimen is analyzed by
the laboratory personnel collecting the specimen

The answer is C. Specimens that are analyzed for drugs of abuse and alcohol
may have medical legal implications. Therefore, handling of these specimens
must follow a chain of custody—procedures to account for the integrity of the
specimen by tracking its handling from the time of collection to reporting of re-
sults. A chain-of-custody form is used to identify each individual in the chain of
custody of the specimen. This form must be completed by each individual to
document the date and purpose of handling the specimen. If the specimen is
aliquoted, a chain-of-custody form must accompany the aliquot. (Henry, p. 37)

38. A patient with a presumptive diagnosis of primary liver disease has an LD-
isoenzyme pattern performed on a fresh serum sample then again on the
same sample the following day. Results are as follows:

Percent of total LD
LD-1 LD-2 LD-3 LD-4 LD-5
Normal control 26 36 20 10 8
Day 1 16 26 18 12 28
Day 2 24 34 20 wy) 13
The most plausible explanation of these results is that overnight the serum
sample was
A. refrigerated or frozen
B. left at room temperature
C. left uncapped
D. diluted with distilled water

The answer is A. Lactate dehydrogenase isoenzymes 4 and 5 are more stable at

room temperature than at 4°C. Both are rich in the M form, which binds NAD+
 CLS Review Questions 181

more weakly, allowing dissociation and subsequent oxidation of the subunit’s

sulfhydryl groups when stored in the cold. (Burtis et al., pp. 670-671)

39. If a patient is suspected of having whooping cough from Bordetella pertus-

sis, which of the following is considered the best type of specimen to iso-
late the organism?

A. Throat swab
B. Nasopharyngeal swab
C. Cough plate
D. Any of the above will isolate Bordetella pertussis if present

The answer is B. Whooping cough is caused by Bordetella pertussis. The best

method for isolating this organism is the use of a nasopharyngeal swab or throat
washing. Throat swabs are not adequate to recover Bordetella pertussis. The cough
plate is considered inferior to the nasopharyngeal swab. (Koneman, pp. 11-14)

40. A sample is drawn off-site for transport to a central lab, with glucose, urea
nitrogen, and electrolytes. The anticoagulant of choice is

A. sodium fluoride
B. potassium citrate
C. lithium heparin
D. sodium iodoacetate

The answer is D. While fluoride salts have been used for preserving glucose in
transported specimens, its presence inhibits urease (used in urea-nitrogen meth-
ods). Neither citrate nor heparin is antiglycolytic. lodoacetate (2g/L) has no ef-
fect on urease, although it does inhibit creatine kinase. (Burtis et al., p. 48)

References
Beck SJ, LeGrys VA. Clinical Laboratory Education (2nd ed). Bethesda, MD:
American Society for Clinical Laboratory Science, 1996.

Bishop M, Duben-Engelkirk J, Fody E. Clinical Chemistry: Principles, Proce-

dures, Correlations (3rd ed). Philadelphia: Lippincott, 1996.

Burtis CA, Ashwood ER (eds). Tietz’s Textbook of Clinical Chemistry (3rd ed).
Philadelphia: WB Saunders, 1999.

Campbell JB. Laboratory Mathematics (Sth ed). St. Louis: Mosby, 1997.

Federal Register. Occupational Exposure to Bloodborne Pathogens. US GPO, )

ae
Ee)
vol. 56 (December 6, 1991). U
i]
te
a
Garza D, Becan-McBride K. Phlebotomy Handbook (Sth ed). Norwalk, CT: Ap- Pal
he
pleton & Lange, 1999. [e)
~
6
he

Henry JB (ed). Clinical Diagnosis and Management by Laboratory Methods °

Ko}
(19th ed). Philadelphia: Lippincott, 1996. 6
al

Koneman EW, et al. Color Atlas and Textbook of Diagnostic Microbiology (4th
ed). Philadelphia: Lippincott, 1992.
182 6. Laboratory Practice

Linne J, Ringsrud K. Clinical Laboratory Science: The Basics and Routine

Techniques (4th ed). St. Louis: Mosby, 1999.

National Committee for Clinical Laboratory Standards (NCCLS). Document G

P 17-T. Villanova, PA: NCCLS, 1989.

Snyder JR, Senhauser DA. Administration and Supervision in Laboratory Med-

icine (3rd ed). Philadelphia: Lippincott, 1998.
 ~n
~~

=d

Ss
AG

Review Tests
>
oY
ce

CLT Review Test

1. A 24-hour urine collection and a plasma sample drawn during the same time
period produced the following results:

Plasma creatinine = 1.2 mg/dL

Urine creatinine = 150 mg/dL
Urine volume = 1.2 L
The creatinine clearance for this patient is
A. 104 mL/min
B. 112 mL/min
C. 125 mL/min
D. 150 mL/min

. Which of the following entities is indicative of disease when found in urine

sediment, regardless of the number present?

A. RBCs‘
B. Hyaline casts”
C. Granular casts
D. Fat globules

. Serum total protein results obtained using the biuret reaction can be falsely
increased if

A. arterial blood is used

B. the specimen is hemolyzed
C. a non-fasting specimen is used
D. lipids are removed prior to analysis

. An enzyme assay that shows substrate depletion should be repeated using

A. less sample
B. less substrate
C. longer light path
D. longer reaction time

183
184 7. Review Tests

5. Which of the following best describes the proper collection of a midstream

urine specimen?

A. After beginning urination into toilet, patient collects some urine into a
container
B. Patient collects the “initial” stream of urine, then urinates the remainder
into toilet
C. Immediately upon rising in the morning, patient collects urine into a
sterile container
D. Urine is removed directly from the bladder by a physician using a nee-
dle and syringe

. Aurine specimen collected from a hospitalized diabetic patient with possi-

ble hepatitis was not refrigerated. It remained at room temperature for 4 h
before being delivered to the laboratory for testing. It was not accepted by
the laboratory, and the nursing station was called. The technician explained
that the specimen should be recollected due to the likely occurrence of
which of the following changes?

A. Odor increases; glucose increases

B. Clarity decreases; bilirubin decreases
C. Color decreases; urobilinogen increases
D. Specific-gravity decreases; ketones decrease

. An arterial blood specimen is collected from a normal, healthy donor for

blood-gas analysis. The specimen was improperly collected, and a large
bubble of room air is present in the syringe. Which of the following changes
can occur?

pH pCO, pO,
A. increase decrease increase
B. increase increase decrease
C. decrease decrease _— increase
D. decrease increase decrease

. Assuming a freshly collected urine is tested, which of the following urinal-

ysis results is physiologically impossible?

A. pH 9.0
Ba SG712003
C. Glucose 3000 mg/dL
D. Urobilinogen 0.1 mg/dL

- When processing urine specimens for analysis, which of the following ac-
tions can cause falsely low counts of urine sediment components on the mi-
croscopic examination?

. Applying the centrifuge brake at the end of centrifugation

. Centrifuging for a longer time than the procedure indicates
. Centrifuging a larger volume of urine than the procedure indicates
. Resuspending the urine sediment in a smaller volume of urine than the
SQ
procedure indicates
 CLT Review Test 185
~
wn
2
10. Select the pattern of serum test results most consistent with obstructive liver Ss
disease. 2
>
v
eg
Total Conjugated Total Alkaline
Bilirubin Bilirubin Phosphatase
A. increased increased increased
B. increased normal increased
C., normal increased decreased
D. increased increased decreased

11. The glucose concentration in normal cerebrospinal fluid is

A. usually less than 40 mg/dL

B. usually greater than 100 mg/dL
C. equal to the plasma-glucose concentration
D. 60 to 80% of the plasma-glucose concentration

12. Which of the following is not required when calibrating a pCO, electrode
on a blood-gas instrument?

A. The barometric pressure

B. Acalomel reference electrode
C. Instrument temperature maintained at 37°C
D. Calibration gases at two different concentrations

13. Four total protein methods are evaluated, method A, B, C, and D. The re-
sults obtained from replicate determinations (n = 100) of the high control by
each method are provided in the Table.

High Control
Method Mean (g/dL) 1SD
A 10.0 0.20
B 10.4 0.20
re 10.3 0.25
D 9.8 0.25

Based on this data, which method demonstrates the greatest precision?

A. Method A
B. Method B
C. Method C
D. Method D

14. Which of the following lists represents the light path through the compo-
nents of a spectrophotometer beginning immediately after the light
source?

A. Entrance slit, sample cuvet, exit slit, monochromator, detector

B. Entrance slit, monochromator, exit slit, sample cuvet, detector
C. Monochromator, entrance slit, sample cuvet, exit slit, detector
D. Monochromator, sample cuvet, entrance slit, detector, exit slit
186
rien
ee 7. Review Tests
ce cha —

15. Osmometers determine osmolality using which of the following colligative

properties?

A. Boiling point elevation

B. Vapor pressure elevation
C. Freezing point depression
D. Osmotic pressure depression

16. Select the urinalysis results that are contradictory.

A. Reagent strip blood—negative; microscopic exam—0-2 RBCs/HPF

B. SSA protein test—negative; microscopic exam—2-5 hyaline casts/LPF
C. Reagent strip leukocyte esterase—negative; microscopic exam—5—10
WBCs/HPF
D. Refractometry specific gravity—1.015; microscopic exam—S-—10 radi-
ographic dye crystals/LPF

17. Review the drawing of crystals present in a urine sediment with a pH of 7.5.
What is the identity of these crystals?

A. Calcium oxalate
Sey
B. Cystine
C. Triple phosphate
D. Uric acid

18. Review the following chemical reaction used on urine reagent test strips.

Aromatic compound + Diazonium salt 24> Azodye

This reaction is used for the detection of
A. bilirubin
B. glucose
C. hemoglobin/blood
D. ketones

19. A red-top tube was discovered on a phlebotomist’s tray 3-1/2 h after it had
been drawn. Which of the following sets of tests could still be run?

A. BUN, creatinine
B. Glucose, electrolytes
C. Total and direct bilirubin
D. Alkaline phosphatase, AST, ALT, LD
 CLT Review Test 187
~
o
-

20. False-negative reagent strip ketone results can occur s

ag
>
. if sufficient ascorbic acid is present Vv
ce
. when a urine specimen is improperly stored
. if the B-hydroxybutyrate concentration is too low
. when free-sulfhydryl drugs are excreted in urine
DaAwS

21. A 24-hour urine is collected and 3200 mL of urine is obtained. Which of the
following terms and causes correlates best with this collection?

A. Nocturia due to chronic renal disease

B. Oliguria due to dehydration and vomiting
C. Anuria due to decreased renal blood flow
D. Polyuria due to inadequate vasopressin secretion

22. A small study of an automated total calcium method was performed by an-
alyzing a low control (mean = 7.0 mg/dL) and a high control (mean = 12.0
mg/dL) in 10 consecutive sample cups. The sample order and the results ob-
tained are:
Calcium
Cup Sample (mg/dL)
1 low 6.9
2 low Tail
3 high 120
4 low 8.0
5 low 7.0
6 high 11.9
7 high 123
8 low 8.1
9 low 6.9
10 low 7.0

Which of the following statements best accounts for the results obtained?

A. Carryover is evident in cups 4 and 8

B. Insufficient mixing has occurred in cup 7
C. Short-sampling has occurred in cups 1 and 9
D. Instrument malfunction, except for reaction in cups 3 and 10

23. Review the drawing of some epithelial cells and blood cells frequently ob-
served in urine sediment. What is the identity of the cell indicated by the
arrow?

Blood Cells
188 ts
SS
ee 7. LINENS
Review Tests
NCSU ee

A. Collecting duct cell

B. Proximal tubular epithelial cell
C. Squamous epithelial cell
D. Transitional epithelial cell

24. A plasma specimen is diluted as follows: 0.3 mL plasma plus 0.6 mL dilu-
ent. The glucose result obtained using this dilution is 265 mg/dL. Which of
the following results should be reported?

A. 265 mg/dL
B. 530 mg/dL
C. 795 mg/dL
D. 1060 mg/dL

25. A sterile container is received in the laboratory. It contains 5 mL of urine

collected by suprapubic aspiration from a 1-month-old child. The following
tests are requested: urinalysis, creatinine, electrolytes (sodium and potas-
sium), microbial culture. Which test should be performed first?

A. Urinalysis
B. Creatinine
C. Microbial culture
D. Electrolytes (sodium and potassium)

26. Which of the following instruments has a 2-point calibration performed

daily using Type I water and a NaCl solution of known concentration?

A. Nephelometer
B. Osmometer
C. Refractometer
D. Spectrophotometer

27. You need to prepare a 1 to 3 dilution of a serum specimen using saline.

Which of the following would result in this dilution?

A. Pipet 0.5 mL serum, then add 1.0 mL saline

B. Pipet 1.0 mL serum, then add 3.0 mL saline
C. Pipet 1.5 mL serum, then add 1.5 mL saline
D. Pipet 2.0 mL serum, then add 5.0 mL saline

28. Which of the following best describes a “noncompetitive” enzyme im-

munoassay (EIA)?

A. Labeled Ag (antigen) + patient Ag + Ab (antibody) > incubate > add

substrate > measure product
B. Well coated with Ab + patient Ag and labeled Ag > wash — add sub-
strate > measure product
C. Well coated with Ag + patient Ag and labeled Ab > wash —> add sub-
strate > measure product
D. Well coated with Ab + patient sample > wash —> add labeled Ab > wash
— add substrate > measure product
 CLT Review Test 189

i
2
29. The following results are obtained on a fresh randomly collected urine spec- S
imen: 2

Parameter Result Confirmatory test Result

a
DV IS)
SG 030 Refractometer: 1.055
Blood: negative
Protein: 30 mg/dL
Glucose: negative Clinitest: positive
Ketone: negative
Bilirubin: positive Ictotest: positive
Urobilinogen: 1.0 mg/dL
Nitrite: negative
Leukocyte esterase: positive

Which of the following statements regarding these results is true?

. Ascorbic acid is causing a false-negative glucose reaction

. The alkaline pH is causing the protein result to be positive
. An abnormal amount of urobilinogen is present in the urine
. Radiographic contrast media (x-ray dye) is causing the high specific
QVaAWS
gravity

30. Which of the following test methods is the most specific for measuring
plasma glucose?

A. o-Toluidine
B. Hexokinase
C. Copper reduction
D. Dye-binding

31. Situation: It is 10:00 am and you are working in the Specimen Receiving
and Processing Area of the laboratory. The following specimens are re-
ceived. Which requires intervention before proceeding with its processing?

Test Requested Collection Tube Rec’d Time Collected

A. Bilirubin red top, foil wrapped 9:30 am
B. Glucose sodium fluoride 8:50 am
C. Jonized calcium heparin, on ice 9:45 am
D. Total protein EDTA 9:50 am

32. Two spectrophotometers are being considered for purchase. Instrument A

has a bandpass of 20 nm and Instrument B has a bandpass of 10 nm. Which
of the following interpretations can be made?

A. Instrument A has greater sensitivity and specificity

B. Instrument B has greater sensitivity and specificity
C. Instrument A has more sensitivity but less specificity than instrument B
D. Instrument B has more sensitivity but less specificity than instrument A

33. The following results are obtained on a patient from the Emergency Room:
 Na* = 145 mmol/L Glucose = 105 mg/dL
Ke = 3.5 mmol/L Creatinine = 1.2 mg/dL
Gls = 108 mmol/L BUN = 20 mg/dL
HCO, = 28 mmol/L

Which of the following results is closest to the calculated osmolality?

A. 283 mOsm/kg
B. 292 mOsm/kg
C. 308 mOsm/kg
D. 317 mOsm/kg

34. Which of the following tests provides the best index of a patient’s average
blood glucose level over a 2-month period?

A. Glucose tolerance
B. Glycated serum protein
C. Glycated hemoglobin
D. C-peptide

35. Which of the following urinalysis results is considered “abnormal,” i.e.,

clinically significant?

A. Bilirubin—small
B. Urobilinogen—1.0 mg/dL
C. 0-2 granular casts per low power field
D. 0-2 white blood cells per high power field
Answer: A

36. A patient who is taking diuretics for congestive heart failure has blood
drawn for a potassium level. The sample is centrifuged and analyzed as part
of a large run. The value obtained is 7.6 mmol/L. The original sample is
pulled and is grossly hemolyzed. The CLT should

A. enter the data and handle as routine results

B. notify the physician immediately that the potassium is elevated
C. rerun the sample and report the results if they are similar to the first re-
sult
D. notify the physician that a new specimen needs to be collected

37. The following results are obtained on a urine specimen:

Reagent strip protein test: negative

Sulfosalicylic acid precipitation test: positive

These results can be caused by an increased urinary excretion of

. albumin
. microalbumin
. Tamm-Horsfall protein
PS. immunoglobulin light chains
Daw

38. A change in the glomerular filtration rate is best assessed using the
 CLT Review Test 191
Ww

4d
. urea clearance test 5
. creatinine clearance test 4
2
. ammonium chloride test C})
ce
. p-aminohippurate (PAH) clearance test
GTaAwS

39. When using the following coupled enzymatic reactions, what is actually
measured to determine the glucose concentration in serum samples?

Glucose + O, S°> gluconic acid + H,O,

H,O, + reduced dye Fet2xidase> oxidized dye + H,O

A. The increase in absorbance

B. The decrease in absorbance
C. The amount of O, consumed
D. The amount of H,O, produced

40. Which of the following urine specimen results needs to be investigated or

confirmed before reporting?

A. Reagent strip bilirubin—negative; ictotest—positive

B. Reagent strip protein—negative; reagent strip pH—8.0
C. Refractometer specific gravity—1.045; microscopic exam—cholesterol
crystals
D. Reagent strip leukocyte esterase—negative; microscopic exam—5-—10
WBCs/HPF

41. A patient in the Emergency Room experienced chest pain 72 hours before
coming to the hospital. Currently, which of the following tests would best
indicate whether an acute myocardial infarction has occurred?

A. Myoglobin
B. TroponinI
C. Creatine kinase, MB fraction
D. CK-MB isoforms

42. As a patient becomes acidotic, the plasma concentration of

A. total calcium increases

B. ionized calcium increases
C. albumin-bound calcium increases
D. calcium complexed with ligands (e.g., phosphate) increases

43. You obtain the following data when performing a cholesterol assay:
Sample Absorbance
150 mg/dL standard 0.200
Normal control 0.200 — (mean: 150 mg/dL; 1SD = 15)
Abnormal control 0.600 (mean: 275 mg/dL; 1SD = 25)
Patient A 0.500
Patient B 0.300

After calculating the cholesterol results, you decide that

192: 7% Review Tests

. the run is acceptable; all results can be reported

. the run is not acceptable; no results can be reported
. patient A’s result can be reported but patient B’s result should not be re-
ported
= . patient B’s result can be reported but patient A’s result should not be re-
@ules!
S)
ported

44. Evaluate the urinalysis microscopic examination results on the first morn-
ing urine specimens obtained on two consecutive days from the same pa-
tient. Which of the urine sediment changes indicates that an infection that
was originally only in the bladder has, on day 2, moved up into the kidney?

A. Day 1: 2-5 RBCs, 2-5 WBCs, mod bacteria

Day 2: 2-5 RBCs, 10-25 WBCs, 0-2 granular casts, many bacteria
B. Day 1: 0-2 RBCs, 5-10 WBCs, 0-2 granular casts, few bacteria
Day 2: 2-5 RBCs, 5-10 WBCs, 0-2 granular casts, mod bacteria
C. Day 1: 2-5 RBCs, 10-25 WBCs, 2-5 hyaline casts, few bacteria
Day 2: 2-5 RBCs, 5-10 WBCs, 0-2 WBC casts, few bacteria
D. Day 1: 5-10 RBCs, 5—10 WBCs, 10-25 hyaline casts, few bacteria
Day 2: 10-25 RBCs, 5-10 WBCs, 0-2 RBC casts, few bacteria

45. Which of the following terms is considered inappropriate for reporting urine
“color?”

A. Amber
B. Bloody
C. Colorless
D. Orange

46. For accurate ionized calcium measurements, the sample

A. must be deproteinized
B. must be protected from photo-oxidation
C. must be anticoagulated with sodium fluoride
D. must be preserved to maintain the patient’s pH

47. You need to prepare a | to 5 (1:5 or 1/5) dilution of a serum specimen using
saline before analysis. Which of the following pipetting steps would result
in this dilution?

A. Pipet 0.1 mL serum, then add 0.5 mL saline

B. Pipet 0.2 mL serum, then add 0.8 mL saline
C. Pipet 0.5 mL serum, then add 2.5 mL saline
D. Pipet 1.0 mL serum, then add 3.0 mL saline

48. A fluorometer measures light that is

. polarized by the chemical reaction

. scattered by insoluble particles produced by the reaction
. emitted by excited electrons as they return to the ground state
. absorbed by excited electrons as they return to the ground state
Gy
 CLT Review Test 193

i
=
49. When an ion selective electrode interacts with its analyte, it produces a Ss
change in the electrode’s
<
)
A. conductance i
B. current
C. resistance
D. potential

50. Electrophoretic separation of proteins on cellulose acetate depends on the

proteins differing in

. concentration
. molecular weight
. net charge
S . number of peptide bonds
Daw

51.jem Which enzyme catalyzes the following reaction?

L-alanine + alpha ketoglutarate > glutamate + pyruvate

A. Alkaline phosphatase (ALP)

B. Alanine aminotransferase (ALT)
C. Aspartate aminotransferase (AST)
D. Gamma-glutamy] transpeptidase (GGT)

52. A patient has consistently high blood glucose results. Which of the follow-
ing hormones is most likely defective or present in insufficient amounts?

A. Cortisol
B. Epinephrine
C. Glucagon
D. Insulin

53. Which of the following assays is considered a heterogeneous immunoassay?

A. Cloned enzyme donor immunoassay (CEDIA)

B. Fluorescence polarization immunoassay (FPIA)
C. Enzyme-linked immunosorbent assay (ELISA)
D. Enzyme-multiplied immunoassay technique (EMIT)

54. When a factor “k” is substituted for “a - b” in Beer’s law, which of the fol-
lowing expressions can be used to calculate the results?

ABA: cak
BY AK =€¢
Cic=k/
D. A-k=c

55 Of the following analytes, which is least useful as an indicator of “obstruc-

tive” liver disease?
194
eet
ee 7. Review
ECW Tests
GSTS

A. Total bilirubin
B. Alkaline phosphatase (ALP)
C. Aspartate aminotransferase (AST)
D. Gamma-glutamy] transferase (GGT)

56. Which of the following changes in blood gas parameters is consistent with
metabolic acidosis?

A. + pH, + pCO, 4 HCO;

B. !pH) + pCOs, J HCO;
C. t pH, | pCo,, t HCO;
DB) tipH, 11pCOs) HCO.

Sie When reviewing QC charts, which of the following situations requires doc-
umentation of action taken on that day?

A. When 2 consecutive control values lie 1.5 SD below the mean

B. When a single control value exceeds 3 SD above the mean
C. When both the high and low controls lie between | and 2 SD above the
mean
D. When the high control value lies between 1 and 2 SD above the mean
and the low control lies between 1 and 2 SD below the mean

58. Which of the following sediment entities will disintegrate in alkaline hypo-
tonic urine?

A. Fat
B. Mucus
C. Red blood cells
D. Renal epithelial cells

59) Each of the following reagent strip tests is based on an azo-coupling reac-
tion that forms an azo-dye except

A. bilirubin
B. glucose
C. leukocyte esterase
D. nitrite

60. For the determination of amylase activity in serum, which of the following
substrates can be used?

A. Olive oil
B. L-aspartate
C. Maltotetraose
D. 4-Nitrophenyl phosphate

61. A telephone request is received at 12:00 pm to repeat a CBC on a specimen

of blood that was collected at 7:00 am. The correct procedure is to

A. allow the specimen to become well mixed through the use of a mixer de-
vice for a minimum of 5 minutes prior to testing
 CLT Review Test 195
~

d
=
B. allow the specimen to return to room temperature and then mix by gen- S
tle inversion six times prior to testing =
?
C. perform the test on the specimen but not report out the platelet count as e)
x
the duration from collection to testing has allowed the platelets to clump
D. inform the caller that a new specimen must be collected

62. A 1/20 dilution of blood is made in a WBC Unopette™. 200 cells are
counted in 4 square millimeters of a Neubauer hemocytometer. What is the
number of leukocytes?

A. 5.0 X 10°/L
B. 8.0 X 10°/L
C. 10.0 X 10°/L
D. 16.0 X 10°/L

63. A large leukocyte has a single nucleus and a stretched out appearance with
abundant blue cytoplasm. The cytoplasm appears to be indented by sur-
rounding RBCs. This cell is most likely a/an

. reactive (atypical) lymphocyte

. monocyte
. toxic neutrophil
. megakaryocyte
UaAwPY

64. Red blood cell morphology characteristic of multiple myeloma is

. auto-agglutination
. stomatocytes
. schistocytes
. rouleaux
DVaAWY

65. Which of the following can be mistaken for a malarial parasite?

A. Basophilic stippling
B. Cabot ring in the figure eight pattern
C. Platelet on a red cell
D. Howell-Jolly body

66. The following red cell parameter results have been achieved using a multi-
channel instrument:

Hb: 7.5 g/dL

HET. | 38%
RBG: 74.0.X 107/L
MCV: 95 f{L
MCH: 18.8 pg
MCHC: 13.2 g/dL
RDW: 12.0%
The clinical laboratory technician should
A. report the results as obtained
B. perform a manual differential to confirm the presence of schistocytes
196
ne 7. Review Tests eS Eee a aaa eee

C. warm the specimen to 37°C and repeat the test

D. replace the empty hemoglobin reagent container

67. An eosinophil count of 800/u1 would be interpreted as

. eosinopenia
. within the reference range
. eosinophilia
. cannot be determined without the white blood cell count
QUAYS

68. The following number of platelets were seen in 10 oil immersion fields of a
Wright’s-stained smear: 5, 4, 6, 9, 10, 8, 7, 8, 8, 10. Which of the following
platelet counts would best correlate with these values?

A. 55-75 X 10°/L
B. 112-150 X 10°/L
C. 250-450 X 10°/L
D. 550-750 X 10°/L

69. All of the peripheral blood smears made by a certain clinical laboratory
technician are too thick. Which of the following corrective actions should
be taken?

A. Lower the angle of the spreader slide to 45 degrees

B. Lower the angle of the spreader slide to 15 degrees
C. Raise the angle of the spreader slide to 45 degrees
D. Raise the angle of the spreader slide to 75 degrees

70. Which of the following cells may be found only in ascitic fluid?

A. Lymphocytes
B. Mesothelial cells
C. Choroid plexus cells
D. Fibrocytes

71. The first of three tubes of CSF appears pink and cloudy. The remaining two
tubes appear to be clear and colorless. This is indicative of a/an

A. bacterial infection
B. uncontrolled diabetes
C. traumatic tap
D. subdural hemorrhage

72. The presence of rare lymphocytes in a cerebrospinal fluid is

. indicative of childhood ALL sequestration

. diagnostic for viral meningitis
. Supportive of cryptococcal encephalitis
S . normal
Gane
 CLT Review Test 197
~
d
Ee
73. A histogram printout portion of an automated CBC shows a bimodal distri- Ss
bution of RBCs with one spike at the origin and one at the 75-85 range a
>
could indicate the presence of oY
ce

A. macrocytes
B. leukemic cells
C. fragmented red cells
D. small platelets

74, The results of an automated CBC include a white blood cell count of 15 X<
10°/L. 10 NRBCs are seen during the 100 cell differential. The correct white
cell count per 10°/L is

ald. 1
Bnl's:0
eto 6
VaAw>
1.4

aS. Because of the presence of an abnormal hemoglobin that is not quantified

correctly by a multi-channel instrument, which of the following other re-
sults must be calculated by hand?

A. MCV and RDW

B. MCH and RDW
C. MCV and MCH
D. MCH and MCHC

76. Given the following data, calculate the reticulocyte production index (RPI).
24-year-old male
Reticulocyte count: 6.0%
Hematocrit: 0.28 L/L
Boel th,
Be 1
G38
De :8

AT, What morphologic term(s) would be used to describe the following red cell
population?

MCV: 82 fL
MCHC: 32.5 g/dL
RDW: 17.4
A. Microcytic normochromic
B. Microcytic hypochromic
C. Normocytic normochromic with anisocytosis
D. Microcytic hypochromic with anisocytosis

78. An entire batch of Wright-stained peripheral blood smears has extremely

red-orange erythrocytes and little to no coloration in the cytoplasm of all of
the white cells. A possible cause would be
198 7. Review Tests

. buffer is too acidic

. buffer is too basic
. stain has been contaminated by water
. stain has
DUALS become too concentrated due to evaporation

ike The Levey-Jennings plot from an automated cell counter indicates a steadily
increasing MCV for the past 4 days. One interpretation is the

. control material has been contaminated

. diluent is degrading
. instrument needs to be cleaned
. control has not been warmed sufficiently prior to use
DUaAnS

80. Which of the following situations will cause falsely elevated cyanmethe-
moglobin levels?

A. Hemoglobin-F levels of 6%
B-RBC count of 3:21 x 1027/L
C. Sulfhemoglobin
D. WBC count of 80 X 10°/L

81. Using a calibrated Miller disk and counting eight successive fields, 163
reticulocytes were counted in square A and 500 RBCs were counted in
square B. The reticulocyte count in percent is

A. 3.2%
B. 3.6%
C. 6.4%
DeIG3%

82. A manual platelet count was performed using a 1/100 dilution, and a total of
200 platelets were counted in a 1-mm/? area. This count best matches which
of the following platelet slide estimates?

A. Markedly decreased
B. Slightly decreased
C. Adequate
D. Markedly increased

83. A false-negative result for hemoglobin S in the whole-blood screening sol-

ubility test can be caused by

. recent transfusion
. increased chylomicrons
. extreme leukocytosis
S . hyperglobulinemia
Daw

84. A cerebrospinal fluid specimen collected from a 9-month-old female had a

cell count of 25 cells/jzL with 90% lymphocytes and 10% monocytes. These
results suggest
 CLT Review Test 199
r=)
d
=
. viral meningitis S
. bacterial meningitis Md
>
. a cerebral infarction i)
c
YS
Yaw. anormal cell count and differential

85. The crystals in a synovial fluid sample appear strongly birefringent when
viewed under polarized light. When aligned parallel with the slow vibration
of light, the crystal is yellow. This crystal is

. apatite
. cholesterol
. monosodium urate
YS
VAWw
. calcium pyrophosphate

86. Your last 20 Wright-stained smears were all too pink in color. What is the
best way to remedy this situation?

A. Make all blood smears thinner

B. Increase the methanol content of the stain
C. Shorten the staining (buffer) time
D. Increase the pH of the buffer

87. Secondary granules first appear in which stage of neutrophilic develop-

ment?

A. Myeloblast
B. Promyelocyte
C. Myelocyte
D. Metamyelocyte

88. A supravital stain must be used to demonstrate the presence of

A. Howell-Jolly bodies
B. siderocytes
C. malarial parasites
D. reticulum

89. An erroneously high spun hematocrit can be caused by

A. reticulocytosis
B. hemolysis of the blood sample
C. reading the buffy coat as part of the packed-cell portion
D. macrocytosis

. A patient has a WBC count of 150.0 x 10°/L. On the 100-cell differential,

10% of the cells exhibit a slightly off-center nucleus with a fine chromatin
pattern. Several of these cells have nucleoli. The cytoplasm is dark blue with
red granules that cover the nucleus. These cells are most likely

A. atypical lymphocytes
B. myelocytes
200
Be
eee 7. Review Tests ————— ees

C. promyelocytes
D. myeloblasts

91. On a normal WBC differential from a 24-year-old male, there are usually
more
A. lymphocytes than any other cells
B. monocytes than eosinophils
C. basophils than eosinophils
D. band neutrophils than lymphocytes

92. A sample is stored for quality-control precision testing. After nearly 24 h at

4°C, the sample is

. appropriate to use immediately

. appropriate to use after warming and mixing for at least 5 min
. inappropriate to use due to swelling of RBCs
. inappropriate to use due to autolysis of WBCs
DUaAwWS

93. To obtain accurate results on a Westergren ESR, blood kept at room tem-
perature should be set up within a maximum of how many hours?

od
oO Re
oBRN

94. A clinical laboratory technician has made ten peripheral blood smears. All
ten show the presence of large amounts of rouleaux. One possible explana-
tion for this is

A. all ten patients have hypoglobulinemia

B. the drop of blood that was used was too big
C. the angle of the spreader slide was too high for the amount of blood that
was put onto the slide
D. there was a prolonged time between the moment at which the blood con-
tacted the spreader slide and the beginning of the push

95. Which of the following situations would falsely decrease the quantitation of
hemoglobin using the cyanmethemoglobin (ferricyanide) method?

A. Large amounts of sulfhemoglobin

B. Large amounts of carboxyhemoglobin
C. Presence of hemoglobin S
D. Absence of hemoglobin A,

96. The following results are obtained on a 60-year-old female:

RBG? £85 x 1027/0

Hb: 7.5 g/dL
Het 0:2
 CLT Review Test 201
Pw)
o
Ke
On the peripheral blood smear, the RBCs should appear Ss
2
. microcytic, hypochromic >
v
. Microcytic, normochromic ce
. hormocytic, normochromic
@ . Macrocytic, normochromic
se
a
ue)

97. The following results were obtained on an electronic cell counter:

RBG. WAGs >< 10M /1

Hb: 9.5 g/dL
fC 23 Wl

The appropriate course of action would be to

. report values as obtained

. repeat determination using a 1/2 dilution
. warm specimen for 15 minutes at 37°C and re-run
S . report
Faw as “unable to determine”

98. On a Wright-stained blood smear small blue inclusions are noted in several
neutrophils. These inclusions should be identified as

A. Dohle bodies
B. Auer rods
C. basophilic stippling
D. toxic granulation

99. A patient has a reticulocyte count of 8.5%. Which of the following best
correlates with this value?

A. Aplastic anemia
B. Hemolytic anemia
C. Pernicious anemia
D. Normal value

100. A 5-month-old male has a hemoglobin of 7.5 g/dL, Hct of 25%, RBC of
3.5 X 10!2/L. Which of the following is the appropriate action?

A. Examine a microhematocrit for lipemia

B. Warm specimen to 37°C and repeat procedures
C. Examine peripheral blood smear for microcytic, hypochromic
RBCs
D. Repeat determination using a 1/2 dilution

101. On a Wright-stained blood smear, 3% of the RBCs have a purple color.

These RBCs should be identified as

A. hypochromia
B. polychromasia
C. target cells
D. spherocytes
202 7. Review Tests

102. A patient has a WBC of 18.0 X 10°/L. There are 85% neutrophils; many
contain toxic granulation. Which of the following is a probable cause?

A. Bacterial infection
B. Viral illness
C. Acute leukemia
D. Agranulocytosis

103. When making smears from a bone marrow aspirate specimen, the clinical
laboratory technician should select

A. clotted specimens
B. material free of fat
C. the last material aspirated
D. gray particles floating in blood and fat droplets

104. Which of the following will cause the greatest effect on the erythrocyte
sedimentation rate?

A. Sickle cells
B. Spherocytes
C. Rouleaux
D. Macrocytes

105. What is the maximum normal time for liquefaction of a semen specimen?

A. 10 minutes
B. 30 minutes
C. 1 hour
D. 2 hours

106. The preferred temperature for prothrombin times is

A. 56°C
Base
C Sere
D. 24-€

107. A 45-year-old patient has a normal prothrombin time and partial thrombo-
plastin time. He experiences oozing from minor injuries and has a pro-
longed bleeding time. This defect could be due to

A. liver disease
B. vascular disease
C. thrombocytopenia
D. thrombocytosis

108. Coagulation studies have been ordered for a patient who is suspected of
having a Factor X deficiency. You should expect prolonged values from
which of the following tests?
 CLT Review Test 203
Po

o
=
A. Bleeding time Ss
B. Fibrinogen =
>
C. Prothrombin time Vv
c
D. AT Ill

109. The most appropriate coagulation test to monitor vitamin K antagonist

therapy is the

. activated partial thromboplastin time (APTT)

. thrombin time
. reptilase time
SLS
Daw. prothrombin time

110. The mean value for a normal prothrombin time control is 12.0 seconds.
One standard deviation is 0.5 seconds. The acceptable range for this con-
trol is seconds.

A. 11.5-12.5
B. 11.0-13.0
C. 10.5-13.5
D. 10.0-14.0

111. A patient has a prolonged prothrombin time and a normal APTT. One con-
dition in which you might expect to have these findings is

A. Factor II deficiency
B. Factor VII deficiency
C. cirrhosis
D. von Willebrand disease

112. Patients with hemophilia B typically have abnormal

A. activated partial thromboplastin time

B. prothrombin times
C. fibrinogen levels
D. Factor V levels

113. Which of the following neutralizes activated Factors V and VIII?

A. t-PA
B. Activated protein C
C. Antithrombin III
D. Fitzgerald factor

114. The result of a prothrombin time (PT) performed on the plasma of a patient
who has been admitted with a diagnosis of a cerebrovascular accident is 34.3
seconds. A 1/2 dilution of patient plasma and fresh normal plasma results in
a PT of 48 seconds. One explanation of this situation is that the patient

A. is severely dehydrated
B. took an overdose of vitamin K antagonists
204 CR
ha 7. Review
he Tests ee eeRe ee ee

C. may have lupus-like anticoagulant ;

D. is responding to the bleeding episode by producing a hyperthrombotic
state

115. A co-factor of protein C is

A. antithrombin III
B. t-PA
C. streptokinase
D. protein S

116. When using an electro-optical instrument, the values for all three levels of
coagulation controls have been rising between 0.5 to 0.9 seconds on each
of the last 4 days. One possible explanation for this is

A. substrate deterioration
B. control contamination
C. loss of internal instrument calibration
D. damaged sensor probes

117. The anticoagulant of choice for coagulation testing is

A. 3.2% EDTA
B. 3.8% sodium fluoride
C. 3.2% sodium citrate
D. 3.8% heparin

118. In order to calculate an INR, which of the following is required from the
manufacturer of the reagent?

A. Control range
B. Mean of the normal range
C. International sensitivity index
D. Date of reagent manufacture

119. In the tube used for coagulation testing how many parts of blood must be
added to one part of anticoagulant?

120. A patient has a normal PT and a prolonged APTT. After mixing normal
plasma with the patient’s plasma, there is still a marked prolongation of the
APTT. What is the most likely cause of the prolongation?

A. Factor VIII deficiency

B. Hypocalcemia
C. Factor XII deficiency
D. Circulating anticoagulant
 CLT Review Test 205

es

d
—
121. A patient has poor wound healing and minor oozing from surgical inci- 5
sions. All of the coagulation tests were normal, except for rapid clot disso- 4
>
lution in SM urea. What is the probable cause of the patient’s bleeding? v
4

A. Poor platelet function

B. Factor VII deficiency
C. Excessive heparin administration
D. Factor XIII deficiency

122. An increased fibrinogen may be caused by

A. inflammation or sepsis
B. acute DIC
C. lupus anticoagulant
D. dysfibrinogenemia

123. A patient is admitted to the emergency room with a working diagnosis of

septic abortion. The following laboratory results were determined:

PA: 18 seconds (N = 10-14)

APTT: 60 seconds (N = 26-39)
aal 30 seconds (10-15)
Fibrinogen: 60 mg/dL (15-400)
Platelet count: 55 X 10°/L (150-450 x 10°/L)

This appears as a case of

A. primary fibrinolysis
B. liver disease
C. disseminated intravascular coagulation
D. hemophilia A

124. The purpose of confidential exclusion of donor units is to

. allow all donors to remain anonymous

. reduce the possibility of transmission of blood borne diseases
. maintain confidentiality when a donor is excluded for any reason
S
Ga. ensure that any donated blood cannot be traced back to the donor

125. For blood collected for transfusion, which of the following is the preferred
solution for cleansing the arm for most donors?

A. 70% alcohol
B. Green soap
C. 0.7% PVP-iodine
D. 90% alcohol

126. According to the AABB Technical Manual, which of the following is not
an adverse reaction of blood donation?

A. Nausea and vomiting

B. Fainting
206 7. Review Tests

C. Convulsions
D. Hives

127. Which of the following storage conditions will best maintain the viability
and function of platelet concentrates for 5 days after collection?

A. 20-24°C with no agitation

B. 4-6°C with agitation
C. 20-24°C with agitation
D. 1-10°C with agitation

128. In performing ABO and Rh testing on donor blood intended for transfu-
sion, the following reactions were obtained:

Donor cells + Donor plasma +

Anti-A Anti-B Anti-D A, Cells B Cells
4+ 0 0 0 3+

What additional testing should the clinical laboratory technician perform

before labeling this donor unit?

A. Test donor cells for the weak D antigen

B. Test donor cells with anti-A,B
C. Test donor serum for anti-A,
D. Repeat ABO typing and Rh typing to double check results

129. Of the following people, who would qualify as a regular blood donor?

A. A 25-year-old man who had a positive test for syphilis 6 months

ago
B. A man who had major surgery and received blood components 8
months ago
C. A woman who was treated for malaria and has been asymptomatic for
five years
D. A woman in the first trimester of pregnancy
Answer: C

130. Before releasing every donor unit from the collection center, each unit
must test negative for

A. antibodies to cytomegalovirus
B. antibodies to hepatitis C
C. malarial parasites
D. bovine spongiform encephalitis (mad cow disease)
Answer: B

131. The screening of a female blood donor yielded the following results:

Weight: 115 lbs

Hemoglobin: 13.0 g/dL
Temperature: 36.5°C
Blood pressure: 145/85 mm Hg
 CLT Review Test 207
a
d
=
In addition, the woman had no recent surgeries; had a tattoo applied 6 Ss
months ago; had not traveled outside the U.S.; had no history of jaundice 2
>
or hepatitis; and took no routine medications (although she had taken 2 as- oY
ce
pirin for a headache 5 days ago). This donor is

A. acceptable as a red cell donor only

B. acceptable as a whole blood donor
C. deferred for at least 6 months
D. deferred indefinitely

132. In addition to the full name and hospital number, a patient’s sample for typ-
ing and compatibility testing must also be labeled with the

A. diagnosis
B. name of the attending physician
C. date of collection
D. initials of the phlebotomist

a33. After centrifugation, an antibody screening tube is shaken to resuspend the

cell button. The cells stream off the button with only occasional small ag-
glutinates in a background of free RBCs. Once the cell button is com-
pletely dislodged, it should be graded as

TNs AES
B. 2+
C_ 3+
D. 4+

134. Mrs. M. delivered an infant two weeks prematurely. Her physician requests
a blood transfusion for Baby M. The results are given below:

Mrs. M’s results Baby M’s results

ABO group: A ABO group: A
Rh type: negative Rh type: positive
Autocontrol: negative DAT: positive
Antibody screen: positive
Antibody ID: anti-D and anti-C

Which of the following units of blood should be selected for transfusion?

A. Group A, Rh-positive, C positive

B. Group A, Rh-negative, C negative
C. Group A, Rh-positive, C negative
D. Group O, Rh-negative, C positive

135. Which of the following techniques can be used to gain reliable antibody
screen and crossmatch results for patients whose serum causes test-cell
rouleaux?

A. Autoabsorption
B. Enzyme pretreatment of cells
208 7. Review Tests ——)

C. Prewarm technique
D. Saline replacement
Answer: D

136. The following reactions were obtained on pretransfusion testing using

monoclonal Anti-A, Anti-B and Anti-D:

Patient cells + Patient serum +

Anti-A Anti-B Anti-D A, Cells B Cells
0 0 34+ 4+ 3+

The patient’s blood type is

A. Group O, Rh-positive
B. Group AB, Rh-positive
C. Group A, Rh-negative
D. Group O, Rh typing is not conclusive because an Rh control was not
tested

137. Serum from the majority of group A individuals contains

. anti-A
. anti-A,B
. anti-B
i=
ssh
M@V. anti-D

138. Given the reactions below, the patient’s group and type are:

Anti-A = Anti-B Anti-A,B Anti-D Rh control

Patient cells 4+ 0 + 3+ 0

A, cells B cells
Patient serum 0 4+

A. Group A, Rh-negative
B. Group A, Rh-positive
C. Group B, Rh-negative
D. Group B, Rh-positive

139. Based on the following red cell reactions, the only Rh genotype that is not
a possibility is:

Antiserum Reaction
anti-C +
anti-D
anti-E
anti-c
anti-e t+
+++

A. Cde/cdE
B. cDE/Cde
 CLT Review Test 209
ww

cf
f=
C. CDe/cDE Ss
D. cDe/cdE a
>
ov
ce

140. Which of the following cells would be an appropriate positive control cell
for antigen-typing procedures using commercially prepared anti-Jk??

A. ce, Fy(a—b+), Jk(a+b+), Le(a—b—)

B. Cce, Fy(at+b—), Jk(a—b+), Le(a—b+)
C. CDEe, Fy(a+b+), Jk(a—b+), Le(a—b+)
D. Ce, Fy(a+b—), Jk(a+b—), Le(a+b—)

141. The following reactions are obtained on ABO testing of a patient’s blood
sample. What is the most likely ABO group?

Patient cells + Anti-A Anti-B Anti-A, lectin

3+ 0 0

Patient serum + _ A, cells A, cells B cells O cells

2+ 0 4+ 0

A. A,
B. A,
C. A, with anti-A,
D. A,B with anti-A,

142. All of the following antibodies are considered to be clinically significant

except

. anti-Le®
. anti-K
. anti-Jk?
FTawyY
. anti-A

143. During interpretation of antibody cell panels, it is important to remember

that M, N, and P, antibodies are most often identified

. at room temperature, 18°C or 4°C

. by acidifying the patient’s serum
. after the antiglobulin test
. after enzymatic treatment of red cells
DawS>

144, Which of the following antibodies is enhanced by acidification of the pa-

tient’s serum?

A. Anti-Fy*
B. Anti-K
C. Anti-M
D. Anti-E

145. Given the following abbreviated cell panel, determine the most probable
antibody(ies) in the patient’s serum.
210
i 7.SSN
Review Tests ee Se a aa

37°C Check
Cae DRESS. c N SS. LISS’ AHG cells
1+ 0O O + + + 0O 0 2+
Dati en Onin 0) 0 + O 0 2+
Bb ti omtee On 0 + + O 0 2+
4,0 + + + (ee @) 1+ NA
5750) Ome +icda0 a 0 0 2+
6102203 +0> + O++ Ge
Sp
ap
ge
apse
Ee
4/0++ tFOoOTOOOC]RA
#~9 Gt-40 1+ NA
A. Anti-E
B. Anti-c
C. Anti-K
D. Anti-E and anti-c

146. What reagent would be most useful in separating anti-C from anti-Fy*?
A. Ficin
B. 2-Aminoethylisothiouronium (2-AET)
C. 2-Mercaptoethanol (2-ME)
D. Low-ionic-strength saline (LISS)

147. Given the following panel, what is the most likely specificity of the anti-
body(ies) in the serum tested? (NP = not performed)

Kyid © Check
DeC. aH e Fy? Fy” Jk? Jk?
LISS AHG cells
l+ + + O +
0 NP +
0
Qieat phlei) 0 st 0 NP
3. + O + + NP
4+ 0 0O + NP
5.30. +5 <0 Se NP
60 O + + NP
Dee Oe) EOF Oia? ce 2+
ord: MOA ees ++t+¢+
O04+4/0
SO+ +Ottt+t++
coe
CO;
CCS
m sr
&]
SC
2] 44+
t++Ot+
Sep Otr+t+t+00
SooNP
©
oe

A. Anti-Fy° and anti-c

B. Anti-K
C. Anti-Fy*
D. Anti-Fy* and anti-D

148. A serum has been tentatively determined to contain anti-c and anti-K. A se-
lected cell panel is composed as shown below. The serum is reacted with
the selected cell panel producing the results shown. (NP = not performed)
Antigens on cells Serum reactions
K OQ AHG Cheek cells
2+ NP
0
2+
2+
2+
0
2+
2+
Qa
S&S
a7
or
SOS]oO
oS
o+
oo
+
OmMmrANMNHBWN 0
 CLT Review Test 211
bd

d
=
These results indicate that Ss
A
>
. there is a third alloantibody present in the serum CY
cf
. the serum contains anti-K but not anti-c
. the serum contains only anti-K and anti-c
. the serum does not contain anti-c but contains anti-K and another
DUaAwS
unidentified alloantibody

149. How long after transfusion must a sample from the donor unit be retained
in the transfusion service?

A. 24h
B. 48h
C. 3 days
D. 7 days

150. Coombs control cells (check cells) are used in AHG testing to detect false

A. positive reactions due to IgG sensitized cells

B. negative reactions due to inactivated anti-IgG
C. positive reactions due to inadequate washing
D. negative reactions due to rouleaux

a51. An incompatibility in the immediate spin phase of pretransfusion-compat-

ibility testing suggests a/an

A. ABO mismatch
B. anti-Fy*
C. positive donor antibody screen
D. Rh antibody

132. A group O, Rh-positive patient experienced a delayed transfusion reaction.

The post-reaction specimen demonstrated anti-c. Select the most appropri-
ate donor genotype for further red cell transfusions.

A. Cde/CDe
B. cdE/cdE
C7 Cpe/cde
D. cde/cde

153. A group A, Rh-negative patient has a transfusion record identifying anti-

Jk* two years ago. Current antibody screens are negative. Which of the fol-
lowing is the best red cell phenotype for transfusion to this patient?

A. Group A, Rh-negative, Jk(a+)

B. Group A, Rh-positive, Jk(a—)
C. Group O, Rh-positive, Jk(a—)
D. Group O, Rh-negative, Jk(a—)

154. A 46-year-old male is expected to need 3-5 units of blood for surgery. He
is group O, Rh-positive and has a negative antibody screen. His transfusion
212Om 7.
Oo Pitino Review
SUIS IV Tests
NR a

history reveals a delayed transfusion reaction 5 years ago. The antibody

identified at that time was anti-e. Which of the following is an appropriate
protocol for pretransfusion testing on this patient?

A. Immediate spin-only crossmatch on random donors

B. Immediate spin-only crossmatch on e-negative donors
C. Crossmatch random donors through the antiglobulin phase
D. Crossmatch e-negative donors through the antiglobulin phase

155. Below are the results of an antibody screen and crossmatches on the serum
of a patient scheduled for surgery. (NP = not performed)

37C Check
IS LISS AHG cells
Screen cell I NP 0 0 Din
Screen cell II NP 0 0 2+
Donor A 0 0 0 2+
Donor B 0 0 0 2+
Donor C 0 0 0 2+

These results should be interpreted as

A. negative antibody screen and compatible crossmatches

B. negative antibody screen and incompatible crossmatches
C. positive antibody screen and compatible crossmatches
D. positive antibody screen and incompatible crossmatches

156. When performing a direct antiglobulin test using polyspecific AHG, no ag-
glutination is detected using IgG-coated red cells (check cells). This test
should be considered

A. negative; report the results

B. invalid; add more anti-IgG and re-centrifuge the tubes
C. positive: report the results
D. invalid; repeat the entire direct antiglobulin procedure

1572 In a Kleihauer-Betke test, the fetal cells

A. appear as “ghosts”
B. stain blue
C. stain light red
D. lyse and are not visible

158. Below are the ABO groups, Rh types, and gestational ages for four preg-
nant women. Which of them is eligible for antenatal Rh-immune globulin?

A. Group O, Rh-positive, 32 wk
B. Group A, Rh-negative, weak D negative, 22 wk
C. Group B, Rh-negative, weak D negative, 28 wk
D. Group AB, Rh-positive, 24 wk
 CLT Review Test 213
J

d
4
159: Below are the results of pre- and posttransfusion testing on four patients 5
suspected of having transfusion reactions. fn
>
Y
ce
DAT Serum hemolysis
pre post pre post
Patient 1 0 0 0 1+
Patient 2 0 2+ 0 0
Patient 3 0 0 0 0
Patient 4 0 0 1+ 1+

Which demonstrate(s) evidence of a possible hemolytic reaction?

A. Patients | and 2
B. Patients 3 and 4
C. Patients 1 and 4
D. Patient 2 only

160. A physician is concerned about the possibility of hemolytic disease of the

newborn in a patient who is in her third trimester. Which of the following
laboratory tests provides the most information about the possibility of he-
molytic disease of the newborn in this case?

A. Direct antiglobulin test on the maternal cells

B. Antibody screening on the maternal serum
C. ABO and Rh typing on the maternal sample
D. Elution of antibody from the maternal cells

161. A unit of cryoprecipitated antihemophilic factor (AHF) must be thawed at

temperatures between

A. 1-6°C
B. 10—20°C
C. 20—24°C
D. 30-37°C

162. Before releasing a unit of blood in an emergency situation, which of the

following procedures must be performed?

A. The physician must sign a statement documenting the urgent need for
the transfusion
B. The laboratory personnel must have a properly labeled sample of blood
from the patient
C. The patient’s history of transfusions must be checked and documented
D. The laboratory must inform the FDA that uncrossmatched O negative
units will be released from the transfusion service

163. A unit of packed red cells was returned to the transfusion service unused.
Examine the data below to determine whether the unit can be reissued.
214 7. Review Tests

Unit entered: no
Time out of the laboratory: 14:53
Time returned to the laboratory: 15:38
Appearance of plasma: clear
Segments attached: 3

A. The unit can be reissued

B. The unit cannot be reissued based on the amount of time out of the lab-
oratory
C. The unit cannot be reissued based on the appearance of the plasma
D. The unit cannot be reissued based on the number of segments attached

164. Which of the following blood components returned within 30 min of issue
can be returned to the transfusion service inventory and reissued to another
patient?

A. A unit of fresh-frozen plasma (FFP) thawed two days ago

B. A unit of cryoprecipitated antihemophilic factor (AHF) with a spike in
one port
C. A unit of RBCs returned unentered with a temperature of 6°C
D. A unit of platelet concentrate that has been refrigerated while out of the
transfusion service

165. Which of the following is performed as routine pretransfusion testing on

all patients?

A. Antibody panel identification

B. Antiglobulin-phase crossmatch
C. Direct antiglobulin testing
D. Examination of prior transfusion records

166. Group O, Rh-positive cells are used for antibody-screening tests because

. anti-A and anti-B do not react with O cells

. anti-A, is detected using O cells
. most recipients are O and Rh-positive
=)
Ps . weak A or B subgroups react with O cells
@Vise)

167. In the gel agglutination method for ABO typing, a 4+ positive reaction is
indicated by red cell agglutinates

A. trapped at the top of the gel column

B. pelleted at the bottom of the gel column
C. distributed evenly throughout the gel column
D. trapped mid-way through gel column

168. Two units of blood are requested for a 46-year-old male who is scheduled
for surgery. The patient has no history of transfusion. The following results
are obtained:
 CLT Review Test 215
e)
od
[=
Immediate Coombs 5
Patient’s serum + spin AHG control 2
>
oY
Screening Cell I 0 0 2+ ce
Screening Cell II 0 0 2+
Screening Cell II 0 0 2+

The appropriate crossmatch procedure for this patient is

A. test donor plasma and patient’s cells on immediate spin

B. test donor cells and patient’s serum on immediate spin and AHG
C. test donor cells and patient’s serum on immediate spin only
D. test patient’s serum with donor cells and a 10 cell panel on immediate
spin and AHG

169. A unit of red blood cells (RBCs) preserved in an additive solution (AS-1)
has a shelf life of

A. 21 days
B. 35 days
C. 42 days
D. 8 weeks

170. Which of the following sets of reactions are typical of a patient with a
weak subgroup of B?

Patient Cells + Patient Serum +

Anti-A Anti-B A, Cells B Cells
A. 0 2+ 4+ 0
Be 0 0 0 0
C30) 4+ 2+ 0
D. 4+ 1+ 0 4+

171. An Anti-Jk* that exhibits dosage would react best with which of the fol-
lowing cells?

A. Cell #1 Jk*(a+b-)
B. Cell #2 Jk*(a-b-)
C. Cell #3 Jk*(a+b+)
D. Cell #4 Jk*(a-b+)

172. The results of a direct antiglobulin test performed on an EDTA sample are
as follows:

Polyspecific
AHG Anti-IgG Anti-C3d
Patient’s Cells 2+ 0 2+
Check Cells NP fas NP

NP = not performed

The correct interpretation of these results is that

216 7. Review Tests

A. The patient’s cells are coated with IgG and complement

B. The patient’s cells are coated with complement only
C. The patient’s cells are coated with IgG only
D. The tests cannot be interpreted due to incorrect procedure

173. Which of the following red blood cell components would be most appro-
priate for a patient who has a history of febrile nonhemolytic transfusion
reactions?

A. Red blood cells—irradiated

B. Red blood cells—washed
C. Red blood cells—rejunvenated
D. Red blood cells—leukocyte reduced

174. Gram-positive cocci in pairs and clusters are isolated from a superficial
skin lesion. The isolate is beta-hemolytic on sheep-blood agar. Further test-
ing reveals that the isolate is catalase-positive and coagulase-positive. The
definitive identification of this organism is

A. Staphylococcus aureus
B. Staphylococcus epidermidis
C. Streptococcus agalactiae
D. Streptococcus pyogenes

175. A transtracheal aspirate yields a pure culture of an alpha-hemolytic, gram-

positive coccus that is catalase-negative. A test to perform in the subse-
quent identification process is

. CAMP reaction
. coagulase
. susceptibility to bacitracin
S . susceptibility to ethylhydrocupreine hydrochloride (optochin)
DAW

176. A child presents with a typical paroxysmal “whoop’-type cough and lym-
phocytosis. The most appropriate primary culture medium to isolate the
suspected etiologic agent is

A. charcoal yeast-extract agar

B. chocolate agar
C. Bordet-Gengou agar
D. Tinsdale agar

We A gram-negative diplococci that is a normal inhabitant of the human na-

sopharynx, but is known to cause serious systemic illness in children and
young adults is

A. Haemophilus influenzae
B. Listeria monocytogenes
C. Neisseria meningitidis
D. Streptococcus pneumoniae
 CLT Review Test 217

~
d
=
178. Most members of the genus Pseudomonas are gram-negative rods that are 5
A
>
A. glucose-fermenters & motile CY
ce
B. oxidase-positive & motile
C. oxidase-negative & nitrate-positive
D. glucose-fermenters & nitrate-negative

179. A microorganism resembling Escherichia coli is isolated from an infected

traumatic wound. After additional tests the organism is identified as
Aeromonas hydrophila. The single best test to differentiate A. hydrophila
from E. coli is

A. Gram’s stain
B. glucose fermentation
C. lactose fermentation
D. oxidase production

180. A STAT Gram’s stain is requested on the purulent sputum specimen of a

55-year-old patient. Microscopic examination of the stained smear shows
numerous polymorphonuclear cells and many gram-positive cocci in pairs.
Halo around the diplococci is noted. The next step for the clinical labora-
tory technician is to

A. phone the report to the physician, indicating findings of 4+ GPCs in pairs

B. set up a sputum culture with “P” disk to confirm the presence of sus-
pected Streptococcus pneumoniae
C. examine the smear more carefully to rule out other potential pathogens
D. repeat the Gram’s stain with a thinner smear, taking care to decolorize
adequately

181 e Which of the following specimens should not be routinely processed for
anaerobic evaluation?

A. blood
B. clean, voided urine
C. synovial fluid
D. transtracheal aspirate

182. Chocolate agar is usually used as primary plating medium for

. spinal fluid
. throat
. stool
Gan}
. urine

183. Several vacationers at a Gulf Coast seaside resort complain of severe ab-
dominal pain and diarrhea after ingesting raw oysters. The media that is
most appropriate for screening these patients’ stools is

A. bismuth sulfite
B. cellibiose arginine lysine
218 7. Review Tests

C. cycloserine cefoxitin fructose

D. thiosulfate citrate bile salts sucrose

184. The reagent(s) used to detect a positive indole reaction for the Enterobac-
teriaceae is(are)

A. alpha-naphthylamine and sulfanilic acid

B. alpha-naphthol and potassium hydroxide
C. paradimethylaminobenzaldehyde
D. tetramethylparaphenylenediamine dihydrochloride

185. Which pair of organisms provides an appropriate quality-control check for

the biochemical reactions on MacConkey agar and on Hektoen enteric
(HE) agar?

A. Escherichia coli, Klebsiella pneumoniae

B. Salmonella enteritidis, E. coli
C. Shigella sonnei, E. coli
D. Providencia rettgeri, K. pneumoniae

186. A saprobic fungus whose micromorphology can be easily confused with

that of the mycelial phase of Histoplasma capsulatum 1s

A. Fusarium
B. Pseudoallescheria
C. Chrysosporium
D. Sepedonium

187. A direct microscopic examination of an exudate from the lung reveals

large spherules with endospores. The thick-walled spherules should alert
the laboratory practitioner to the possibility of

A. Cryptococcosis
B. coccidioidomycosis
C. candidiasis
D. blastomycosis

188. Quality-control regimen is to be selected for the following tests:

Phenylalanine deaminase (PAD)

Indole production
Voges-Proskauer (V-P)

Which pair of stock culture organisms would you select as suitable to ver-
ify the performance of these three tests?

A. Klebsiella pneumoniae, Proteus vulgaris

B. P. vulgaris, Escherichia coli
C. E. coli, Enterobacter aerogenes
D. E. aerogenes, K. pneumoniae
 CLT Review Test 219
~

cf
=
189. Which of the following parasites are most likely to be overlooked on a wet s
preparation and detected on a permanent-stained slide? 2
>
cc}
ce
A. Protozoa
B. Larvae
C. Helminth eggs
D. Proglottids

190. Several cysts and trophozoites are seen on trichrome stain-permanent

mount and on iodine preparation from stool concentrate. Which of the fol-
lowing are characteristic of Entamoeba histolytica?

A. Cysts with five to eight nuclei and chromatoid bodies with splintered
ends
B. Trophozoites with one nucleus with an eccentric karyosome
C. Cysts with two to four nuclei characterized by small, round, centrally
located karyosomes
D. Granular vacuoles containing bacteria and debris

191. Which of the following organisms would most likely be seen in a urethral
discharge?

A. Balantidium coli
B. Enteromonas hominis
C. Giardia lamblia
D. Trichomonas vaginalis

192. Which of the following situations would most likely produce falsely de-
creased zones of inhibition on a Kirby-Bauer disk-diffusion susceptibility
test?

A. Use of an antimicrobial disk with a higher-than-recommended concen-

tration of an antimicrobial
B. Use of an inoculum that is too light
C. Use of Miieller-Hinton agar thinner than 4 mm
D. Use of Miieller-Hinton agar thicker than 4mm

193. In a broth dilution test, the lowest concentration of an antibiotic that pro-
duces an irreversible killing of the organism is called the minimal

. antibiotic concentration
. bactericidal concentration
. inhibitory concentration
. susceptible concentration
DVaAWwS>

194, The test that would most likely be ordered for a patient who develops diarrhea
after being hospitalized for an upper urinary-tract infection for five days is

A. stool culture for enteric pathogens

B. stool for parasite exam
220
a 7. Review Tests ee eS ee

C. fecal fat (qualitative)

D. stool for Clostridium difficile

195. To help distinguish fungal elements in a direct wet preparation of a sus-

pected ringworm infection, the recommended preparation is

A. India ink
B. Gram’s stain
C. 10% potassium hydroxide
D. acid-fast stain

196. Germ-tube production within 3 h of incubation of the organism in bovine

serum at 37°C is indicative of

A. Cryptococcus neoformans
B. Candida albicans
C. Torulopsis glabrata
D. Trichosporon beigelii

197. Rheumatic fever and glomerulonephritis are diseases commonly associ-

ated with which organism?

A. Staphylococcus aureus
B. Streptococcus agalactiae
C. Enterococcus faecalis
D. Streptococcus pyogenes

198. A 19-year-old college student was seen for the continuation of a purulent ure-
thral discharge despite treatment for suspected gonorrhea. Symptoms re-
solved after a course of tetracycline. Etiology of his urethritis was most likely

A. Chlamydia trachomatis
B. herpes simplex
C. Neisseria species
D. papillomavirus

199, The bacterial enzyme tryptophanase breaks down the amino acid trypto-
phan to produce

A. phenylpyruvic acid
B. indole
C. acetylmethylcarbinol
D. urea

200. The duodenal-aspirate and Enterotest-capsule techniques may be used to

recover

A. Ascaris lumbricoides
B. lodamoeba biitschlii
C. Giardia lamblia
D. Entamoeba histolytica
 CLT Review Test 221

~
d
i=
201. A direct antigen detection test is a presumptive means for identifying 5
which organism in cerebrospinal fluid? 2
>
CY
ce
A. Cryptococcus neoformans
B. Rhodotorula species
C. Candida albicans
D. Naegleria species

202. In suspected cases of tularemia caused by Francisella tularensis, the pre-

ferred plating medium is

A. Thayer-Martin
B. Sabourand
C. Bordet-Gengou
D. cystine blood agar

203. A small, microaerophilic, curved, gram-negative rod was isolated from a

diarrhea stool specimen. Further characterization revealed the organism to
be oxidase-positive, resistant to cephalosporin, susceptible to nalidixic
acid, and hippurate-hydrolysis positive, and it grew at 42°C. Identification
of this organism is

A. Yersinia enterocolitica
B. Campylobacter jejuni
C. Bacillus cereus
D. Salmonella typhi

204. Helicobacter pylori is associated most commonly with

A. traveler’s disease
B. Crohn’s disease
C. arthritis
D. gastric ulcer

205. Stool cultures from children with a day-care outbreak of diarrhea revealed
an oxidase-negative, nonlactose fermenting, nonmotile, gram-negative
rod. These characteristics presumptively indicate

A. Salmonella species
B. Shigella species
C.Ecoli OIST-H7
D. Campylobacter species

206. The first screening test of choice for human immunodeficiency virus
(HIV) antibodies is the

A. ELISA
B. fluorescent antibody
C. cell culture technique
D. RPR
222
oS 7. Review
ES Tests
SSO ee ——————

207. A beta-hemolytic, gram-positive rod was isolated from the cerebrospinal

fluid of a baby with signs of meningitis. The isolate, which grew on sheep-
blood agar, demonstrated tumbling motility. The presumptive identity of
the isolate is

A. group-B streptococcus
B. Haemophilus influenzae
C. Streptococcus pneumoniae
D. Listeria monocytogenes

208. A modified acid-fast smear of the diarrheic stool of a dairy farmer revealed
red spherical structures averaging 6 4m in diameter. These findings are
consistent with

A. giardiasis
B. cryptosporidiosis
C. pneumocytosis
D. ascariasis

209. The Epstein-Barr virus is associated with which of the following?

A. Hepatitis
B. Infectious mononucleosis
C. Exanthem subitum (roseola)
D. Chicken pox

210. An organism growing on Martin-Lewis media is proven to be a gram-neg-

ative diplococci, oxidase-positive, with a carbohydrate utilization pattern
as follows:

Glucose: positive
Maltose: negative
Sucrose: negative ~
Lactose: negative

This isolate produces beta-lactamase by cefinase method. The clinical lab-

oratory technician must do the following to complete this report.
A. Comply with the policies governing reporting of communicable dis-
eases
B. Perform a complete susceptibility test before reporting
C. Repeat the carbohydrate testing to verify the identification
D. Perform additional testing to differentiate pathogen from non-pathogen

211. The biological-safety cabinet is used during the processing of specimens

for virus cultures primarily to

A. prevent having to use latex gloves in handling specimens

B. protect technicians from potential aerosols
C. protect the viral specimens from other types of bacterial or fungal
agents
D. prevent excessive decontamination of work-area surface
 CLT Review Test 223
Sd

d
4
212. Which of the following pairs of organisms does the optochin susceptibil- 5
ity test differentiate? {o
>
Y
ce
A. Group A beta-hemolytic streptococcus/Group B streptococcus
B. Streptococcus agalactiae/Enterococcus
C. Enterococcus sp./Group D
D. Group D streptococcus/ Viridans streptococcus
E. Viridans streptococci/Streptococcus pneumoniae

213. A bacterial structure, which consists of 2 layers of lipopolysaccharides

(outermembrane) in addition to the thin layer of peptidoglycan network,
exists in the cell wall of which of the following organisms?

A. Gram-negative bacteria
B. Gram-positive bacteria
C. Both gram-positive and gram-negative bacteria
D. Mycoplasmas

214. Organisms that can grow in the presence or absence of oxygen are called

. obligate aerobes
. aerotolerant anaerobes
. facultative anaerobes
. microaerophilics
QUAY

215. Erythrogenic toxin capable of causing scarlet fever is produced by a lyso-

genic strain of

A. Neisseria gonorrhoeae
B. Streptococcus pneumoniae
C. Streptococcus pyogenes
D. Staphylococcus aureus
E. Neisseria meningitidis
Answer: Cc

216. A 25-year-old female patient presented in the emergency room with fever,
nausea, vomiting, and extreme fatigue. On examination, the physician dis-
covered skin rash on her trunk and extremities. Additional history revealed
that the patient is on the 4th day of menses. The patient described most
likely has

. scalded skin syndrome

. staphylococcal food poisoning
. scarlet fever
. toxic shock syndrome
. Guillain-Barre’s syndrome
moawe

BAT. A urine sample that is shown to contain gram-positive cocci and gram-neg-
ative rods is inoculated on a sheep blood agar, MacConkey agar, and Co-
lumbia CNA agar. The Columbia CNA is included in the plating protocol
because it
224 7. Review Tests

. inhibits gram-positive cocci

. contains colistin and nalidixic acid as inhibitory agents
. provides good growth for both gram-positive and -negative bacteria
. contains X and V factors
. Shows lactose fermentation
mOoawpe
Answer: B

218. Which of the following is a common cause of urinary tract infection

among sexually active women?

A. Staphylococcus epidermidis
B. Staphylococcus aureus
C. Staphylococcus saprophyticus
D. Enterococcus
E. Viridans streptococci

219. Staphylococcus aureus causes a wide variety of infections, ranging from

wound to pneumonia. Treatment with penicillin has not been effective be-
cause of the

A. inability of penicillin to penetrate the membrane of S. aureus

B. antagonistic reactions caused by penicillin
C. production of beta-lactamase by S. aureus
D. production of penicillin acetylase by S. aureus

220. Osteomyelitis is diagnosed by isolation of the organism from the blood and
is a complication of an infection caused most often by

A. Proteus mirabilis
B. Enterococcus faecalis
C. Staphyloccus epidermidis
D. Staphylococcus aureus
E. Escherichia coli

221. A wound culture grows colorless colonies on MacConkey agar. O-F glu-
cose media were inoculated with the isolate. The results are:

Open tube +
Closed tube +
The correct interpretation of the results is that the organism

A. oxidizes glucose
B. ferments glucose
C. is biochemically inert
D. is most likely contaminated by another species
Answer: B

222. Exudates from a patient with acute epiglotittis show gram-negative, non-
motile, pleomorphic coccobacilli on direct smear. No growth is found on
MAC or BAP. On chocolate agar in enhanced CO, semiopaque colonies
appear. The organism is glucose-positive and grows only around the strip
that contains both X & V factors. This organism is
 CLT Review Test 225
~
4)
<
A. Haemophilus influenzae Ss
B. Haemophilus parainfluenzae 4
>
C. Haemophilus aphrophilus )
cf
D. Escherichia coli

223. An anaerobic gram-positive spore-forming rod is isolated from an intra-ab-

dominal abscess following bowel surgery. The organism produces colonies
on anaerobic blood agar that show double-zone of hemolysis. The organ-
ism that you will suspect is

A. Prevotella species
B. Clostridium perfringens
C. Propionibacterium acnes
D. Bacteroides fragilis

224. A patient who has experienced fever for the last several days is suspected
of a condition referred to as undulant fever. Which of the following is the
optimal clinical specimen to be collected from this patient?

A. Feces
B. CSF
C. Blood
D. Nasopharyngeal exudates
E. Transtracheal exudate

225. Identify a bipolar-staining gram-negative bacillus isolated from an infected

cat bite that does not grow on MacConkey but produces small colonies on
blood; oxidase-positive, positive-indole, ferments glucose, and negative
urea.

A. Bordetella bronchiseptica
B. Pasteurella multocida
C. Eikenella corrodens
D. Francisella tularensis
E. Brucella abortus

226. A physician suspects that a patient has neurosyphilis. A CSF specimen

from this patient is sent to the laboratory with a request to perform an RPR.
The CLT should

A. perform an RPR titer

B. perform an undiluted RPR
C. reject the specimen and request a serum specimen
D. request that a VDRL be ordered and the RPR be cancelled

227. A slide agglutination test for CRP shows no agglutination when undiluted
serum is tested. When a 1:5 dilution of serum is tested, strong agglutina-
tion is seen. The most likely cause for this discrepancy is

A. incorrect dilution technique

B. prozone reaction
226
ee 7. Review Tests —————————

C. failure to add the CRP reagent to the test system when the sample was
tested undiluted
D. failure to rotate the slide for the full time recommended

228. An agglutination assay was prepared by adding 0.4 mL of saline to each of

5 tubes. 0.1 mL of patient serum was added to tube number 1, mixed, and
0.1 mL was then transferred to tube 2. 0.1 mL was then serially transferred
to tubes 3, 4, and 5. 0.1 mL was discarded from tube 5. Indicator cells were
added in a negligible amount. Agglutination was seen in tubes 1, 2, and 3.
The patient’s titer should be reported as

A. 8
Bus
(O75)
1D), P23)
Answer: D

229. A serum VDRL test was performed on a patient with a rash on his body
and a recent painless mouth lesion. The test was performed as follows:
0.5 mL of fresh patient serum was mixed with 1/60 mL of VDRL antigen
prepared in VDRL-buffered saline in the ceramic ring of a slide. The slide
was rotated for 4 min at 180 rpm. Microscopically, the test showed no
clumping. Controls were acceptable.
The CLT should
A. report the result as nonreactive
B. repeat the assay with freshly prepared VDRL antigen
C. repeat the assay with heat-inactivated serum
D. report the result as reactive

230. The laboratorian opening a new lot of RPR-antigen suspension notices that
all of the bottles contain suspension that is white. The most likely expla-
nation for this observation is

A. charcoal was omitted from the suspension

B. choline chloride was omitted from the suspension
C. flocculation has occurred spontaneously
D. the cardiolipin has agglutinated

231. The source of I antigen in the cold agglutination assay is

A. adult group O cells

B. cord group O cells
C. horse red cells
D. sheep red cells

232. In a latex-agglutination test for bacterial antibodies, serum from a 35-year-

old cattle breeder yields a Brucella titer of 640 and a Francisella titer of
160. These results suggest

A. cross-reaction of Brucella antibodies with Francisella tularensis antigen

 CLT Review Test 227
a
o
=
B. cross-reaction of Francisella antibodies with Brucella antigen S
C. the patient is infected with both Brucella abortus and Francisella tu- =
>
larensis v
ce
D. the patient is suffering from a severe case of tularemia

Z53. When performing a cold-agglutination assay, the CLT noticed that the tem-
perature of the refrigerator was 20°C following incubation. How will this
affect the results of the assay?

A. The temperature is acceptable; the results will be unaffected

B. The results will not be affected if the assay is reincubated at —20°C
C. False-negative results will occur
D. False-positive results will occur

234. The following results were obtained when a differential absorption to de-
tect the antibody for infectious mononucleosis was performed:

Left side of slide: Patient’s serum + guinea pig reagent + horse cells:
Agglutination
Right side of slide: Patient’s serum + beef erythrocytes + horse cells:
No agglutination

The best interpretation of these test results is

A. an invalid test result

B. a normal serum reaction
C. a positive test for serum sickness
D. a positive test for infectious mononucleosis

235. In the cold-agglutinin assay to detect postinfection antibody, the end point
is

A. the last dilution of patient serum in which no agglutination is present

B. the last dilution of patient serum in which agglutination is present
C. the first dilution of patient serum in which there is agglutination
D. the first dilution of patient serum in which there is no agglutination

236. An agglutination assay requires that the initial screening serum dilution be
1:40. Which preparation will produce that dilution?

A. 1 pL serum plus 3.9 mL diluent

B. 1 pL serum plus 39 pL diluent
C. 1 pL serum plus 40 pL diluent
D. 1 pL serum plus 3.9 pL diluent

237. Which dilution is considered a doubling dilution?

A. 0.5 mL of serum plus 0.5 mL of diluent

B. 2 mL of serum plus | mL of diluent
C. 1 mL of serum plus 2 mL of diluent
D. The desired volume must be known before this can be calculated
228
ps
nS 7. RN
Review Tests ee eS

238. The heterophile antibodies directed against the Forssman antigen will not
react with

A. guinea pig kidney cells

B. sheep erythrocytes
C. horse erythrocytes
D. beef erythrocytes

239. A quantitative VDRL gave the following results:

lei ED 1:4 1:8 EG

WR R R WR NR
The patient results should be reported as
. reactive, 4 dilutions
. reactive, 8 dilutions
. weakly reactive
. inconclusive
GTaAwS>

240. A cold agglutinin titer of 512 after incubation at 4°C was obtained on a
specimen from a patient complaining of chest pain, productive cough, and
fatigue. The titer did not lessen when the tubes were then incubated at
37°C. The most probable cause for these results is

. Mycoplasma pneumoniae
. antibody other than a cold agglutinin
. incorrect titer preparation
. anti-I with high thermal amplitudes
DUaAwS

241. Needles must be discarded

. In an autoclavable bag
. with the needle recapped
. in a puncture-resistant container
a . after they are cut with a needle-cutting device
weno

242. The source of a class-C fire is

= Clecthic
. organic solvents
. paper or trash
. combustible metals
echt
SR@Y

243. Which of the following is responsible for ensuring a safe workplace?

A. Health Care Financing Administration

B. Occupational Safety and Health Administration
C. Clinical Laboratory Improvement Act of 1988
D. Centers for Disease Control

244. Flammable chemicals such as waste ether and chloroform

 CLT Review Test 229

ee)
vn
2
. may be flushed down the drain with copious amounts of water Ss
. may be safely sent to a landfill with the regular trash 4
>
. Should be incinerated VY
cf
. should not be used in the clinical laboratory because of the danger
DVaAwWS

245. Which of the following liquids has the lowest flashpoint and is therefore
the most flammable?

A. Class IA
B. Class IC
C. Class II
D. Class I

246. Which of the following precautions must be observed when working with
corrosive materials in the laboratory?

A. Work in a Class II biosafety cabinet

B. Wear gloves and goggles
C. Wear face protection and shoe covers
D. Put corrosive material in container and add water

247. Products that may be discharged into a sanitary sewer system and flushed
with copious amounts of water include

. any liquid infectious waste product

. any liquid infectious waste except when designated “From Isolation”
. suctioned fluids, urine, and small amounts of unclotted blood
. no infectious waste product should be discharged into a sanitary sewer
QVaAWPY
system

248. The disinfectant of choice during a biological-spill cleanup is

A. bleach (undiluted)
B. bleach (1:10 dilution)
C. sodium hydroxide (1:10 dilution)
D. benzidine (1:10 dilution)

249. The sum of multiple values divided by the total number of values is the

A. coefficient of variation
B. mean
C. ratio
D. standard deviation

250. In a normal distribution of results, the mean value +1 SD will exclude

A. 55% of the population

B. 32% of the population
C. 5% of the population
D. 1% of the population
230
en 7. Review Tests ee eee

251. Values within the 2 standard deviations of the mean would include what
percentage of all values?

A. 90
Bos
Ca)
D. 100

252. The agency that issues a license to users of radionuclides and sets down
rules for handling and disposal of radionuclides is the

A. NRC
B. OSHA
Cr EPA
D. CLIA-88

Zo: Which of the following parameters cannot be predicted in method-evalua-

tion studies?

A. Reference range
B. Sensitivity and specificity
C. Random error
D. Systematic error

254. A CLT is given an unknown sample to document competency in the

performance of glucose testing. The CLT obtains a result of 195 mg/dL;
the control values are within the acceptable range. What should the
CLT do?

A. Report the result as 195 mg/dL

B. Repeat the test to confirm the result
C. Ask another CLT to perform the test to confirm the result
D. Dilute the sample and repeat the test

255% Which of the following pieces of hardware is an integral component in al-

lowing test orders entered in an HIS to be effectively transmitted to the
LIS?

A. CPU
B. Interface
C. Magnetic tape
D. Memory

256. While performing a glucose test on an automated analyzer, the CLT re-
ceives a delta check warning. This is an example of which of the follow-
ing?

A. A pre-analytical function of the LIS

B. An analytical function of the LIS
C. A pre-analytical function of the HIS
D. A post-analytical function of the HIS
 CLT Review Test 231
ww
yy
2
257. As defined by CLIA 88, personnel performing moderate complexity test- 5
ing must possess documentation of training and a minimum of a 2
>
oY
ce
A. high school diploma
B. vocational training certificate
C. baccalaureate degree
D. national certification

258.Three continuing education units (CEUs) can be equated to

A. 30 contact hours
B. 3 contact hours
C. 3 credit hours
D. 3 semester terms

259. How many grams of sodium hydroxide are required to prepare a 200-mL
solution of a 10% (weight per volume) solution? (Atomic weights: Na =
23; O = 16; H = 1)

A. 4g
B. 10g
C. 20 g
D. 40g

260. The normality of an unknown HC] solution is 7.2. Calculate the specific
gravity of this HCI solution given the assay percentage of HCI (21.6%) and
the atomic weight of HCl (36.5).

A. 1.424
Bad 2217
Caleh9
D. 1.08

261. When there are five or more consecutive values distributed on one side of
the mean, it is known as a

A.shift
B.normal occurrence
C.trend
D.reliable measurement
Answer: A

262. Which of the following terms identifies the chemical reagent with the
highest purity?

A. Analytic grade
B. Chemically pure
C. Technical
D. Commercial

263. Calculate the concentration in milliequivalents per liter for a solution of 80

mg/dL NaOH. (Atomic weights: Na = 23; O = 16; H = 1)
232 i. Review Tests

A. 2 mEq/L
B. 8 mEq/L
C720 mEq/L
D. 40 mEq/L

264. The label on a reagent container needs only to contain

A. the name and concentration of the reagent

B. the name of the reagent
C. the name, concentration, date prepared, and initials of the preparer
D. the name, concentration, and the date prepared

265. 500 wL is equal to which of the following?

A. 50 mL
BeOStnl?
CG, D inl,
D. 0.05 mL

266. A serial dilution is set up by pipetting 0.1-mL serum into 0.9-mL saline in
tube 1, and serially transferring 0.5 mL through tubes 2, 3, 4, and 5, each
of which contains 0.5-mL saline. What is the dilution in tube number 5?

A. 1:16
B. 1:80
CME s
DP T16O

267. Which of the following is used to measure the rpm of a centrifuge?

A. Ohmmeter
B. Rheostat
C. Voltmeter
D. Tachometer

268. A microscope has the following marks on the objective lens: 10 X .25NA
and a 10 X ocular. What is the total magnification?

A. 100 X
B. 1,000 x
C. 25nX
D. 250 X

269. The function of a condenser on a microscope is to

. regulate the amount of light passing through the objective

. magnify the image
. reverse the image
. project and center the light through the specimen and objective lens
OAS
 CLT Review Test 233
~
cf
4
270. On linear coordinate graph paper, using the ordinate for absorbance and 5
the abscissa for concentration, a straight line through the origin and three at
>
plotted standards indicates all of the following except the Vv
ce

A. concentration of the standard vs. the absorbance of the standards is linear

B. concentration of the standard vs. the % T is linear
C. test complies with Beer’s law
D. concentration of the standard vs. the log % T is an inverse relationship

271. Which part of the microscope should be adjusted to increase brightness of

a microscopic field?

A. Condenser
B. Iris diaphragm
C. Light-source rheostat
D. Prism

272. A pipet should be wiped off

. before lowering the meniscus to the calibration mark

. after lowering the meniscus to the calibration mark
. never if it is a volumetric pipet
. only if it is a TC (to contain) pipet
DUaAWwPS

273. The following data are obtained from a spectrophotometric analysis that
follows Beer’s law up to 300 mg/dL:

Absorbance of standard = 0.250

Absorbance of unknown = 0.100
Concentration of standard = 100 mg/dL
Dilution of unknown = 1:10
What is the concentration of the unknown?

A. 250 mg/dL
B. 400 mg/dL
C. 2,500 mg/dL
D. Cannot calculate because it exceeds the limits of Beer’s law

274. A “discrete analyzer’ that allows random access

. enables parallel analysis to be performed

. provides for a group or batch of samples to be run together
. allows the operator to select both method and order of test performance
. allows the operator to select the method to be performed on each sam-
VUaAW>
ple sequentially

275. A procedure calls for an incubation of 30°C. Your water bath has a ther-
mometer that only reads in degrees Fahrenheit. What should the ther-
mometer read when the water bath is at the correct temperature for this
procedure?
234
ht
re 7. Review
EN Tests
OSS

Boek
Broo
€562-F
D. 86°F

276. Which of the following formulas may be used to convert absorbance (Abs)
to percent transmittance (%T)?

A. Abs = 1 + log %T
B. Abs = 2 — log %T
C. %T = log T + logA
D. Abs = 1 — log %T

277. Which of the following wavelengths of light are visible to the unaided eye?

A. 300 to 700 nm
B. 200 to 800 nm
C. 400 to 700 nm
D. 400 to 900 nm

278. When a blue filter is placed in the path of a white light source, the filter
will

. transmit wavelengths other than blue

. transmit the red wavelengths
. absorb only the blue wavelengths
S . absorb wavelengths other than blue
Daw

279. You are a phlebotomist and must draw a blood sample from a trauma pa-
tient in the emergency room. The patient has an IV in his left wrist and a
cast on his right arm. Which of the following sites should be used to ob-
tain blood for a glucose analysis?

A. Vein in the left hand

B. Left median cubital vein
C. Right median cubital vein
D. Earlobe

280. You have been informed by central receiving that the stock of EDTA va-
cutainer tubes is depleted. The company cannot ship these tubes until next
week. Which of the following, if any, would be an alternative choice for
CBCs in the hematology laboratory?

A. Sodium fluoride
B. Iodoacetate
C. Heparin
D. There is no suitable substitute for EDTA vacutainers
Answer: C

281. When a blood sample is drawn by a syringe, the order for filling vacutainer
tubes should be
 CLT Review Test 235
~

o
=
A. red, blue, purple Ss
B. blue, purple, red es
>
C. purple, blue, red Vv
ce
D. red, purple, blue
Answer: B

282. When collecting a blood sample from an intravenous line, the volume of
blood to be discarded before collecting the sample is

AS 0!0 mi
B. 2.0 mL
C550 mL
D. 10 mL

283. When multiple blood samples are drawn, a sample for coagulation studies
should be drawn

A. prior to a plain (red) tube

B. after all other samples have been drawn
C. immediately after a blood culture sample
D. prior to a hematology sample

284. A sample for an arterial blood gas determination should be transported to

the laboratory

A. with routine samples

B. packed with ice
C. within 8 hours
D. via a pneumatic transport system
Answer: B

285. If a patient refuses to have a blood sample drawn, the phlebotomist should

A. restrain the patient

B. summon help
C. refrain from drawing the sample
D. draw the sample anyway
Answer: Cc

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 CLS Review Test 237

ed

d
=
CLS Review Test S
SS
aS SS a Se a DSS SIS) aS
>
Y
4

1. The following results were obtained from a fasting 45-year-old male:

Glucose: 180 mg/dL Cortisol: elevated

BUN: 8 mg/dL Aldosterone: normal
Na*: 135 mmol/L ACTH: elevated
KY 3.0 mmol/L
Cle: 100 mmol/L
HCO;~: 24 mmol/L
These results are most consistent with a diagnosis of
A. Cushing’s syndrome
B. glucagon producing tumor
C. pituitary hypofunction
D. Type-II diabetes mellitus
Answer : A

2. After overnight refrigeration, a serum specimen separates with a thick

creamy layer above clear serum. Sample analysis gives the following re-
sults.

Reference Interval
Triglyceride: 200 mg/dL (40-160)
Cholesterol: 250 mg/dL (140-220)
HDL cholesterol: 20 mg/dL (30-70)
Lipoprotein electrophoresis: chylomicrons markedly elevated
Which of the following is an appropriate interpretation?
A. The cholesterol result should be much higher
B. The HDL cholesterol result should be much higher
C. The triglyceride result should be much higher
D. The lipoprotein electrophoresis should show more abnormalities

3. The following serum chemistry results are obtained from a 53-year-old fe-
male.
Test Result Reference Interval
Serum:
AST: 120 U/L (5-34)
ALT: 185 U/L (5-35)
ALP: 785 U/L (30-90)
GGT: Spe) OE (5-75)
Bilirubin
Total: 10.8 mg/dL
Direct: 8.6 mg/dL
These results are most consistent with a diagnosis of
A. hemolytic anemia
B. hepatitis
C. Dubin-Johnson syndrome
D. biliary obstruction
238 7. Review Tests

4. The two most significant sources of error in accurate ammonia determina-

tions are sample handling and

short shelf life of the test reagents

inability to automate the test procedure
need for age-dependent reference ranges
Uaw> ammonia contamination in the laboratory

. Methods for determining creatinine levels have been developed based on

each of the following reactions except

A. conversion by urease to urea, then measurement of the urea

B. reaction with alkaline picrate, then measurement of the orange-red chro-
mogen formed
C. enzymatic production of ammonia from creatinine followed by ammo-
nia quantitation
D. enzymatic conversion to creatine followed by a reaction catalyzed by
creatine kinase to measure the amount of creatine formed
Answer: A

6. Prolonged vomiting, mineralocorticoid excess, diabetic ketoacidosis, or

chronic gastric suction can cause

A. hypoxia
B. hyperkalemia
C. hypernatremia
D. hypochloremia

. Several bubbles of room air are trapped in the pO, and pCO, measuring
chambers of a blood-gas instrument. A sample assayed with these bubbles
present will have falsely

. decreased pO, and decreased pCO, results

. decreased pO, and increased pCO, results
. increased pO, and decreased pCO, results
2@ . increased
Wi pO, and increased pCO, results

. A blood ethanol level of 100 mg/dL indicates

A. a lethal concentration in most adults

B. probable impairment of cognitive or motor skills
C. a false elevated value if serum ketones are present
D. that the detection threshold for assay has been exceeded

- Which of these patterns of results is consistent with primary hyperparathy-

roidism?

Serum Serum Urine Urine

Ca fe Ca Je
A. t t t +
B. Tt 1 i t
Cos if 1 1
D. + t +
 CLS Review Test 239

w
d
f=
10. A serum protein electrophoresis is performed. The clinical laboratory scien- Ss
tist suspects that the sample used was plasma, not serum, because of a char- 2
>
acteristic peak in the tC)
ce

A. alpha, region
B. alpha, region
C. beta region
D. gamma region

11. A cerebrospinal fluid (CSF) electrophoresis reveals numerous oligoclonal

bands; whereas the same patient’s serum electrophoresis is normal. These
results are characteristic of

. bacterial meningitis
. multiple myeloma
. multiple sclerosis
. Intracerebral hemorrhage
VUaAnPY

12. National published guidelines for laboratory assessment of increased risk of

coronary artery disease indicate borderline HDL-cholesterol levels fall be-
tween

A. 35-54 mg/dL
B. 130-159 mg/dL
C. 200-249 mg/dL
D. 250-500 mg/dL

13. If the amount of labeled ligand added in a competitive immunoassay is ac-

cidentally twice as much as the procedure calls for, the amount of

A. bound labeled ligand will decrease

B. bound labeled ligand will increase
C. free patient ligand will decrease
D. free and bound labeled ligand will not be altered

14. A moderately hemolyzed serum sample will cause falsely elevated results
for each of the following analytes except

A. creatine kinase (CK)

B. phosphorus
C. potassium
D. sodium

15. Which of the following isotopes can be measured using a gamma scintilla-
tion counter?
140
3H
125]

VOWS 1609
240
me 7. Review lh
Tests eee ne ee

16. Each of the following can be used to perform a wavelength calibration

check on a spectrophotometer except a

A. deuterium lamp
B. didymium filter
C. holmium-oxide filter
D. pure solution of NAD/NADH

17. Which of the following urine specimens is the “specimen of choice” for the
purpose indicated?

A. To evaluate glucosuria—1st morning void

B. To evaluate bacteriuria—midstream clean-catch
C. To evaluate hemoglobinuria—2 h timed collection
D. To evaluate proteinuria—random, catheterized collection

18. Given the following fluorometer readings, calculate the value of the un-
known:

Sample Reading
10.0 mg/dL standard 45
Standard blank 2)
Unknown 50
Unknown blank 10

A. 9.0 mg/dL
B. 10.0 mg/dL
C, 11Sineg/di
De samoldie
Answer B

19. The following results are obtained on a urine specimen collected from an
underweight three-week-old infant:

Glucose by reagent strip: negative

Glucose by copper reduction test: 500 mg/dL

Which of the following statements best explains the results obtained?

A. The reagents for the copper reduction test are outdated
B. A sugar, such as galactose, is being excreted in the urine
C. Infant multi-vitamins are causing a false-positive copper reduction
test
D. Dietary peroxidases are causing a false-negative glucose by reagent
strip

20. One unit (U) of enzyme activity is defined at a specific temperature and pH
as the amount of enzyme that catalyzes the reaction of

one mole of substrate per sec

one millimole of substrate per sec
one millimole of substrate per min
GAS
one micromole of substrate per min
 CLS Review Test 241

~
cf
4
21. Using Beer’s Law, calculate the concentration of analyte X in the following s
patient’s sample: =
>
ov
Absorptivity coefficient of analyte X: 0.20 L X mmol-! X cm-! ce

Spectrophotometer path length: 1.0 cm

Absorbance reading of patient sample: 1.000
A. 0.005 mol/L
B. 0.50 mmol/L
Co20 mol/L
D. 5.0 mol/L

22. Which of the following macroscopic urinalysis results should initiate a mi-
croscopic examination?

A. pH—7.5
B. Nitrite—positive
C. Ketones—moderate
D. Glucose—100 mg/dL

23. The temperature control for a blood-gas instrument is malfunctioning and is

currently at 39°C. Blood-gas determinations using this instrument would
give falsely

. decreased pH, increased pO,, and increased pCO, results

. decreased pH, decreased pO, and decreased pCO, results
. Increased pH, increased pO;, and increased pCO, results
. increased
UaAWS> pH, decreased pO, and decreased pCO, results

24. A patient has consumed a mixture of barbiturates. Which of the following

assay techniques is best able to identify the specific barbiturates ingested?

A. Gas chromatography (GC)

B. Radial immunodiffusion (RID)
C. Fluorescence-polarization immunoassay (FPIA)
D. Enzyme-multiplied immunoassay technique (EMIT)

25. Chloride quantitation can be performed by the coulometric titration or by

potentiometric methods. If a bromide-containing medication is being taken
by a patient, the serum chloride values for this patient’s specimen can be

A. accurate by either method

B. falsely increased by both methods
C. falsely increased by the potentiometric method
D. falsely increased by the coulometric-titration method

26. A plasma sample was analyzed using ion selective electrodes (ISEs) and the
following electrolyte results obtained:

Na* = 140 mmol/L

K* = 14.0 mmol/L
Cl- = 112 mmol/L
HCO,- = 18 mmol/L
242
en 7. Review
ee Tests
ee nnn ee ee _

What action should be taken next?

. The sample was slightly hemolyzed; request a new sample
. Suspect improper anticoagulant; check collection tube then redraw
. Report the critically high potassium result to the physician immediately
. Check the linearity range to determine if the sample should be diluted
DUAL
and rerun for an accurate potassium result

27. A heparinized arterial blood gas specimen from a patient breathing room air
is received in the laboratory. The time of collection is not indicated. Review
the results obtained.

Results Reference Interval

pH = 7.50 (7.35-7.45)
pCO, = 20 mm Hg (32-48)
pO, = 138 mm Hg (80-108)
HCO,- = 15 mmol/L (22-26)
These results are most consistent with a sample that
. is actually venous blood
. contained a significant amount of room air
. was kept at room temperature for | h before analysis
. had an excessive amount of heparin present in the collection syringe
DawS

28. A physician orders a urinalysis to follow-up previous microscopic hema-

turia in a patient. Due to short staffing in the laboratory, performance of the
urinalysis will be delayed for 3 hours. How should the urine specimen be
stored?

A. Freeze at —20°C
B. Refrigerate at 2-8°C
C. Keep at room temperature (20—23°C)
D. Add 1 drop glacial acetic acid for each 5 mL urine

29. A 19-year-old pregnant female is scheduled for an oral glucose tolerance

test (OGTT) to evaluate possible gestational diabetes mellitus. She arrives
in the outpatient clinic and when questioned about her diet states that she
has eaten “mostly fast foods” for the past 3 days. Since dinner last night, the
only thing she has eaten is a granola bar about a half-hour ago. What action
should be taken?

A. Reschedule the test for the next day and explain the need to eat a well-
balanced breakfast
B. Reschedule the test for the next week and explain the importance of di-
etary compliance
C. Draw blood for a glucose determination; if the result is less than 126
mg/dL, perform the OGTT
D. Wait 2 h and draw a 2-h postprandial blood sample; then begin the
OGTT if the 2-h postprandial result is < 200 mg/dL

30. Calculate the low-density lipoprotein cholesterol (LDL-C) using the fol-
lowing data:
 CLS Review Test 243

Pe)
d
=
Total cholesterol: 200 mg/dL S
High-density lipoprotein cholesterol (HDL-C): 20 mg/dL 2g
>
Triglyceride: 150 mg/dL Vv
ce
A. 30 mg/dL
B. 45 mg/dL
C. 150 mg/dL
D. 180 mg/dL

31. Which of the following enzyme determinations can be helpful in establish-

ing the presence of seminal fluid?

A. Acid phosphatase (ACP)

B. Alkaline phosphatase (ALP)
C. Lactate dehydrogenase (LD)
D. Isocitrate dehydrogenase (ICD)

32. Which of the following cells when encrusted with bacteria is called a “clue
cell?”

D, Cell D

33. Which of the following substances can cause a urine to be cloudy and is also
considered pathologic?

A. Lipids
B. Mucus
C. Spermatozoa
D. Squamous epithelial cells

34, Which of the following blood collection tubes is preferred for both glucose
and electrolyte analysis?

A. EDTA/purple top
B. Lithium heparin/green top
C. Sodium fluoride/gray top
D. Sodium heparin/green top

OS. A 46-year-old female complains of fatigue, cold intolerance, and dry

skin. Without decreasing her activity or changing her diet, she has gained
eight pounds. The results from a series of thyroid function tests are as
follows:
244
See 7.
SoapReview
a ea Tests
OeFen aee

Total T,: decreased

TSH: decreased
Free T, index: decreased
THBR: decreased
A dose of TSH was administered and a post-injection total T, level pro-
duced a result greater than the initial T, level. Based on these results, which
of the following glands can be ruled out as the cause of her hypothy-
roidism?
A. Ovary
B. Hypothalamus
C. Thyroid gland
D. Pituitary gland

36. A 65-year-old woman experienced sharp chest pain, pain radiating down
her left arm, and nausea. Thinking the pain was indigestion, she did not
seek immediate medical attention. Four days later, she visits her doctor. If
she had an acute myocardial infarction (AMI), which of the following car-
diac markers would you expect to be elevated at this time?

A. TroponinI
B. Myoglobin
C. CK-MB (mass)
D. CK-MB isoforms ratio

37. The protein concentration of a cerebrospinal fluid (CSF) specimen exceeded

the linear range of the method. A dilution of the specimen was made by
adding 0.5 mL of CSF to 1.0 mL of saline. The protein value obtained using
the diluted sample was 24 mg/dL. What protein concentration should be re-
ported for this CSF specimen?

A. 48 mg/dL
B. 72 mg/dL
C. 96 mg/dL
D. 120 mg/dL

38. Four laboratories performed replicate analyses (n = 40) using the same lot
number of control serum. Using the results obtained, the following statisti-
cal parameters were determined. Based on this information, which labora-
tory appears to have the best accuracy?

LabA LabB LabC LabD

SD 0.18 0.23 0.14 O27
CV% 3a 4.3 2.8 4.4
Bias +1.0 +0.2 +3.0 Sella

A. LabA
B. Lab B
C. LabC
D. Lab D

39. The following urine values are obtained:

 CLS Review Test 245
Cd

g
=
Specific gravity = 1.004 5
Osmolality = 180 mOsm/kg 4
>
24-h urine volume = 3 L ov
4

These data suggest the condition of

. dysuria
. 1sothenuria
. oliguria
. polyuria
GaAwS

40. Oval fat bodies, fatty casts, and free-floating fat droplets in the urine sedi-
ment correlate best with

. nephrotic syndrome
. acute tubular necrosis
. acute glomerulonephritis
PSP
Daw. acute interstitial nephritis

41. The urine collection of choice for a reagent strip nitrite test is a

A. random collection
B. 24-h timed collection
C. first morning collection
D. 2-h postprandial collection

42. Which of the following specific gravity results correlates best with a diag-
nosis of diabetes insipidus?

1.005
1.015
1.025
VAY
1.030

43. A patient’s urine specimen is known to be contaminated with radiographic

contrast media. Despite this interferent, which of the following specific
gravity methods is best able to assess this patient’s renal concentrating abil-
ity using this specimen?

A. Urinometer
B. Refractometer
C. Reagent strip
D. Densitometry

44. When analyzing a negative control sample using urine multiconstituent

reagent strips, all test pads produce negative results except for the protein
pad. A trace protein result is obtained. What action should be taken?

A. Document and resolve the protein result before testing patient

samples .
B. This performance is acceptable because the result is within +1 color
block of the expected value
 Resolve the protein result, then document only the acceptable result ob-
tained before testing patient samples
Document the results, but because the color change on the protein pad
can be difficult to read, a slightly positive result is acceptable for this
negative control

45. The following routine urinalysis results are obtained:

Macroscopic Exam:
Parameter Result
pH: 6.5
SG:3010
Blood:small
Protein:300 mg/dL
Glucose: negative
Ketone: negative
Bilirubin:negative
Urobilinogen: 1.0 mg/dL
Nitrite:
positive
Leukocyte esterase:positive
Microscopic Exam: 5-10 RBCs per high-power field
10-25 WBCs per high-power field
0-2 WBC casts
0-2 renal cell casts
0-2 granular casts
few renal epithelial cells
few bacteria
These findings are most consistent with a diagnosis of
acute cystitis
nephrotic syndrome
. acute pyelonephritis
vow acute glomerulonephritis

46. Select the microscopic technique that is best able to differentiate hyaline
casts from mucous threads.

A. Bright-field microscopy
B. Polarizing microscopy
C. Phase-contrast microscopy
D. Fluorescence microscopy

47. Review the following results:

Leukocyte esterase: negative

Microscopic exam: 5—10 WBCs per high-power field
Each of the following statements explains these results except which one?
. The WBCs present are lymphocytes
. The amount of leukocyte esterase present is below the test’s sensitivity
The cells are really dead trichomonads that were misidentified as WBCs
VaOw>
A free-sulfhydryl drug is causing the leukocyte esterase to be falsely
negative
Answer: D
 CLS Review Test 247

tot
d
ia
48. A urine specimen is delivered to the laboratory for routine analysis. The col- S
lection time is not noted on the label. The following results are obtained: 2
>
CY
4
Macroscopic Exam:
Color: yellow-brown
Clarity: slightly cloudy

Parameter Result
pHs 55
SG: 1.029
Blood: negative
Protein: negative
Glucose: negative
Ketone: negative
Bilirubin: negative
Urobilinogen: 0.2 mg/dL
Nitrite: positive
Leukocyte esterase: negative
The physician questions the results because the patient is jaundiced and has
an increased serum bilirubin. A possible explanation is that
bacteria in the urine have consumed the bilirubin
the specimen is too acidic; adjust the pH and re-test
the high specific gravity is interfering with the reagent strip bilirubin test
VOWS
the specimen was not properly preserved and the bilirubin has photo-ox-
idized

49. A urinalysis is requested on 10 mL of urine. Which of the following steps

will produce a 12:1 concentration of urine sediment for the microscopic ex-
amination?

A. Centrifuge 4 mL urine, then remove 3.5 mL supernate

B. Centrifuge 6 mL urine, then remove 5.5 mL supernate
C. Centrifuge 8 mL urine, then remove 7.5 mL supernate
D. Centrifuge 10 mL urine, then remove 9.5 mL supernate

50. Which of the following sets of macroscopic and microscopic examination

results suggest a specimen mix-up during the performance of the urinalysis,
i.e., the macro results do not agree with the micro results?

A. Nitrite negative; micro exam reveals few bacteria

B. pH 7.0; micro exam reveals calcium oxalate crystals
C. Protein test negative; micro exam reveals fatty casts
D. Leukocyte esterase test positive; micro exam is negative for bacteria

51. A procedure calls for 0.5 mL serum. You perform the analysis using 200 »L
and the value obtained is 25 mg/dL. Which of the following results should
be reported?

A. 6.3 mg/dL
B. 10.0 mg/dL
C. 62.5 mg/dL
D. 100 mg/dL
52. A severely lipemic sample in a red top tube is received and ultracentrifuged
to clear the serum. This sample is no longer acceptable for which of the fol-
lowing tests?

A. Amylase
B. Lipase
C. Total protein
D. Triglyceride

53. A physician contacts the laboratory to “add” a glycated hemoglobin (GHb)

determination onto the morning blood specimens collected 30 minutes ear-
lier from a patient. Collection tubes included an EDTA/purple top, a sodium
citrate/blue top, a red top, and blood culture tubes. Which of the following
actions should be taken?

A. Have the Microbiology lab aseptically withdraw 5 mL from a blood cul-

ture tube
B. Have the Hematology lab send the EDTA tube after they finish with the
CBE
C. Retrieve a portion of the red top tube being processed for a protein elec-
trophoresis
D. Have the Coagulation lab send the blue top tube after they complete the
protime
Answer B

54. A sodium fluoride tube is sent to the laboratory for the following tests: glu-
cose, Na*, K*, Cl, total calcium and creatinine. Which of the following ac-
tions should be taken?

A. Acceptable for all tests; proceed with testing

B. Acceptable for glucose; recollect for the other tests
C. Acceptable for the electrolytes; recollect for the other tests
D. Not acceptable for any of the tests; recollect in lithium heparin

55. A slightly hemolyzed specimen is acceptable for the analysis of each of the
following except

A. Kt
BeGls
C. Nat*
DF Ga

56. Which of the following components of an automated instrument is impli-

cated when a “carryover” problem exists?

A. Bar code reader

B. Detector
C. Incubator
D. Sample probe

57. In automated chemistry analyzers, analyte measurements are routinely per-

formed by all of the following except
 CLS Review Test 249

A. agglutination
ks
Ss
B. fluorometry
s
C. nephelometry
&
D. reflectance photometry

58. Which of the following charts/graphs is routinely used to record daily qual-
ity control results?

date

chart A chart B chart C chart D

A. ChartA
B. Chart B
Chart C
DW Chart D

_ 59. During the analysis of patient samples, which of the following is an appro-
priate protocol for responding to “critical values” when obtained?

A. Dilute sample and repeat analysis in the next run

B. Contact the patient’s healthcare provider immediately, documenting
their name, the date, and time called
C. Print out a result report; sign and date it, then deliver the hardcopy to the
patient’s healthcare provider immediately
D. Inform your supervisor when he/she returns from lunch for them to con-
tact the patient’s healthcare provider

60. Which of the following control materials is at an appropriate medical deci-

sion level for clinical use?

A. Potassium; low control value—3.0 mmol/L

B. Blood gas pH; low control value—pH 6.00
C. Total calcium; high control value—25.0 mg/dL
D. Total serum protein; low control value—2.0 g/dL

61. Review the two sets of laboratory results from the same hospitalized patient.
The specimens were collected 4 hours apart and the delta between values is
provided.

Na K Cl HCO, BUN Creat Ca Gap

Current 142 2.6 126 17 15 0.6 Syl =]
Previous 139 4.6 105 26 23 0.9 8.4 8
Delta ST | Dies edit buna Qin Sint itywere ees 91
Which of the following statements best explains the “current” results from
this patient?
250
pele 7. Review
SOETests een ones oe ee Eee

. The current specimen demonstrates IV contamination

. The patient is currently experiencing a respiratory arrest
. The patient was in renal failure but is now showing improvement
. The current specimen is not from the same patient, i.e., mislabelled spec-
Sie
Gr
imen or specimen mix-up

62. An elderly patient from a car accident is brought to the Emergency Room.
It is possible that the individual suffered a heart attack or stroke. Review the
test results that were obtained over a 12-hour period. The values in paren-
theses are expected in healthy individuals.
Myoglobin CK-MB Troponin I
Time (<90 pg/L) (<5 pg/L) (<10 pg/L)
At admission 85 4 8
4h later 105 3 8
8 h later 167 4 9
12 h later 160 4 9
These results are most consistent with
. Skeletal muscle trauma
. atypical healthy individual
. an acute myocardial infarction, i.e., MI
DUaAwS
. acerebrovascular accident, i.e., stroke

63. Which of the following statements best describes the function of the mem-
brane of an ion specific electrode (ISE)?

. To reduce interference in samples with increased plasma lipids

. To prevent protein from coating the reference and measuring electrodes
. To discriminate solutes and interact selectively with the analyte of interest
. To enable enhanced electrical conductivity between the sample and the
DUaAwS>
electrode

64. A 23-year-old male is on phenytoin (dilantin; an anticonvulsant) and the

physician requests a trough sample for therapeutic drug monitoring (TDM)
purposes. The blood specimen should be collected

A. just before a dose

B. 30 minutes after a dose
C. in the morning after an 8 to 12 hour fast
D. after 5 to 7 half-lives of the drug have occurred

65. A single tube of cerebrospinal fluid is received in the laboratory and the fol-
lowing tests requested: total protein, albumin, IgG quantitation, microbial
culture, Gram stain, leukocyte count, and differential cell count. As the
Clinical Laboratory Scientist responsible for processing this sample, where
should the tube be sent first?

A. Microbiology, for culture and Gram stain

B. Hematology, for leukocyte count and differential
C. Chemistry, for total protein, albumin, IgG quantitation
D. Aliquot the small volume specimen and send a portion to each laboratory
 CLS Review Test 251
~

cf
4
66. A heparinized specimen is received in the hematology laboratory. Which S
procedure would be acceptable on this specimen? 2
>
Y
c
A. Peripheral blood smear
B. WBC count
C. Osmotic fragility
D. Platelet count

67. An EDTA specimen received in the laboratory is noted to contain a very

small clot. For what procedure(s) is this specimen acceptable?

. Platelet count only

. ESR only
. No procedures will be accurate
PY. Hemoglobin and hematocrit
UAW if they are performed by manual
methods

68. A clinical laboratory scientist makes peripheral blood smears that are con-
sistently too short and too thick. Which of the following actions should be
taken to improve the quality of the smears?

A. Lower the angle of the spreader slide

B. Increase the angle of the spreader slide
C. Maintain the same angle on the spreader slide and increase the size of
the drop
D. Maintain the same angle and increase the pressure on the spreader slide

69. All of the peripheral blood smears stained with a Romanowsky stain have
bluish erythrocytes, and the nuclei of the leukocytes appear deep purple.
What is the probable cause?

A. Excess buffer for stain solution

B. Smears are too thin
C. Buffer is too alkaline
D. Insufficient staining time

70. An average of 7 platelets per oil-immersion field are seen on a peripheral

blood smear prepared by the wedge method. What is the approximate
platelet count x 10°/L?

A. 11-14
B. 50-70
C. 105-140
D. 500-700

71. A hemoglobin value of 10.3 g/dL would correlate with a microhematocrit of

A. 0.31 L/L
B. 0.34 L/L
C. 0.36 L/L
D0.39 Ti,
252
a 7. en
Review Tests ——————————e————E—Eee

V2 A hemoglobin and hematocrit are ordered on an EDTA specimen with

lipemic plasma. In performing the manual cyanmethemoglobin procedure
using spectrophotometry, the clinical laboratory scientist should

A. centrifuge the hemoglobin dilution and read the supernatant

B. dilute the sample 1/2 with distilled water; read and multiply results by 2
C. add 0.01 mL of patient plasma to 5 mL of cyanmethemoglobin reagent
and use this as the test blank
D. add 0.02 mL of patient plasma to 10 mL of cyanmethemoglobin reagent;
read and multiply result by 2

73. The following results are obtained on an EDTA blood specimen:

RBC = 2.50 X 10'/L

Hb = 10.0 g/dL
Het = 0.30 L/L
RBC indices calculated from these values best correlate with which of the
following morphologies on the peripheral blood smear?
A. Microcytic, hypochromic
B. Microcytic, normochromic
C. Normocytic, normochromic
D. Macrocytic, normochromic

74. To obtain accurate results on a Westergren ESR, blood kept at room tem-
perature should be set up within a maximum of how many hours?

>
UAW
ORNS

TY A reticulocyte count is performed on an EDTA sample from a 45-year-old

male with an RBC count of 3.80 X 10!7/L, Hb of 11.5 g/dL, and Het of 0.35
LIL. The reticulocyte count is 0.9%. The corrected reticulocyte count (cor-
rected for anemia) is

A. 0.4%
B. 0.6%
C. 0.7%
D. 0.8%

76. A patient is admitted to the emergency room with extensive burns. Expected
erythrocyte morphologic features would include

A. microspherocytes
B. hypochromia
C. codocytes
D. drepanocytes

77. A patient has a WBC count of 60.0 X 10°/L. On the 100-cell differential,
5% of the cells have dark blue cytoplasm with red granules that cover the
 CLS Review Test 253

nucleus. The nucleus has a fine chromatin pattern and is slightly off center.
Several of these cells have nucleoli. These cells are most likely
Revie
Test
. myeloblasts
. promyelocytes
. myelocytes
. atypical lymphocytes
De
we

78. Laboratory tests on a 4-year-old boy yielded the following results:

fb: ) 11.0: 9/dL IW BC ses/03 GulOo/L;

Hct, 0.37 L/L polys: 57%
RBCs 5.2) x 107/L bands: 2%
RDW: 13.5% lymphs: 38%
monos: 3%

Codocytes and occasional basophilic stippling were seen on the peripheral

blood smear. Based on these initial findings, which procedure would be in-
dicated next?
A. Test for infectious mononucleosis
B. Serum lead and free-erythrocyte protoporphyrin
C. Hemoglobin electrophoresis and Hb A, quantitation
D. Serum B,, and folate levels

ie A patient has a WBC count of 20.0 X 10°/L. There are 45 nucleated RBCs
per 100 WBCs. The corrected WBC is

ie 7 ox LOY
B. 13.8 X 10°/L
CF19.9 < 10°/L
D. 20.0 X 10°/L

80. A screening solubility test for sickling hemoglobins is ordered on a patient

with a hemoglobin of 5.0 g/dL. Which of the following will provide the
most accurate results?

A. Add 0.02 mL of blood to 2.0 mL of dithionite reagent

B. Decrease sample volume to 0.01 mL
C. Add 0.02 mL of blood and increase reagent volume to 4.0 mL
D. Increase sample volume to 0.04 mL

81. The following results were obtained on an osmotic fragility test:

NaCl Patient Control

(% solution) (% hemolysis) (% hemolysis)
0.00 100 100
0.10 100 100
0.20 100 100
0.30 100 97
0.35 100 89
0.40 100 60
0.45 100 10
254
ia
ae 7. Review Tests eS

0.50 Of 0
0.55 96 0
0.60 92 0
0.65 1) 0
0.70 35 0
0.85 0 0
These results indicate
A. increased fragility of the patient’s erythrocytes
B. normal results for patient and control
C. decreased fragility of the patient’s erythrocytes
D. invalid results due to inaccurate control results

82. Pappenheimer bodies are suspected on a Wright’s-stained peripheral blood

smear. Which confirmatory stain should be done?

A. New methylene blue

B. Feulgen
C. Prussian blue
D. Crystal violet

83. The following results were obtained on a well-controlled leukocyte alkaline

phosphatase stain:

Score No. of cells

0 6
1 20
2 4]
3 24
4 12
These results indicate
A. chronic myelogenous leukemia
B. acute lymphocytic leukemia
C. paroxysmal nocturnal hemoglobinuria
D. leukemoid reaction

84. A cerebrospinal fluid is diluted 1/10. A total of 160 WBCs is counted using
the 4 corner squares on both sides of the hemocytometer. What is the
WBC/mm??

A. 200
B. 400
C2000
D. 4,000

85. On a cytospin preparation from a pleural fluid, 50% of the cells have the fol-
lowing characteristics:

Uniform, regular arrangement

Some cells resemble a “fried egg”
Some have multiple nuclei
 CLS Review Test 255

w
d
fos
Smooth nuclear outline and homogeneous chromatin 5
When present in clumps, there are clear spaces between the cells 4
>
(“windows”) C
cf
How would these cells be classified?

A. Atypical (reactive) lymphocytes

B. Mesothelial cells
C. Tumor cells
D. Ependymal cells

86. Which of the following is an acceptable preservative for bone-marrow

biopsy specimens?

A. EDTA
B. Sodium citrate
C. Zenker’s solution
D. Xylene

87. Examination of a Wright’s-stained bone-marrow smear reveals many large

cells (20-80 zm) with globular cytoplasmic inclusions. The cytoplasm has
fine marks in it that resemble chicken scratches or crumpled tissue paper.
Cytochemical analysis of the cell contents confirms the presence of gluco-
cerebroside. The cells are suggestive of

A. multiple myeloma
B. Gaucher disease
C. Niemann-Pick disease
D. Chediak-Higashi syndrome

88. A 70-year-old male with a diagnosis of pneumonia has the following results
on an electronic cell counter that uses the principle of electronic impedance:

WBC: 15.0 X 10°/L

RBC 3.24-<104/L
Hb: 14.8 g/dL
Het; 0.39. L/L

What action should be taken by the clinical laboratory scientist?

A. Report results as obtained as quickly as possible

B. Perform a manual hemoglobin using a plasma blank
C. Perform a manual hemoglobin; spin down before reading % transmit-
tance
D. Warm the specimen and rerun it

89. The following results are obtained on controls on an electronic cell counter:

Assay value (published)

Normal WBC: BO 0,60 ~ LO7L
Abnormal WBC: 15.5 + 0.9 X 10°/L
Normal RBC: A See) O9ex< 7102
Abnormal RBC: 1.54 + 0.12 X 10!?7/L
256 7. Review Tests

When plotted on a Levy-Jennings quality control chart (+ 2SD), values for

the last 8 shifts are represented below:

Laboratory Values

® TE
8.0 SSS 15.0 SE

7.6 £ 14.4 Heb ancien ae ek er

Normal WBC Abnormal WBC

4.68 —> - ; 1.60 a

“5.ae

A! 00 arr =
onan oe oc @aaa! 1.50 eikirs
Riel i = weal b,
eereer crrenereoe
4.52 OR 1.40
Normal RBC Abnormal RBC

These data indicate that the

. instrument is in control
. diluent has become contaminated
. controls have deteriorated
. lysing agent has expired
DVaAWS

90. The following results were obtained on a 45-year-old female who com-
plained of fatigue and easy bruising. Results of a CBC were:

WBC: 35108 < 1072/1

Hb: 8.6 g/dL
Het: 0:26 L/L
Platelets: 26.0 <X 10°/L
The differential revealed 10% blasts, 85% promyelocytes, and 5% mono-
cytes. Which of the following chromosome abnormalities would be consis-
tent with the above laboratory results?
Ay, 0(9:22)
B. +8
Cats: i)
D. t(1;8)

91. Which of the following leukemias may relapse in the cerebrospinal fluid be-
fore blasts appear in the peripheral blood?

A. Acute lymphoblastic
B. Chronic myeloid
C. Acute myeloid
D. Chronic lymphocytic

92. A synovial fluid is examined by polarized light using a red compensator.

Needle-like crystals are observed that are yellow when parallel to the com-
pensator and blue when they are perpendicular to it. These crystals should be
identified as

A. calcium pyrophosphate
B. monosodium urate
 CLS Review Test 257
ded

cf
=
C. cholesterol Ss
D. calcium oxalate 2
>
CY)
c

93. In chronic myeloid leukemia (CML), the leukocyte alkaline phosphatase is

characteristically

A. increased
B. normal
C. decreased
D. variable

94, A 70-year-old male presented with a WBC of 75.0 X 10°/L, platelet count
of 160 X 10°/L. The differential exhibited a majority of small lymphocytes
with clumped chromatin. This disease is most likely of what origin?

A. T-cell
B. B-cell
C. NK cell
D. Monocytic

95. The following results were obtained on a cerebrospinal fluid from a 5-year-
old child with fever:

WBC: 1500/mm?
RBC: 3/mm?
Glucose: 20 mg/dL
Gram stain: gram-positive diplococci
Which of the following would you expect to find on the differential?
A. 10% polys, 90% lymphs
B. 10% polys, 50% lymphs, 30% eosinophils, 10% monocytes
C. 95% polys, 5% lymphs
D. 30% polys, 30% lymphs, 40% monocytes

96. Which of the following stains would be helpful in differentiating refractory

anemia (RA) from refractory anemia with ringed sideroblasts (RARS)?

A. Acid phosphatase with tartrate inhibition

B. Kleihauer-Betke
C. Butyrate esterase
D. Prussian blue

97. A clump of cells is observed in a bone marrow aspirate. The cells have the
following appearance: 30 p with a single eccentrically placed nucleus.
There is abundant cytoplasm, and there is a chromophobic area (hof) located
away from the nucleus. These cells should be identified as

A. lymphocytes
B. osteoblasts
C. osteoclasts
D. plasma cells
258 7. Review Tests —

98. A patient complained of bone pain and fatigue. Hemoglobin was 8.0 g/dL,
WBC 11.0 X 10%/L, platelets 125 X 10°/L. Sedimentation rate was 60
mm/hr. Clumps of plasma cells are seen in the bone marrow. The most prob-
able diagnosis is

. chronic lymphocytic leukemia

. acute myeloid leukemia
. hairy cell leukemia
. multiple myeloma
DaAaLY

99. Several cells were observed on a peripheral blood smear in which the nu-
cleus had separated lobes and chromatin was dark with a very smooth pat-
tern. Which of the following conditions could account for this appearance?

A. Bacterial infection
B. Viral infection
C. Cell death
D. Megaloblastic anemia

100. A platelet count performed on an EDTA tube was 26.0 X 10°/L. On the pe-
ripheral blood smear platelets appeared to be adequate. However, some
platelets were noted adhering to neutrophils. How could an accurate
platelet count be achieved?

A. Collect specimen in sodium citrate

B. Vigorously shake the EDTA tube
C. Warm specimen at 37°C for 15 minutes
D. Estimate from peripheral blood smear

101. A five-year-old male visited his pediatrician because of a persistent upper

respiratory infection. His hemoglobin was 6.8 g/dL, WBC 8.8 X 10°/L,
and platelet count was 49 X 10°/L. Blasts and NRBC were seen on the pe-
ripheral blood smear. On the bone marrow there were sheets of small blasts
with scant cytoplasm. Flow cytometric analysis demonstrated 90% posi-
tivity for TdT, CD 10, HLA-DR, and CD 19. The most probable diagnosis
is

A. B-cell ALL
B. T-cell ALL
C. B-cell CLL
D. AML

102. A patient had a WBC of 95.0 < 10°/L with 7 blasts, 13 promyelocytes, 28
myelocytes, 8 metamyelocytes, 15 bands, 23 polys, 4 basophils, and 2
eosinophils. Which of the following molecular abnormalities would be
characteristic of this disorder?

A. BCR/ABL
B. DEK/CAN
C. PML/RARAa
D. C-MYC/IgH
 CLS Review Test 259
~
cf
4
103. A fresh, slightly bloody spinal fluid was received in the laboratory. The Ss
RBC count was 6,000/mm°. WBC count was 25/mm;°. Fluid supernatant 2
>
was yellow. What would these results indicate? CF)
ce

A. Bacterial meningitis
B. Intracranial hemorrhage
C. Viral meningitis
D. Traumatic spinal tap

104. Fluid from a pleural effusion was slightly bloody and had a nucleated cell
count of 300/mm?. On the cytocentrifuged slide clumps of cells were ob-
served that appeared three-dimensional and had molded nuclei. Mitotic
figures were also noted. What is the probable identification of these cells?

A. Histiocytes
B. Plasma cells
C. Tumor cells
D. Mesothelial cells

105. Given the following data, calculate the reticulocyte production index (RPI).

54-year-old male
Reticulocyte count: 6.6%
Hematocrit: O21
A. 1.6
B. 1.8
Comes We)
Dede.

106. A 30-year-old female had the following results on her CBC:

WBC = 15,000/mm? (15.0 X 10°/L)

Polys = 71%
Lymphs = 23%
Monos = 5%
Eos:'= 1%
This patient can be said to have absolute
A. leukocytosis, neutrophilia, and lymphocytopenia
B. leukocytosis, neutrophilia, lymphocytopenia, and monocytopenia
C. leukopenia, neutrophilia, monocytopenia, and eosinopenia
D. leukocytosis and neutrophilia

107. An adult female had a total leukocyte count of 3.0 X 10°/L. There were
40% neutrophils, 52% lymphocytes, 6% monocytes, and 2% eosinophils.
This patient has which of the following conditions?

A. Absolute neutropenia
B. Absolute lymphopenia
C. Relative eosinophilia
D. Relative monocytosis
260
ee
ee 7. Review Tests

108. In a semen specimen examined within 60 minutes of collection, the mini-

mum percent of sperm that must show moderate to strong motility to be
considered normal is

A. 20
B. 30
Cx50
D. 90

109. A semen specimen was received at 11:00 AM. At 12 noon it remained vis-
cous. What is the appropriate action?

A. Allow an additional hour for liquefaction

B. Place specimen in 37°C incubator for 15 minutes
C. Treat with a chemical to facilitate liquefaction
D. Request new specimen

110. The reference range for hematocrit on a control sample is 42 + 3%. A

hematocrit determination was performed 5 times in succession; the results
in % were 37, 38.5, 37.2, 36.8, 38.3. These results are

A. neither accurate nor precise

B. both accurate and precise
C. precise, but not accurate
D. accurate, but not precise

111. In establishing the normal range for prothrombin time, a laboratory ana-
lyzed samples from ten healthy donors (five women and five men). One
donor was analyzed each day. All specimens were handled in the same
manner and analyzed with the same lot number of reagent. One donor fell
three standard deviations from the mean and was eliminated. What in this
laboratory’s protocol might bias the results of the normal range?

A. Both healthy and ill donors should have been assayed to get a more ac-
curate result
B. The donor that was an outlier should not have been eliminated from the
data
C. The sample size was too small
D. All of the specimens should have been analyzed on the same day

112. The results of a patient’s prothrombin time are 12 sec (mean normal, 11.9
sec). The activated partial thromboplastin time is 65 sec. The APTT
showed no correction on a 1:1 mix with fresh normal plasma. What condi-
tion can cause these results?

A. Factor-VIII deficiency
B. Factor-IX deficiency
C. Lupus inhibitor
D. Factor-XII deficiency

113. A 6-year-old male presents with a history of bruising and frequent episodes
of mild bleeding. The results of lab tests are:
 CLS Review Test 261

ie

d
=
Platelet count: 260 x 10°/L (150-450 x 109/L) S
Ri: 11.8 sec (11.0-12.0 sec) =
>
APTI: 28 sec (24—30 sec) v
ce
What further testing is indicated?
A. Platelet-aggregation studies
B. Factor-IX assay
C. Factor-VIII assay
D. Thrombin time

114. A patient has a history of repeated spontaneous abortion. Coagulation stud-

ies reveal an elevated APTT, normal PT, and normal platelet function.
Which test should be performed to determine if the prolonged APTT is due
to a lupus inhibitor?

A. Mixing studies with normal plasma

B. Mixing studies with factor-deficient plasma
C. Antinuclear-antibody test
D. Platelet-neutralization test

115. What is used to set the 100% baseline reading on a platelet-aggregation in-
strument?

A. The patient’s platelet-rich plasma

B. The aggregation reagent
C. Saline
D. The patient’s platelet-poor plasma

116. Which disorder can display decreased activity of FVII:C; vWF:Ag;

vWER:Co; and a prolonged bleeding time?

A. Hemophilia A
B. Hemophilia B
C. von Willebrand disease
D. Hypothrombinemia

at7. The International Normalized Ratio (INR) should be used in conjunction

with the prothrombin time (PT) to monitor therapy with

A. oral anticoagulants
B. hirudin
C. heparin
D. fibrinolytic agents

118. Which of the following is true of high sensitivity thromboplastin reagents

(low ISD?

A. Lead to greater prolongation of the PT than low sensitivity (high ISI)

thromboplastins
. Lead to shorter PT times than low sensitivity (high ISI) thromboplastins
. May give decreased FV levels in normal plasma
. May cause “cold activation” of stored plasma resulting in elevated
wen:
FVII assays
262 7. Review Tests

119. The anticoagulant of choice for specimen collection for the PT/INR assay
is which of the following?

A. 4.0% sodium citrate

B. 3.8% sodium citrate
C. 3.2% sodium citrate
D. 2.8% sodium citrate

120. A clinical laboratory scientist performs an APTT on a freshly processed

plasma sample, and it is prolonged. He performs a 1:1 mixing study using
a normal pooled frozen specimen and the APTT does not correct into the
normal range of the APTT. He stores the specimen at —70°C overnight until
the special coagulation laboratory can evaluate the sample for the presence
of a lupus anticoagulant. The special coagulation laboratory rapidly thaws
the specimen and repeats the APTT. The result is normal. Which of the fol-
lowing can cause this phenomenon?

A. Elevated d-dimers
B. Elevated FVUI
C. Cold activation of FVII
D. Elevated residual platelets in the platelet-poor-plasma specimen

121. A clinical laboratory scientist performs an APTT on a freshly processed

plasma sample. The APTT is prolonged. A 1:1 mixing study is performed
using a normal pooled frozen specimen and the APTT does not correct into
the normal range of the APTT. Which of the following assays can be used
to distinguish between a factor inhibitor and a lupus anticoagulant?

A. Factor VIII activity assay

B. Hexagonal phase phospholipid assay
C. Factor Xa chromogenic assay
D. Activated protein C resistance assay

122. Unfractionated heparin can be monitored with which of the following as-
says?

APPT
B. Fibrinogen
CyARTE
D. Antithrombin

123. Low-molecular-weight heparin can be monitored with which of the fol-

lowing assays?

A. Anti-Xa
B. Thrombin time
C. Fibrinogen
D. APTT

124. Unfractionated heparin must have which of the following coagulation in-
hibitors present in normal amounts in order for it to properly anticoagulate
a patient?
 CLS Review Test 263

jes d
A. Protein C Ss
B. Protein S 2
2
C. Antithrombin CC)
4
D. Alpha-2 antiplasmin

125. In addition to calcium ions, what two components make-up the prothrom-
bin time reagent?

A. Tissue factor and phospholipid

B. Reptilase venom and thrombin
C. Phospholipid and thrombin
D. Negatively charged particles and tissue factor

126. Which of the following tests may be used to confirm a positive screening
test for a lupus anticoagulant?

A. Activated partial thromboplastin time

B. Protamine sulfate test
C. Prothrombin time
D. Hexagonal-phase phospholipid neutralization

127. A series of hemostasis tests is ordered on a specimen that is slightly he-

molyzed. What is the best course of action?

A. Perform the tests on an electro-mechanical instrument because hemol-

ysis only interferes in photo-optical instruments
B. Perform the tests on a photo-optical instrument because hemolysis only
interferes in electro-mechanical instruments
C. Perform the tests on both a photo-optical and electro-mechanical in-
strument and average the results
D. Reject the specimen or qualify the results, as hemolysis implies partial
activation of platelets

128. A 2-year-old child recovering from a viral infection presents with a platelet
count of 20.0 X 10?/L. The most probable etiology of the thrombocytope-
nia is

. heparin-induced
. neonatal alloimmune
. chronic idiopathic
>
WO. acute idiopathic

129. A patient scheduled for a platelet aggregation study took two aspirin the night
before to help him sleep. Which aggregation response will not be inhibited?

A. Epinephrine
B. ADP
C. Arachidonic acid
D. Ristocetin

130. Which of the following does not affect platelet storage?

264
ci 7. Review
NE ATests a a a a ee

A. Type of plastic bag

B. Storage temperature
C. Irradiation
D. Agitation method

131. Exceptions to regular blood-donation requirements can be made for

A. paid donors
B. pregnant women
C. healthy athletes
D. autologous donations

132. A female donor weighing 98 Ibs. (44.5 kg) comes into the donor center to
make a directed donation for a family member. Determine the amount of
blood that can be drawn from this donor.

A. 400 mL
B. 405 mL
C2 450m
D. 495 mL

133. One unit in a run has an HIV 1/2 screening test result just above the cut-
off. The next step should be to

A. repeat the test in duplicate

B. perform a Western blot test
C. inform the donor of the positive test and ask additional history ques-
tions
D. add the donor to the permanent deferral list

134. Which of the following donors would be investigated as a “look back”

case?

A. A donor newly diagnosed with HIV who previously tested negative

B. Amale who is donating for the first time and with a positive test for an-
tibodies to HCV
C. A donor with an indeterminate Western blot confirmatory test for
HIV
D. A donor with a screening test for HIV 1/2 with a value twice the cutoff
value

135. A woman delivered an infant two weeks prematurely. Her physician or-
dered postnatal testing due to the infant’s jaundice. The results are given
below:

Mother’s results Baby’s results

ABO group: A ABO group: O
Rh type: negative Rh type: negative
Autocontrol: negative DAT: positive
Antibody screen: positive
Antibody ID: anti-D
 CLS Review Test 265
~

ch
4
What procedures should be performed next? S
4
>
A. Acid elution of maternal cells and antibody identification on the eluate 7)
cc
B. Autoabsorption of anti-D from maternal serum using maternal cells
C. Autoabsorption using the infant cells and antibody identification on the
absorbed serum
D. Heat elution of the baby’s cells and repeat of Rh typing on the eluted
cells

136. After performing an antibody-identification panel, the presence of anti-Sd?

and possibly another alloantibody were suspected. To perform further test-
ing and identify the second antibody, the CLS decided to eliminate the pos-
sible interference of the anti-Sd? by

A. destroying the Sd* antigens on the panel cells with ficin

B. absorbing the anti-Sd? with hydatid-cyst fluid
C. neutralizing the anti-Sd? with Sd(a+) urine
D. performing an autoabsorption

137. A clinical laboratory scientist treated screening cells and panel cells with
AET (2- aminoethylisothiouronium bromide). Which of the following an-
tibodies will not react with these AET-treated cells?

A. Anti-P1
B. Anti-Fy?
C. Anti-Jk?
D. Anti-K

138. A lectin that, when appropriately diluted, has anti-A, characteristics is

A. Bandeiraea simplicifolia
B. Ulex europeaus
C. Dolichos biflorus
D. Arachis hypogea

139. In performing an antigen phenotype using anti-Fy*, the best phenotype to

use as a positive control is

A. Fy(a—b+)
B. Fy(at+b+)
C. Fy(a—b—)
D. Fy(a+b-—)

140. Below are the results of ABO grouping and Rh typing on a patient for
whom a type and hold order has been received:

Patient cells + Anti-A Anti-B Anti-D

0 3+ mf 2+

Patient serum + Acells B cells

3+ 0
266ee
ch
ee 7. Review OI
Tests

These results are most consistent with

A. the reactions of a patient with antibody-coated cells

B. the reactions caused by rouleaux
C. the weak reaction of an acquired B antigen
D. transfusion of group O cells to a group B patient

141. A 72-year-old woman with a history of ulcerative colitis entered the emer-
gency room with severe abdominal pain and a hemoglobin level of 6 g/dL.
The attending physician ordered four units of blood. The results of pre-
transfusion testing are recorded below:

Patient cells + Anti-A Anti-B Anti-A,B Anti-D Rh control

4+ I+ A+ 3+ 0

Patient serum + _ A cells B cells O cells Autocontrol

0 4+ 0 0

The next step taken to resolve this problem should be to

A. regroup the patient’s cells with monoclonal or acidified human anti-B
B. identify the extra antibody with an antibody panel
C. immediately crossmatch the patient’s serum with group-A donor cells
D. perform an autoabsorption using patient cells and serum

142. A 91-year-old male fell and broke a hip and requires surgery to pin the
fracture. Two units of blood were ordered. The patient’s pretransfusion
testing results are recorded below:

Patient cells+ Anti-A Anti-B Anti-A,B Anti-D Rh control

0 0 0 0 0

Patient srrum+_ A cells B cells O cells Autocontrol

0 0 0 0

The next step taken to resolve this discrepancy should be to

A. crossmatch the patient’s serum with O positive donor cells
B. open a new lot of reagent A and B cells; retest the patient’s serum
C. place the reverse grouping tubes and the autocontrol in a 4°C refriger-
ator for 15 minutes, spin, and read
D. draw a new sample from the patient because two patient specimens
must have been mixed up

143. A 44-year-old man needs 3 units of packed red blood cells for back surgery.
The patient’s cells fail to react with anti-A and anti-B; his serum reacts with
A, B, and O cells. The next logical step to resolve this problem is

A. crossmatch the patient’s serum with random donor cells at 37°C

B. identify the antibody(ies) using a panel of group O cells
 CLS Review Test 267
~
d
BS
C. perform an autoabsorption using the patient’s own cells 5
D. titer the serum against the autologous control as well as random donor =
>
units; compare the results and choose the least incompatible units oY
ce

144. The antibody least likely to show dosage is

A. anti-D
B. anti-M
C. anti-Fy*
D. anti-Jk*

145. A request for 3 units of packed red cells is made for a male patient, aged
80 years, who will undergo surgery to repair a broken hip. He is group O,
Rh-negative and has a positive antibody screen in the AHG phase of test-
ing. A transfusion history indicates that he received 2 units of whole blood
in 1979. The results of the antibody panel are given below:

Cell Check
ne C D E c e K k_ Fy? Fy? Jk? Jk”>M N S~— AHG cells
1 fe Ve Oneteete O + 0 + + 0 + + + IF NP
2 + + 0 0 + 0 + + + +.-0 4+ 0 + = I+ NP
3 te tee eO) te Ot 0 + OO + Ft + U+ClCUN 2+
4 Oe ie + OO + + 0 + + + Sn” +.) ale NP
5 0 O + + + O + + + + + + «+ ~«~0 1+ NP
6 PORE) Per AR OP SET ein 0) see OF 10050 2+
NP = not performed

The antibody in the patient’s serum is most likely

. anti-C
. anti-D
. anti-Jk?*
. anti-Jk>
UawS

146. Which of the following sets of reactions would be most consistent with the
presence of anti-I? Testing was carried out at 4°C.

Patient serum + Patient serum + Patient serum +

patient cells group O adult cells group O cord cells
A. 4+ 4+ 0
B. 4+ 4+ 4+
Cal + 4+ 4+
D. 1+ 2+ 1

147. The antibody screen and both crossmatches on a patient serum were posi-
tive at the immediate-spin phase of testing. All other phases of testing per-
formed (LISS 37°C and AHG) gave no reactions. A ten-cell panel was
tested. Seven of the ten cells reacted with the serum at immediate spin and
room temperature but not at AHG. The autocontrol was negative at all
phases of testing. The most likely specificity of the antibody is
268
ree
eee 7. Review Tests
Ae ———

. anti-K
. anti-N
. anti-I
DVUaAwDLY
. anti-c

148. The antibodies in a patient’s serum have been tentatively identified as anti-
M and anti-K. To be 95% certain that these two antibodies are both present
and that no other antibodies are present, a selected-cell panel should be
tested. Which cells from the panel below should be selected for this purpose?

Cellno. D C E ec e Kk = MaeNeeaSs ss
1 ty ort ah 0, yh sO me ects) + 0O ft euiken A
2D + + 0 0 Forks oectie, BOD ct ented iO
3 te utOe pacer tat On = JOR et on eee eee
4 i ©On ocOu, eyrbewy Gee On wectonl mals ent
5 One OO + + 0O Bet hae LO) + +
6 OF. Ogre 5 SO + + + + O
7 0-0" 8000 + oe 4 Oe + +
8 0 #0 (OF st erry te tf. 30 + O +
9 0 0 0 + + O + + O + 0
10 0 0 0 + + O + 0 0 + +
1] + 0 + + + O + O 0 + +
A. Cells 1, 2, 3, and 6
B: Cells 1, 2, 4-5, 4.8; 9-10; and 11
C. Cells 2, 3, 4, 6, 7; 8; 9, 10; and 11
D. Cells 1, 10, and 11

149. Given the following pattern of reactivity, select the antibodies most likely
present in the serum.

Cell Check
no D C Ec eK k MN S§S s5_ Fy? Fy? AHG cells
1 $e eb at 0) 0. ee eee ee INE
2 depot) (Oi Oe KA 0m EY ets ted Oe Ee? ore ae 0 2+
3 0 0 OO FY ots a be 10 et oetea OPT 0) alee eNP
4 #) On 4+ 000) eGo tet SO Oe 2 NP
5 Str S0 6+ 6 TOT OR E+ 6O> Rees Be) 2+
6 OS:0730 +24 On OMe +? + REO) WEHBO 2+

NP = not performed

A. Anti-C and anti-M

B. Anti-E and anti-K
C. Anti-Fy* and anti-M
D. Anti-C and anti-E

150. The major crossmatch tests patient serum against

A. donor cells
B. patient cells
C. group A, and B cells
D. screening cells
 CLS Review Test 269
re)
d
—
151. Upon testing a patient for a presurgical workup, the CLS determines that Ss
the patient is group B, Rh-negative and has a negative antibody screen. =
>
During surgery the next day, 2 units of packed cells are ordered STAT. The Y
4
crossmatch with one unit is incompatible at the AHG phase. The CLS
crossmatches two more units; they are both compatible. The most likely
cause of the incompatibility with one unit is

A. the patient has a positive DAT

B. the patient is Rh-positive and has been mistyped
C. the donor has a positive DAT
D. the donor has an unexpected antibody in the serum

152. Additional units of blood have been ordered on a patient transfused 3 days
ago with two units of packed red cells. Pretransfusion testing now demon-
strates incompatible crossmatches and a positive antibody screen at the im-
mediate-spin and antiglobulin phases of testing. Polyspecific antiglobulin
serum was used in the AHG phase. Anti-I was identified. Which of the fol-
lowing procedures would be most useful in finding compatible units?

A. Select I-negative units for the crossmatch

B. Cold autoabsorption
C. Enzyme pretreatment of donor cells
D. Prewarmed crossmatch

153. A patient is group O, Rh-positive. The patient’s serum contains no unex-

pected antibodies. Which of the following donor units can be expected to
be compatible in the crossmatch?

A. A-negative
B. B-negative
C. O-negative
D. AB-positive

154. A patient’s sample gives the following reactions on pretransfusion

testing:

Patient cells + Anti-A Anti-B Anti-D Rh control

4+ 0 0 0

Patient serrum+ A, cells Beells ScreencellI Screen cell I

1+ 4+ 0 0

Which of the following red cell units would be acceptable for transfusion
if blood is needed urgently without time for further testing?

A. A-positive
B. A-negative
C. AB-negative
D. O-negative

15S; Pretransfusion testing on a patient gives the following reactions:

270 ee————————————EEEE—
ee 7. Review
eS Tests

Patient cells + Anti-A Anti-B Anti-D Rh-control

0 0 3+ 0)

Patient srrum+ A cells B cells Auto-control

4+ 4+ 0

Antibody screen IS 37°C LISS AHG _— Check cells

cell I 0) I+ 2+ NP
cell II 0 0 0 2+

NP = not performed

These results are consistent with

. acquired B antibody
. autoantibody
. rouleaux
i . unexpected alloantibody
emo

156. After examining a patient, the physician ordered a DAT. The nurse used a
red-top tube to obtain the specimen, permitted the blood to clot, and cen-
trifuged and refrigerated the tube overnight before sending the specimen to
the laboratory for testing the next day. The results of the DAT are given
below:

Polyspecific | Monospecific | Monospecific

AHG IgG anti-C3
DAT 1+ 0 1+
Check cells NP 2+ NP

NP = not performed

These results indicate

. IN-Vivo sensitization with complement

. In-vitro sensitization with complement
. IN-vivo sensitization with IgG
a
i . In-vitro
wen: sensitization with IgG

157. A DAT on the cells of a patient taking medications for hypertension is

found to be 3+ positive. The patient’s serum reacted with all panel cells at
the AHG phase. The best procedure to use to prepare the serum for subse-
quent testing, assuming the patient has not been recently transfused, is

. absorption with drug-treated cells

. autoabsorption using AET-treated cells
. absorption using selected cells
. autoabsorption after ZZAP treatment of cells
GVaAwS

138. A group O, Rh-negative mother delivers a group A, Rh-negative infant

with a negative DAT. The mother’s antibody screen and identification
demonstrate a weakly reactive anti-D. The CLS should
 CLS Review Test 271
re)
d
iS
. issue Rh-immune globulin for the mother Ss
. indicate that the mother is not a candidate for Rh-immune globulin A
>
. investigate the origin of the anti-D oY
ce
a . repeat the infant’s DAT
whence

159. Which of the women below is not a candidate for Rh-immune globulin
(RhIg), assuming that all of the women have delivered Rh-positive in-
fants?

A. O, Rh-negative, weak D-positive, negative antibody screen

B. A, Rh-negative, weak D-negative, negative antibody screen
C. A, Rh-negative, weak D-negative, positive antibody screen, anti-K
identified, antenatal RhIg administered,
D. B, Rh-negative, weak D-negative, positive antibody screen, anti-D
identified, antenatal RhIg administered

160. Which of the following cases would most likely result in an immediate he-
molytic transfusion reaction?

A. Group O packed cells transfused to a group A patient

B. Group B packed cells transfused to a group O patient
C. Group A packed cells transfused to a group AB patient
D. Group O packed cells transfused to a group B patient

161. Below are the results of preliminary tests done to investigate a possible
transfusion reaction:

DAT Serum/plasma hemolysis

Pretransfusion patient sample 0 absent
Posttransfusion patient sample ile. absent
Pretransfusion donor segment 0 absent
Posttransfusion blood bag 0 absent
These results are consistent with

A. febrile transfusion reaction

B. nonhemolytic transfusion reaction
C. hemolytic transfusion reaction
D. absence of a transfusion reaction

162. A physician has requested a unit of blood for exchange transfusion of a

1,000-g acidotic infant with hyperbilirubinemia born to a mother whose
CMV antibody status is unknown. Which of the following units of blood
would be best to prepare the resuspended whole blood for this transfu-
sion?

A. Directed donation, hemoglobin—S—negative, CMV-negative unit col-

lected 16 days earlier
B. Irradiated, CMV-negative unit outdating in 28 days
C. Frozen, deglycerolized unit processed 18 h earlier
D. Leukocyte-reduced, irradiated, hemoglobin—S-negative unit collected
4 days earlier
272
cc 7.
acaReview 8S)
Tests2 Pee ee CR eee Se Oe

163. An intrauterine-exchange transfusion is ordered for the fetus of an A posi-

tive mother with a strongly reactive anti-Fy*. Which of the following red-
cell units would be appropriate for the transfusion?

A. A positive, Fy(a—)
B. A negative, Fy(a—)
C. O positive, Fy(a+)
D. O negative, Fy(a—)

164. Which of the following observations suggest bacterial contamination of a

unit of RBCs?

A. A yellow color in the segments

B. A green hue to the supernatant fluid, although the cells appear normal
C. A dark purple unit compared to the segments
D. White debris at the supernatant/red-cell interface

165. Seven percent of the inventory of a transfusion service is usually O nega-

tive. 500 units of red cells are used in an average month. If at least four
units of O negative are necessary at all times for emergencies, what is the
number of O negative units needed per day?

Ore
ORDNA

166. A unit of red blood cells is returned to the transfusion service unused. The
unit has not been entered, was issued at 09:13 and returned at 09:30, has
clear plasma, and no segments remain attached. Based on this information,
determine whether the unit can be reissued.

A. The unit can be reissued

B. The unit cannot be reissued based on the time out of the laboratory
C. The unit cannot be reissued based on the appearance of the plasma
D. The unit cannot be reissued based on the number of segments attached

167. During issuance of a unit of packed red cells, the floor nurse picking up the
blood reads the following information to the CLS who is checking the
records for issue:

Thompson, Michael J. 133660

Donor type: B negative

The records being checked by the CLS reveal the following:

Thompson, Michael J. 133666

Patient type: B positive

Can this unit be released?

eas
B. No; the Rh types do not match
 CLS Review Test 273

td

d
=
C. No; the patient names do not match S
D. No; the patient numbers do not match =
>
Answer: D Cy
ce

168. What is the proper label for a blood product prepared as follows: Twelve
hours after collection, a unit of whole blood collected in CPDA-1 is
centrifuged at 4°C using a “heavy” spin. The plasma is expressed into a
satellite bag and stored at 1-6°C for 24 h. The plasma is then frozen at
tS °C.

A. Fresh frozen plasma

B. Liquid plasma
C. Plasma
D. Recovered plasma

169. An ABO grouping yielded the following results:

Patient cells + Anti-A, = Anti-A Anti-B = Anti-A, B

0 1+ 0 1+

Patient serum+ A, cells A,cells_ B cells O cells

4+ 0 3+ 0

This patient’s results are consistent with

A. group O
B. group AB
C. subgroup of A
D. group-O patient with unexpected alloantibody

170. Below are the results of an ABO grouping:

Patient cells + Patient serum +

Anti-A Anti-B A, cells B cells
3+ 0 0) 0

The most likely interpretation of these results is that the patient

. is a subgroup of A
. is a group A newborn
. is group A and has been multiply transfused with group O cells
YS. has rouleaux due to multiple myeloma
UAW

171. Following FDA regulations, the clinical laboratory scientists performed

platelet counts on platelet concentrates from four separate donors collected
and processed during the month. The counts were as follows:

Donor A: 5.3 X 10!°/bag

Donor B: 4.2 X 10!°/bag
Donor C: 5.7 X 10!°/bag
Donor D: 4.6 X 10!°/bag

Based on these results, the CLS should

274i AL
ei 7. Review
SE Tests a eee

A. investigate explanations for low concentrations in the platelet concen-

trates
B. investigate explanations for high concentrations in the platelet concen-
trates
C. investigate explanations for excess variability between concentrations
in the four platelet concentrates
D. report acceptable quality-control results for platelet concentrates

172. Below is the label for a patient sample submitted to the blood bank for type
and crossmatch. Assuming that the date is today, is the sample acceptable
for testing?

Thomas, Marilyn
ID 76-15405
7-15-01 15:05 CB

A. The sample is acceptable

B. The sample is not acceptable because it lacks the patient’s room num-
ber or location
C. The sample is not acceptable because it lacks the name of the patient’s
physician
D. The sample is not acceptable because the patient’s middle name or ini-
tial is missing

173. A serum has been tentatively determined to contain anti-c and anti-Fy?.
Which of the cells below would be best to adsorb the serum and separate
the antibodies so that only anti-Fy* would be recovered from the eluate of
the adsorbing cells?

A. CcDEe, Fy(a+b—), Kk
B. ce, Fy(a—b+), Kk
C. CDe, (Fya+b+), kk
D. CDe, Fy(at+b—),.kk

174. The transfusion service receives an order for 4 units of packed red cells for
a surgical patient. Blood grouping and typing results are as follows:

Cell grouping Serum grouping

anti-A: 0 A, cells: 4+
anti-B: 4+ B cells: 1+
anti-A,B: 4+
anti-D: 0 US and AHG)
Rh control: 0 (IS and AHG)

A next step required to solve this problem would be to

A. draw a new blood sample from the patient and repeat all test procedures
B. set up a cell panel to identify the antibody causing the typing problem
C. test the patient’s serum with A, cells and the patient’s red cells with
anti-A, lectin
D. repeat the ABO-antigen grouping using 3 X-washed, saline-suspended
cells
 CLS Review Test 275

Po)
d
A
175. Which of the following is not characteristic of the reactivity of cold ag- Ss
glutinins? =
>
Vv
cc
A. They react optimally at temperatures between 1—10°C
B. The reactions obtained are reversible after warming
C. They react strongly with cord cells
D. They will agglutinate most adult human red cells, regardless of blood
group

176. The antibody panel below can be used to identify antibodies against all of
the following antigens except

Cellno. D C E c ee K _ k_ Fy? Fy? Jk? Jk> MN

1 oct sae O00 £0 ysOivte sWiieockou chs ecQloeck +
zy tonto) Ojoaieete 1O>uiety, 20 +752-One Sankt 0
3 Pet Onariteed0e atvietas Odliese my +
+ Tones s decOm {Orn +i Bow imoteh matalish +
5 Oe OO ee OL eae oe of ara a ot
Ay Fy*
B. Jk°
C.M
Drak

177. A patient requiring a transfusion has a positive autologous control at im-

mediate spin. All serum tests done at 37°C and with AHG are negative. The
antibody is identified as anti-I. The patient’s history reveals transfusion of
several units of blood at another institution within the past month. What is
the procedure of choice to obtain compatible blood at this time?

. Absorb the patient’s serum with the donor cells at 4°C

. Absorb the patient’s serum with the patient’s cells at 4°C
. Perform all tests at 37°C and convert to the antiglobulin phase
. Perform
UaAaPY warm autoabsorptions with the patient’s cells and the patient’s
serum

178. A blood sample from a neonate was received for typing and DAT. The test
results on the mother and neonate are given below:

Mother’s Baby’s
results results
Anti-A 0 0
Anti-B 0 4+
A, cells 4+ NP
B cells 4+ NP
Anti-D 0 A+
Rhcontrol 0 aE
DAT NP 2+
Anti-M 0 4+
Anti-K 0 ihe

NP = not performed
276 7. Review Tests

The mother has anti-M and anti-K in her serum. No other unexpected
antibodies were detected. The baby is being given penicillin for a
streptococcal infection. The most likely cause for the baby’s positive DAT
is

. maternal anti-D coating the baby’s Rh-positive cells

. maternal anti-M coating the baby’s M-positive cells
. maternal anti-K coating the baby’s K-positive cells
. drug-induced hemolytic
DGaAwWLY anemia due to penicillin administration

179. A 44-year-old woman has a hemoglobin level of 6.1 g/dL. Leukocyte and
platelet counts are within reference limits. The patient is group O, Rh-neg-
ative, and has no unexpected blood-group antibodies in her serum. Cross-
matches are compatible. However, 15 min after the first transfusion is
started, she experiences a sudden anaphylactic reaction, including diffi-
culty in breathing and hives. Subsequent units of transfused washed red
cells are tolerated well. The most probable explanation for these findings
is that the

A. patient has antibodies against WBCs

B. patient has antibodies against IgA
C. donor has IgG antibodies
D. patient has antiplatelet antibodies

180. An isolate from a urinary tract infection grows as a porcelain-white, buty-

rous colony that is nonhemolytic on sheep-blood agar. The isolate is a cata-
lase-positive, gram-positive coccus. Biochemical testing reveals the fol-
lowing reactions:

Tube coagulase: negative Mannitol: acid

Modified oxidase: negative
Novobiocin sensitivity: resistant
This isolate is best identified as
A. Micrococcus species
B. Staphylococcus epidermidis
C. Staphylococcus saprophyticus
D. Stomatococcus species

181. A sputum culture yields predominantly alpha-hemolytic, flat colonies on

sheep-blood agar that on Gram’s stain reveal gram-positive cocci in pairs.
Which biochemical tests will aid in the identification of this isolate?

A. Bacitracin and sulfamethoxazole-trimethoprim susceptibility

B. Bile esculin hydrolysis and 6.5% NaCl tolerance
C. Catalase test and CAMP reaction
D. Optochin susceptibility or bile solubility

182. A catalase-negative nonhemolytic gram-positive coccus isolated from a

urine specimen from a 42-year-old woman hydrolyzes bile esculin and
grows in the presence of 6.5% NaCl. This isolate could be
 CLS Review Test 277

~
d
4
A. Streptococcus bovis 5
B. Enterococcus faecalis a4
>
C. Streptococcus pneumoniae Cc}
ce
D. alpha-hemolytic Streptococcus viridans group

183. To establish a definitive diagnosis of diphtheria, which of the following

must be confirmed?

A. Biochemical test results

B. Methylene-blue micromorphology
C. Tellurite reduction
D. Toxin production

184. The following results are obtained from a nonlactose-fermenting, gram-

negative rod isolated from a urinary tract infection:

Triple sugar iron: alk/acid Citrate: negative

H,S: negative | Phenylalanine deaminase: positive
Indole: positive Urease: positive
Motility: positive Ornithine: positive
The identity of this organism is
A. Morganella morganii
B. Proteus mirabilis
C. Providencia alcalifaciens
D. Providencia stuartii

185. A green colony type with black center on Hektoen agar is inoculated to a
stool screen using triple sugar iron (TSI) agar, lysine iron agar (LIA), and
Christensen’s urease. The following reactions develop:

TSI: — alkaline/acid and gas, H,S-positive

LIA: _ lysine-positive, H,S-positive
Urease: negative
These results are consistent with a species of
A. Citrobacter
B. Escherichia
C. Proteus
D. Salmonella

186. A patient diagnosed as having bacterial vaginosis complains of malodor-

ous vaginal discharge. A direct smear of the vaginal exudate on Gram’s
stain reveals epithelial cells that are covered with masses of small gram-
variable coccobacillary rods suggestive of “clue” cells. This finding is in-
dicative of

A. Chlamydia trachomatis
B. Gardnerella vaginalis
C. Neisseria gonorrhoeae
D. Lactobacillus species
278 7. Review Tests

187. Laboratory diagnosis of primary atypical pneumonia is established by

. serological tests
. culturing the causative agent on sheep-blood agar
. acid-fast staining of sputum smears
. the use of tissue culture techniques
Gawe

188. From a sputum specimen, an acid-fast bacillus grows on Lowenstein-Jensen

medium for 18 days at 35°C capneic incubation. Initially, the colonies are
buff, raised, and rough when grown in the dark. After exposure to light, no
change in pigmentation is detectable. On examination under 10 magnifi-
cation and on stain, serpentine cording is seen. Which of the following char-
acteristics confirm the identity of the most likely etiologic agent?

A. Niacin-positive, nitrate-positive
B. Niacin-negative, nitrate-positive
C. Niacin-positive, nitrate-negative
D. Niacin-negative, nitrate-negative

189. A gram-negative rod is inoculated into nitrate broth and incubated for 24
h. After equal amounts of alpha-naphthylamine and sulfanilic acid are
added, no color develops. Zinc dust is added and still no color develops.
What action should you take?

A. Make up new reagents and check with quality-control stains

B. Repeat the nitrate test after 48 h of incubation
C. Interpret the results as negative
D. Interpret the results as positive

190. Sodium polyanetholsulfonate is added to blood culture media to

. prevent clotting
. activate complement activity
. enhance phagocytosis
sesh. enhance the growth of fastidious pathogens
SM@

191: Which of the following bacterial species is unacceptable for performing

quality-control testing of anaerobic jars or glove boxes?

A. Prevotella melaninogenicus
B. Clostridium novyi
C. Clostridium tertium
D. Peptostreptococcus anaerobius

192. Blastomyces dermatitidis can be differentiated from the saprobic species of

Chrysosporium and Pseudoallescheria by

. rapid growth of the colony

. Single conidia produced directly from hyphae or conidiophores
. ability to convert to a yeast phase at 35°C-37°C
. inability to grow on media containing cycloheximide and chloram-
SQV
phenicol
 CLS Review Test 279

~
d
4
193. Persistent athlete’s foot plagues a local baseball team in training season. A Ss
study is undertaken to identify the organism from each team member with 2
>
typical signs of the fungal disease. The organism grows out in 12 days on VY
4
Sabouraud’s dextrose agar and Sabouraud’s with chloramphenicol and cy-
cloheximide as a snowy-white, velvety colony that turns burgundy-wine on
the reverse side with age. Rare long, narrow, smooth-walled macroconidia
are seen On microscopic preparation. Thin, clavate, peg-shaped microconi-
dia are borne laterally. Based on these data, a likely etiologic agent is

A. Microsporum audouinii
B. Microsporum canis
C. Trichophyton mentagrophytes
D. Trichophyton rubrum

194, The purpose of the iodine solution used in the direct-preparation technique
for screening stool specimens is to

. enhance morphologic detail of organisms

. check for motility of trophozoites
. precipitate fecal material
. Stain debris and background material
UALS

195. An important cause of pneumonia in patients with acquired and congenital

immunologic disorders is an organism that in a lung impression smear
stained with a monoclonal antibody fluorescent stain reveals clusters of
cysts in a “honeycomb” appearance. The identity of this organism is

A. Toxoplasma gondii
B. Pneumocystis carinii
C. Babesia
D. Sarcocystis

196 Babesia may infect humans and multiply in red cells; however, it can be
differentiated from malarial agents because Babesia

A. has crescent-shaped gametocytes

B. forms hemozoin pigment in red cells
C. also occurs in leukocytes
D. develops maltese cross forms

197. A patient with a mild pneumonia that is suggestive of ornithosis would be

infected with

A. Chlamydia psittaci
B. Chlamydia trachomatis
C. Mycoplasma pneumoniae
D. rhinovirus

198. Cell-culture media have antimicrobials as ingredients to

A. enhance cell penetration

B. sterilize the medium
280 7. Review Tests

C. increase the cytopathic effect

D. reduce bacterial contamination

199. To develop a minimum inhibitory concentration (MIC) procedure by

macro-broth-tube dilution you need to determine the required concentra-
tion of antimicrobial for preparation of working-stock solution. The high-
est concentration of antimicrobial to be tested will be 128 wg/mL. Two
milliliters of stock are transferred directly to the first tube, and twofold se-
rial dilutions are prepared in subsequent tubes. One milliliter of standard-
ized inoculum is added to each tube. Based on these parameters, the con-
centration of antimicrobial in the working stock solution must be

A. 256 wg/mL
B. 512 pg/mL
C. 1,024 pg/mL
D. 2,048 pg/mL

200. The following results are obtained from a gram-positive coccus isolated
from a patient with urinary tract infection:

Catalase: negative Resistant to vancomycin

PYR hydrolysis: negative Leucine aminopeptidase: negative
Bile esculin: negative Growth in 6.5% NaCl: negative
Gas from glucose: positive
This isolate is best identified as
A. Enterococcus faecium
B. Aerococcus
C. Pediococcus
D. Leuconostoc

201. A direct wet smear of stool demonstrated bile-stained, mammillated, thick-

shelled eggs in 1-cell stage. The presence of these eggs would indicate a(n)
infection with

A. Enterobius vermicularis
B. Ascaris lumbricoides
C. Necator americanus
D. Strongyloides stercoralis

202. The following results are obtained from a slender, gram-negative rod iso-
lated from an intra-abdominal abscess:

No growth in the presence of 1-mg kanamycin disk

Growth in the presence of 5-mg vancomycin disk
No growth in the presence of 10-mg colistin disk
Indole: positive
Lipase: negative
The identity of this organism is
A. Bacteroides fragilis
B. Bacteroides gracilis
 CLS Review Test 281
~
"
2
C. Fusobacterium nucleatum s
D. Fusobacterium necrophorum =
>
Vv
c

203. Organisms that grow best with greater carbon-dioxide concentrations than
are found in ambient air are called

. Microaerobic
. capnophilic
. humidophilic
GVaAwS
. anaerobic

204. Specimens for viral isolation

. Should be incubated at 37°C for 2 h prior to inoculation

. should be placed on ice and transported at once to the laboratory
. should be frozen and transported at once to the laboratory
VaAW>Y
. Should be incubated at room temperature for 2 h prior to inoculation

205. Mycobacteria that are pigmented in the dark are termed

. nonphotopigmented
. nonphotochromogens
. scotochromogens
. photochromogens
VaAWSY

206. The standard inoculum of bacteria to be used in antimicrobial-susceptibil-

ity testing (disk method) can be determined by the use of a

A. 0.5 McFarland standard

B. 1.0 McFarland standard
C. 1.5 McFarland standard
D. 2.0 McFarland standard

207. Which of the following primary-media combinations is appropriate for ini-

tial subculture of blood cultures?

A. Sheep-blood agar, MacConkey agar, Hektoen enteric agar

B. Sheep-blood agar, MacConkey agar, thioglycolate broth, chocolate
agar
C. Sheep-blood agar, MacConkey agar, chocolate agar
D. Sheep-blood agar, MacConkey agar, chocolate agar, CDC-anaerobic
blood agar

208. The ability of an organism to degrade the amino acid tryptophan as a re-
sult of the enzyme tryptophanase can be measured by

A. the citrate-utilization test

B. the phenylalanine-deaminase test
C. the Voges-Proskauer test
D. the indole test
282 7. Review Tests

209. Members of the Bacteroides fragilis group can be selected by using which
of the following media?

A. CDC sheep-blood agar

B. Bacteroides bile-esculin agar
C. Phenylethyl-alcohol, sheep-blood agar
D. Thioglycolate medium

210. A stool specimen from a five-year-old patient with bloody diarrhea is re-
ceived by the laboratory. Which of the following media would be used to
detect Escherichia coli 0157:H7?

A. MacConkey-sorbitol agar
B. Phenylethyl-alcohol agar
C. Xylose-lysine desoxycholate agar
D. Brilliant-green agar

211. Microscopic examination of a stool specimen for ova and parasites re-
vealed spherical, thick-shelled eggs (31 < 43 wg) with prominent radial
striations. The eggs possessed three pairs of hooklets within the embry-
onated oncosphere. The identity of this parasite is most likely

A. Taenia species
B. Hymenolepis diminuta
C. Hymenolepis nana
D. Diphyllobothrium latum

212. Lyme disease is caused by the bite of a tick infected with

A. Borrelia vincentii
B. Borrelia recurrentis
C. Borrelia burgdorferi
D. Borrelia hermsii

213. Cryptosporidum and Isospora species are difficult to detect without special
staining. Which of the following stains may be used to demonstrate these
organisms?

A. Trichrome stain
B. Chlorazol-black E stain
C. Iron-hematoxylin stain
D. Modified Kinyoun’s acid-fast stain

214. The specimen of choice for darkfield examination to detect Treponema

pallidum is

A. blood
B. urine
C. spinal fluid
D. fluid from a chancre

215. All members of the Enterobacteriaceae are

 CLS Review Test 283

. Oxidase-negative
. mannitol-positive
. Citrate-positive Revie
Test
GVaAwS>
. sucrose-negative

216. An isolate from an animal bite gave the following results:

Gram-negative coccobacillus Catalase: positive

Growth on blood agar indole: positive Oxidase: positive
Penicillin disk: susceptible

This isolate is best identified as

A. Kingella kingae
B. Pasteurella multocida
C. Eikenella corrodens
D. Actinobacillus actinomycetemcomitans

217. The following are reported on a given work day:

1. Observation of AFB organisms on a direct smear of a sputum

2. Identification of Neisseria gonorrhoeae from a genital specimen of a
female outpatient
3. Positive findings of Entamoeba histolytica trophozoites and cyst forms
4. Oxacillin resistance noted in a Staphylococcus aureus isolate from an
inpatient

What additional steps, if any, are required?

A. No. 1 requires follow-up of AFB cultures

B. No. 4 requires repeat testing to confirm this unusual susceptibility
pattern
. All reports require communication with epidemiology or infection-
control personnel
CO). No. 3 requires serologic testing for invasive strains to determine diag-
eet
nosis of extraintestinal amoebiasis

218. A 65-year-old alcoholic male with fever, chills, nausea, and vomiting is ad-
mitted to the hospital. On further examination, the patient seems incoher-
ent and confused. CSF and blood cultures are taken and sent to the labora-
tory for examination. Initial findings on the CSF:

Protein: 250 mg/dL

Glucose: 30 mg/dL (serum glucose 110 mg/dL)
WBC: — 1200/cu mm
PMNs: 90%
Bands: 10%
CSF direct gram stained smear: many WBCs, many gram-positive, lancet-
shaped diplococci
Which of the following will you suspect to recover?
A. Group A streptococcus
B. Group B streptococcus
284
a
a 7. Review Tests

C. S. aureus
D. S. pneumoniae
E. H. influenzae

219. A patient complaining of sharp back pains suspected of having cholecystitis

is taken to surgery. The infected gallbladder is removed and exudates from
the gallbladder are sent to the laboratory for culture. In an infected gallblad-
der, which of the following organisms would you attempt to recover?

A. Yersinia enterocolitica
B. Vibrio cholerae
C. Salmonella typhi
D. Shigella dysenteriae
E. Campylobacter jejuni

220. Exudates from the abdominal wound of a 75-year-old hospitalized patient

grow gram-positive cocci that produce the following results:

SBA: nonhemolytic small gray colonies

MacConkey: no growth
Catalase: negative
PYR: negative
6.5% NaCl: negative
Bile esculin hydrolysis: positive
Which of the following is the most likely identification of this isolate?
A. S. saprophyticus
B. S. epidermidis
C. Enterococcus sp.
D. Group D streptococcus
E. Viridans streptococcus

221. A gram-negative bacillus was isolated from the cerebrospinal fluid of an in-
fant with a CSF shunt. The organism produced mucoid colonies on Mac-
Conkey agar, oxidase-positive, and gave the following biochemical results:

TSI agar: K/K g-H,S=

PAD: negative
Indole: negative
Motility: positive
Urease: negative
Nitrate reduction: positive
Citrate: positive
The most probable identity of this organism is:
A. Escherichia coli
B. Stenotrophomonas maltophilia
C. Acinetobacter baumanii
D. Pseudomonas aeruginosa
E. Klebsiella pneumoniae

222. A 45-year-old Hispanic male who works in a meat-packing factory pres-

ents to the ER with history of intermittent fever, chills, sweats, and malaise
 CLS Review Test 285

do
d
4
for the past two days. Small gram-negative rods are isolated from the blood 5
cultures. The following characteristics are observed: =
>
ov
[4
CO, required
H, S produced
Presence of thionin: no growth
Presence of basic fuchsin: growth
Urease: positive in 2 hours
Which of the following is the most likely identity of the isolate?
A. Bacillus anthracis
B. Bacillus cereus
C. Brucella abortus
D. Brucella melitensis
E. Brucella suis

223. A blood culture from a patient with septicemia yields an encapsulated

yeast with the following characteristics: failure to produce germ tubes, ure-
ase positive, produces brown pigment on bird seed agar. Which of the fol-
lowing is the most likely identification of this yeast?

A. Candida albicans
B. Candida pseudotropicalis
C. Cryptococcus neoformans
D. Torulopsis glabrata
E. Saccharomyces cerevisiae

224. Respiratory exudates from a 69-year-old woman who was hospitalized for
viral pneumonia grow small gram-negative rods that produce colorless
colonies on MacConkey agar. The patient has received inhalation therapy
for the last 10 days. The organism shows the following reactions:

TSI agar: K/K H,S>

Oxidase: negative
Motility: negative
10% lactose slant: oxidized
Nitrate reduction: negative
O/F glucose: open: positive
closed: negative
Which of the following is the most likely identification?
A. Stenotrophomonas maltophilia
B. Pasteurella multocida
C. Acinetobacter baumanii
D. Pseudomonas aeruginosa
E. Acinetobacter lwofii

225. An acid fast bacilli recovered from an induced sputum has the following
characteristics:

Slow growth at 37°C

Niacin test: negative
Pigmented after exposure to light only
286 7. Review Tests

Nitrate test: positive

Catalase test: positive
The identity of this Mycobacterium species is
A. M. kansasii
B. M. tuberculosis
C. M. simiae
D. M. chelonei
E. M. avium complex

226. Blood culture isolates from a man who was injured while working on his
boat produce large yellow colonies on TCBS agar. The cytochrome oxi-
dase-positive, gram-negative curved rod produces the following screening
characteristics:

TSI agar: A/Kgas~H,S=

Catalase: positive
Nitrate reduction: positive
Lysine: positive
Indole: positive
O/129 susceptibility: no growth
Broth with 0% NaCl: no growth
3% NaCl: growth
8% NaCl: no growth
The most probable presumptive identification of this isolate is
. Aeromonas hydrophila
. Yersinia enterocolitica
. Vibrio cholerae
. Vibrio parahaemolyticus
. Vibrio alginolyticus
mOoaAwSY

227. A 29-year-old male is seen by a physician for a purulent urethral discharge.

Gram stain of the discharge shows gram-negative intracellular diplococci.
The etiologic agent of his urethritis will produce which of the following
biochemical tests results:
CTA Carbohydrate Utilization
Oxidase Dextrose Lactose Maltose Sucrose
A. + + = +
B. + + = = =
AP ae oF = —=
(i

D. + = = = =
E. + + fs bi =

228. An 8-year-old girl is admitted to the hospital with a 3 day history of fever,
abdominal pain, diarrhea, and vomiting. Stool occult blood was positive.
Stool culture grew many oxidase-negative, lactose-negative colonies after
24 hours’ incubation that yielded the following results:

ONPG: positive
TSI agar: K/Ag-H,S=
Citrate: negative
 CLS Review Test 287

%
2
Urease: negative 8
Motility: 35°C: negative =
25°C: negative we
PAD: negative
LIA: P/Y
Which of the following is the most probable identification?
A. Providencia stuartii
B. Yersinia enterocolitica
C. Morganella morganii
D. Shigella sonnei
E. Providencia rettgeri

229. A 43-year-old woman from South Texas was admitted to the hospital for
investigation of a chronic cough and chest pain. She was on chemotherapy
for breast cancer and was being examined for metastasis. She had experi-
enced a flu-like illness recently after a trip to Arizona for a medical con-
sult on her cancer. X-rays showed well-defined density on her right lobe.
Tuberculin test was negative. The biopsy showed the structure below. This
finding is consistent with which of the following?

A. Coccidioidomycosis
B. Blastomycosis
C. Aspergillosis
D. Histoplasmosis
E. Nocardiosis

230. Identify the fungal isolate shown below that was recovered from the blood
of a bone marrow transplant patient.
288 TO
BOS
Se 7. INEVISW
Review Tests
NSS

A. Aspergillus
B. Penicillium
C. Rhizopus
D. Mucor
E. Blastomyces

231. The parasitic agent shown below was recovered from a stool of a patient
who complained of abdominal cramps and loss of appetite. The agent
shown is known to produce

. malabsorption syndrome
. iron deficiency anemia
. intestinal obstruction
. extraintestinal infection
. vitamin B,, deficiency anemia
mMmOoOQwWS

232. The following are concentrations and ring diameters for an IgA radial im-
munodiffusion (RID) plate:

Standard 1 420 mg/dL 8.8mm

Standard 2 220 mg/dL 7.9mm
Standard 3. 50 mg/dL 5.4 mm
Standard 4 22mg/dL 3.8mm
Unknown — 2.2 mm
What is the appropriate action?
A. Dialyze the serum to concentrate it, then reassay
B. Extend the standard curve through the origin and read the results for 2.2
mm
C. Perform the assay on a low-level IgA plate
D. Repeat the assay, applying the unknown sample to the RID plate twice

233. Immunoelectrophoresis was performed using serum from a 62-year-old fe-

male. When her serum reacted with anti-total immunoglobulin anti-serum,
broad, elliptical arcs were seen corresponding to IgA and IgG controls, and
a sharply peaked, very dense arc was seen corresponding to the IgM con-
trol. These results are consistent with

A. IgG and IgA gammopathy

B. free-light chains in the serum
 CLS Review Test 289
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C. an IgD reacting in concert with IgM Ss
D. a monoclonal IgM in the patient’s serum i
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234. An immunofixation electrophoresis yielded a dense, dark-staining band

when patient’s serum reacted with IgM antiserum. A band with the same
electrophoretic mobility and similar density was seen when patient’s serum
reacted with kappa antiserum. These results indicate

A. an IgM-kappa monoclonal protein

B. contamination of the kappa antiserum
C. increased polyclonal IgM-kappa
D. normal levels of IgM-kappa
Answer: A

235. What is the correct order for performing a Western-blot assay for HIV?

A. Electrophorese the HIV lysate on polyacrilamide gel; transfer to nitro-

cellulose strips; apply unknown serum; add enzyme conjugate; add
substrate
B. Electrophorese the unknown serum on polyacrilamide gel; transfer to
nitrocellulose strips; apply HIV lysate; add enzyme conjugate; add sub-
strate
C. Electrophorese the HIV lysate on nitrocellulose gel; transfer to poly-
acrilamide gel; apply unknown serum; add substrate; add enzyme con-
jugate
D. Electrophorese the unknown serum on nitrocellulose gel; transfer to
polyacrilamide gel; apply HIV lysate; add substrate; add enzyme con-
jugate

236. A 45-year-old inmate in a correctional facility has a nonreactive RPR and

a positive FTA-ABS. He has no signs or symptoms of syphilis. What is the
most likely explanation for these results?

A. The inmate currently has syphilis

B. The inmate has had syphilis in the past but is not currently infected
C. The FTA result is inaccurate; it should be negative if the RPR is nonre-
active
D. The RPR is inaccurate; it must be reactive if the FTA is positive

237. An RPR-card test yielded the following results:

1:1 1:2 1:4 1:8 1:16

Patient R R R Rm NR
The patient’s result should be reported as
. reactive, 1:4 dilution
. reactive, 1:8 dilution
. reactive, 1:16 dilution
. nonreactive
GDaAwS>

238. A ten-year-old male is seen by his pediatrician for a sore throat. A strep-
tozyme screen is positive and the ASO titer is less than 60 Todd units.
290 7. Review Tests

What is the next step?

A. No further testing is necessary; the child does not have a group A strep-
tococcal infection
B. Perform an anti-DNase B assay
C. Perform an ELISA for ASO
D. Repeat the ASO neutralization test; it should be positive if the strep-
tozyme test is positive

239. When performing a slide agglutination test for C-reactive protein (CRP),
the CLS notices that the undiluted sample shows no agglutination, but the
1:5 dilution shows agglutination. How should these results be interpreted?

A. The patient’s serum contains a high level of anti-CRP

B. The patient’s serum contains no CRP
C. The reaction exhibits a postzone effect
D. The sample was incorrectly diluted

240. In the indirect immunofluorescence test to detect antibody to nuclear anti-

gens on the HEp? substrate, the patient’s titer was 160 and the pattern was
speckled. What should be done next?

A. Confirm the presence of the ANA using mouse liver or kidney

B. Perform a double-diffusion assay to determine if the Sm antibody is
present
C. Perform the Crithidea luciliae assay
D. Perform a passive hemagglutination assay to determine if SS-DNA is
present

241. Which assay is an example of direct immunofluorescence?

A. Detecting immunoglobulin in serum using fluorochrome-labeled anti-

human globulin -
B. Detecting immunoglobulin in a skin biopsy using horseradish peroxi-
dase-labeled anti-human globulin
C. Detecting C3 in the glomerular basement membrane using a fluo-
rochrome-labeled anti-human C3
D. Detecting syphilis-specific IgG in the absorbed fluorescent treponemal
assay

242. The following results were obtained on a slide agglutination test for the de-
tection of rheumatoid factor:

Undiluted patient’s serum + IgG-sensitized sheep RBCs: Agglutination

Patient’s serum diluted 1:10 + IgG-sensitized sheep RBCs: Agglutination
Positive control + IgG-sensitized sheep RBCs: Agglutination
Negative control + IgG-sensitized sheep RBCs: No agglutination

These results should be intrepreted as

A. normal
B. negative
 CLS Review Test 291
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d
-
C. positive Ss
D. false-positive =
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ie4

243. A ligand assay to detect HBs antigen (HBsAg) is performed by incubating

the patient serum and alkaline phosphatase-labeled HBs antigen with a
paddle coated with monoclonal antibody directed against the antigen. After
washing, the paddle is incubated with p-nitrophenol phosphate; the ab-
sorbance is read at 405 nm. Which statement is correct?

A. The absorbance will be directly related to the concentration of HBsAg

in patient serum and bound-enzyme activity
B. This is a homogeneous, competitive assay
C. The greater the concentration of HBsAg in the patient serum, the lower
the measurable enzyme activity
D. This is a heterogeneous, sandwich-type (noncompetitive) assay

244. In a competitive radioimmunoassay (RIA) procedure to detect thyroxine,

the ratio of counts per minute (CPM) of the bound fraction is compared to
the total count. The total count in a competitive RIA procedure is the CPM
when

. No tracer is added
. no unlabeled ligand is present
. maximum binding by the unlabeled ligand occurs
. minimum binding by the unlabeled ligand occurs
DVaAwS

245. While performing the classic anti-streptolysin-0 neutralization test, the

laboratorian noticed that the cell control showed hemolysis, the strep-
tolysin-0 reagent control showed hemolysis, the negative serum control
showed hemolysis in all tubes, the positive serum control showed hemol-
ysis at all dilutions, and the patient serum showed hemolysis at all dilu-
tions. What is the best explanation for these results?

A. The complement reagent is too concentrated

B. Distilled water was used as the diluent
C. The incorrect concentration of cells was used
D. The streptolysin-0 reagent was incorrectly reconstituted

246. In the hemagglutination-inhibition assay to measure rubella antibody, no

agglutination was observed in any dilution from 1:8 through 1:512. Assum-
ing that the serum was treated to remove nonspecific inhibitors and natural
agglutinins and that the controls were acceptable, this result indicates

. an absence of rubella antibody in the test serum

. ahigh titer of rubella antibody in the test serum
. the patient is currently infected with rubella
. the patient is susceptible to rubella infection
VAY

247. Interpret these infectious mononucleosis test results from a patient com-
plaining of fever and joint pain.
 Heterophile presumptive test: 1:148
Davidsohn differential test:
Guinea pig kidney absorption: 1:14
Beef erythrocyte absorption: 1:14

A. The patient has infectious mononucleosis

B. The patient has Forssman antibodies from a Salmonella infection
C. The patient has serum sickness
D. Rheumatoid factor is causing a false-positive reaction in the het-
erophile presumptive test

248. A red-top tube for a cold-agglutinin assay was drawn on a patient during
the evening shift. The CLS found the requisition and the tube of unsepa-
rated blood in the refrigerator the next morning. What should be done
next?

A. Spin down the tube and assay the serum

B. Place the tube at 37EC for an hour before spinning down the tube and
removing the serum to assay
C. Perform an elution on the red cells from the sample and run the assay
on the eluate
D. Spin down the tube and heat-inactivate the serum before running the
assay

249. A hemagglutination test for rheumatoid factor yields the following results:

1:20 1:40 1:80 1:160 1:320

Patient agg agg agg agg no agg
agg = agglutination; no agg = no agglutination

This finding is

. hot suggestive of rheumatoid arthritis

. Suggestive of rheumatoid arthritis
. inconclusive; paired sera should be tested
. indicative of rheumatic fever
DaAwSY

250. In flow-cytometric analysis, forward-angle light scatter (FALS) indicates

cell

> . concentration
B. granularity
C. size
D. surface markers

251. 0.1 mL of serum is added to a test tube containing 0.4 mL of saline. If 0.2
mL of this mixture were transferred to a test tube containing 0.2 mL of
saline, the final dilution would be

A. 1:2
Baalks
 CLS Review Test 293

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=
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5
D. 1:20 =
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252. An IgG RID plate was set up on Friday afternoon and read on Monday
morning. What type of graph paper should be used to construct the stan-
dard curve?

A. Log-log
B. Semi-log
C. Logit
D. Linear

253. In the FTA-ABS, the organisms appeared to be staining with a smooth lin-
ear pattern of green fluorescence. This suggests

. a biologic false-positive result

. circulating immune complexes
. specific antibody to Treponema pallidum is present
GawS
. the presence of antibody that reacts with cardiolipin

254. In the indirect immunofluorescence assay to detect antibody to nuclear anti-

gens, the nuclei in resting cells appeared to stain evenly and the chromo-
somes in dividing cells also stained evenly. The antibody present reacts with

. ss-DNA
. deoxyribonucleoproteins (DNP)
. ribonucleoproteins (RNP)
S . extractable nuclear antigens
Daw

255. A heterogeneous immunoassay to detect rubella antibody will

A. detect both IgG- and IgM-class antibody

B. require a step to separate free from bound label
C. require calibration with a World Health Organization standard
D. be an automated assay

256. In a noncompetitive enzyme immunoassay to detect ferritin, the ab-

sorbance of the negative control was greater than the absorbance of the
positive control. What should be done?

A. This is expected; report the absorbance values

B. This is expected; calculate the concentration of the unknowns
C. This is unexpected; repeat the assay with new controls
D. This is unexpected; repeat the assay with new patient samples

257. In a radioimmunoassay to detect the beta subunit of human chorionic go-

nadotropin (hCG), the patient counts per minute (CPM) were greater than
the CPM of the highest standard. The next step is to

A. concentrate the patient sample and reassay

B. dilute the patient sample and reassay
294 7. Review Tests

C. dilute the standards and reassay

D. extend the standard curve and read the extrapolated patient result in
mIU/mL

258. In the test for anti-DNase B, the patient’s serum is diluted in buffer and in-
cubated with DNase B at 37°C. If the patient has anti-DNase B, the anti-
body will

. agglutinate the DNase B antigen

. hemolyze the DNase B coated RBCs
. neutralize the DNase B enzyme
. compete with DNase B for antigen binding sites
DUawPS

259. In performing a flow cytometric analysis for enumeration of lymphocyte

subsets, antibodies to CD4 will stain

A. B cells
B. NK cells
C. cytotoxic T cells
D. helper T cells

260. The indicator system in the complement fixation assay consists of

A. guinea pig complement

B. known antibody coated with hemolysin
C. sheep red blood cells coated with hemolysin
D. all of the above

261. An Ouchterlony double diffusion test resulted in a smooth elliptical arc of

precipitation between the antigen wells and the antibody well, concave to
the antibody well. This can be interpreted as

A. a line of identity
B. a line of non-identity
C. a line of partial identity
D. an error due to overfilling of wells

262. Needles should be recapped

. before disposal
. never
. never, because they must be cut before disposal
. never, unless a special recapping device is used
@rone

263. The most environmentally acceptable method for disposal of most chemi-
cal waste products is

A. burial
B. disposal to a sewer system
C. incineration
D. listed in the appropriate Material Safety Data Sheet (MSDS)
 CLS Review Test 295

~
d
4
264. The CDC recommends the following precautions be followed to avoid the Ss
potential of infection to laboratory workers 2
>
oY
c
A. blood and body fluid precautions
B. patient contact precautions
C. standard precautions
D. universal precautions

265. According to the Occupational Safety Health Administration (OSHA), if

the outside of a regulated waste container becomes contaminated, the con-
tainer should be

A. autoclaved immediately
B. washed with soap and water
C. wiped off with bleach
D. placed into a second container

266. A Clinical Laboratory Scientist just finished pouring off a whole rack of
chemistry specimens when he/she accidentally knocked the rack off the
counter onto the floor. Standard protocol was followed in cleaning up the
spill, but his/her gloves were observed to be bloody. Which of the follow-
ing should be done next?

A. Go to occupational health for an exposure workup

B. Wash off the gloves before removing them
C. Immediately remove the gloves and wash hands
D. Put on a clean pair of gloves

267. The danger of explosion from highly flammable solvents may be reduced
by all of the following except

. disposal of flammable solvents in the sewer with large quantities of water

. using a fume hood
. Storing at temperatures below their flashpoint
}S. Maintaining small quantities outside of a flammable storage cabinet
9aW

268. A safety rule regarding the proper handling of hazardous chemicals is

A. add water to concentrated acid rather than acid to water when prepar-
ing solutions
B. concentrated acids may be stored in the same cabinet as concentrated
bases
C. all patient specimens are to be considered potentially infectious
D. an MSDS must be readily accessible for each chemical used in the clin-
ical laboratory

269. Which of the following has developed a labeling system to show the haz-
ards associated with the chemical or material contained within a container?

A. Environmental Protection Agency

B. Occupational Safety and Health Administration
296
ee
eee 7. Review Tests

C. National Fire Protection Association

D. Joint Commission on Accreditation of Health Care Organizations

270. According to organizational theorists, the functions of management in-

clude all of the following except

A. planning
B. motivating
C. organizing
D. purchasing

271. Which of the following guarantees hospital employees the right to engage
in collective bargaining?

A. Wagner Act
B. Clinical Laboratory Improvement Act (CLIA)
C. National Labor Relations Act
D. Taft-Hartley Act

272. A new method of glucose testing is compared to an accepted reference

method by running split samples from 40 patients by each method. The
least squares regression analysis is calculated. The type of error indicated
by an upward shift of the line that does not intersect the origin is a

. constant error
. proportional error
. random error
S . systematic error
Daw

273. The term that means reproducibility among replicate determinations of a

sample is

. accuracy
. precision
. reliability
S . Standard deviation
Daw

274. The coefficient of variation is the

. Square root of the variance from the mean

. standard deviation expressed as a percentage of the mean
. sum of the squared differences from the mean
. confidence interval of the mean
Daw.

275. A CSF specimen arrives in the laboratory. The outside of the container is
visibly contaminated with blood. The receiving technologist calls the floor
to inform them that the test will not be performed because the tube is con-
taminated. The physician calls the supervisor to complain. Which should
be done next?
 CLS Review Test 297
~

@
=
A. Support the tech’s decision and confirm to the physician that the test S
will not be performed a
>
B. Advise the physician to transfer the specimen to a clean tube if he/she Vv
co
wants the test to be performed
C. Advise the tech to decontaminate the outside of the container and run
the test
D. Advise the physician that an exception will be made this one time, but
to be more careful in the future

276. The government licensing agency for use of radionuclides is

D. NCCLS

277. The percentage of normally distributed population that is expected to fall

outside of 2 SDs is

A. 2.5%
B. 5%
CPI5%
D. 95%

278. In the clinical laboratory, a patient specimen labeled with a bar code im-
proves the efficiency and accuracy of all of the following except

. specimen tracking
. patient identification
. inventory control
. result reporting
VAY

279. The pre-analytical functions of a laboratory information system include all

of the following except

A. test ordering
B. generating work lists
C. printing specimen labels
D. collecting the required specimen

280. The post-analytical functions of a laboratory information system include

all of the following except

A. generating chart reports

B. printing result reports
C. workload recording
D. quality-control measures

281. The best audiovisual aid to assist in learning RBC morphology is

298 whol
aa
ee 7. entReview Tests
eee See wn ee

. textbook color plates

. overhead projector transparencies
. self-study computer program
we)
8 . videotape
T@inee)

282. By attending an approved continuing-education program of one-hour in

length, an individual can receive credit for

A. 10.0 CEUs (continuing education units)

B. 1.0 CEUs
C. 0.1 CEUs
D. 0.01 CEUs

283. A continuing-education format using group interaction facilitates the learn-

ing experience by

A. presenting authoritative viewpoints

B. inviting a wide range of informed opinion
C. presenting information in an organized way
D. developing teamwork and sharing experiences

284. Calculate the concentration in milliequivalents (mEq) for a solution con-

taining 58.5 mg/dL of NaCl. (Atomic weights: Na = 23; Cl = 35.5)

A. 1.0 mEq/L
B. 5.0 mEq/L
C. 10.0 mEq/L
D. 20.0 mEq/L

285. You need to prepare 600 mL of a standard solution containing 140 mmol/L
sodium ions, and you are using a stock solution containing 2.5% (w/v)
sodium sulfate. How. much stock solution is needed to make the desired
standard? (Molecular weights: Na 23; S 32; O 16)

A. 200 mL
By 239 me
C. 420 mL
D. 477 mL

286. How many milliliters of 0.75N HCl would be required to neutralize 280
mL of 1.25N NaOH?

A. 168
B: 262.5
C. 467
D. 560

287. The best way to monitor stability, sterility, and expiration of reagents is to

A. check the reagent expiration dates

B. review QC results
 CLS Review Test 299
re)
4)
Ee
C. visual inspection of reagent containers 3
D. watch for instrument flags =
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Y
ig

288. What is the molar concentration of magnesium in a solution containing

200 mEq/L magnesium chloride?

A. 0.1 mol/L
B. 0.2 mol/L
C. 0.3 mol/L
D. 0.4 mol/L

289. You need 100 mL of a 1:20 dilution of a patient’s urine. What volume of
urine is required?

A. | mL
B. 5 mL
C. 410m
D. 20 mL

290. Which of the following NCCLS specifications in the description of reagent

grade water would qualify the water as Type I?

A. pH = 5.0-8.0
B. Resistivity = 2.0 Mohm centimeter
C. Passed through 0.2 micron filter
D. 10° colony-forming units per milliliter

291. A solution is placed in two different cuvettes, and an absorbance reading

is taken of each. In the first cuvette, the solution’s absorbance is 0.250,
while in the second cuvette, the same solution has an absorbance of 0.500.
From this, you can deduce that the first cuvette is the di-
ameter of the second cuvette, and that this is a good example of

A. one-half............. Lambert’s Law

B. the same as......... Bougher’s Law
C. one-fourth.......... Westgard’s Law
DO UWACE vv esgeccscene: Beer’s Law

292. Ion selective electrode methodologies are available for all of the following
analytes except

A. glucose
B. potassium
C. CO,
D. iron

293. Darkfield microscopy is accomplished by

A. decreasing the intensity of the light source

B. lowering the condenser
300 7. Review Tests

C. closing the aperture on the condenser

D. using a light ring in the condenser to supply oblique light

294. Which of the following represents a diagram of a spectrophotometer?

A. Hollow cathode—Cuvette—Monochromator—Detector—Readout
B. Cuvette—Light source—Monochromator—Detector—Readout
C. Monochromator—Light sourcee—Cuvette—Detector—Readout
D. Light souree—Monochromator—Cuvette—Detector—Readout

295. The purpose of the didymium filter used with the broad-bandwidth spec-
trophotometer is to

. align the galvanometer beam

. produce monochromatic light
. adjust the concentration range of the solution
= . check the wavelength calibration
22)
SN@)

296. Which of the following terms represents the most meaningful expression
of centrifuge speed?

A. Revolutions per minute

B. Relative centrifugal force
C. Dynes per second
D. Absolute revolutions per second

297. A measurement, taken at an angle to the incident beam, of the amount of

light scattered or reflected by small particles in a sample cuvette is the
principle of

A. fluorometry
B. nephelometry
C. turbidimetry
D. mass spectrophotometry

298. In calibrating a pH meter, which of the following solutions would provide

the best calibration results?

. Solution A; pH=1.0
. Solution B; pH=2.0
. Solution C; pH=4.0
. Solution D; pH=10.0

. Solutions 1 & 2
. Solutions 2 & 3
. Solutions 3 & 4
. Solutions
Gawpr
RWNe 1 & 4

299. When using anhydrous calcium sulfate (Drierite) as a dessicant, cobalt

chloride is added
 CLS Review Test 301

w
d
i
. as an indicator of the water-absorption capacity of the dessicant S
. to increase the water-absorption capacity of the calcium sulfate A
>
. as an inert salt to increase the volume of the total dessicant package - @
cf
. to reduce dust formed by the calcium sulfate and increase length of use
VUaAWwS

300. Additional tests have been requested on a patient. The phlebotomist has
collected only a purple-top EDTA tube. Which of the following tests can
be performed on this tube without interference from the anticoagulant?

A. Calcium
B. Alkaline phosphatase
C. Creatinine
D. Creatine kinase

301. When performing a finger stick blood collection, you should always

. wipe away the first drop of blood with a fresh alcohol pad
. collect the first drop of blood
. wipe away the first drop of blood with gauze
PY. begin collecting the specimen immediately after puncturing the site
Daw

302. The proper color of tube to collect a coagulation specimen in is

A. lavender
B. dark blue
C. light blue
Dred

303. The proper protocol for semen collection includes all of the following ex-
cept

. collection at home and delivered to the lab within 1 hour

. collection at the laboratory, refrigeration for 30 minutes before testing
. collection in a sterile container
. collection
DUaAwPS> after sexual abstinence of 3 days

304. The best anticoagulant additive for blood glucose testing is

. sodium fluoride
. sodium citrate
. sodium heparin
a . sodium acetate
me
we

305. When shipping specimens to a referral laboratory the most important vari-
able to control during transport is

. temperature
. light
. air pressure
. vibration
Taw}
302 7. Review Tests ee

306. The site of collection for a blood-culture specimen should be disinfected

by applying

. 70% alcohol and waiting until the area is dry before puncture
. 2% povidone-iodine and waiting until the area is dry before puncture
. surgical soap liberally and waiting 5 min before puncture
@)
Ss
Ws-. 2% povidone-iodine, waiting 2 min, and following with a 70% alcohol
wipe

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LWW takes youtothecutting edge
of Clinical Laboratory Science|
| resources:
Ref. RB 38.25 .N34 2002

NCA review for the clinical

laboratory sciences

0 Nat Tala Fram Thic

ps entlyand cae the morphology oftells.tron peripheral bloodand bone
arrow. 2002/Approx 973 images/CD-ROM for Windows/Single-user ISBN: 0-7817-2661-1
Anderson’s Electronic Atlas of Hematologic Disorders.
i$ multimedia CD-ROM categorizes and describes hematologic disorders. Each disorder includes a description of
linical features, pathology, laboratory features (including morphologic characteristics), and treatment.
03/ Approx 900 images/CD-ROM for Windows
Anderson’s Atlas of Hematology
Anderson’s Atlas of Hematology is a convenient, full-color, spiral-bound manual of blood cells, which enables readers to
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LOCATED AT
CIRCULATION DESK
_ Marler: Direct Smear Atlas: AMonograph of Gram-Stained Preparations of Clinical Specimens, 2001, 0-7817-2663-8
6) larler: Direct Smear Atlas: ACD-ROM of Gram-Stained Smear Preparations of Clinical Specimens, 1998, 0-683-30514-X
~ MacFaddin: Biochemical Tests for Identification of Medical Bacteria, 3°4 Edition, 2000, 0-683-05318-3
Konemani: Color Atlas and Textbook of Diagnostic Microbiology, 5" Edition, 1997, 0-397-51529-4
bneman: LWW’s Organism Central CD-ROM, 2001, 0-7817-2179-2

Available at your local health science bookstore, OR, CALL: 1-800-638-3030 Me

(Outside the U.S., call, 301-223-2300); FAX: 301-223-2400; Online: LWW.com .
LIPPINCOTT
BLS/KC 2/02 H2LSH518 WILLIAMS & WILKINS
The all-in-one review for both CLT and CLS!

This easentialnreviewok prepares readers for CLT ondcls certification and re-certi
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The Fourth Edition offers a variety of features:
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.. Color images of microorganisms in the microbiology sectin
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a ISBN 0-781?-3190-9

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