NCA Clinical Laboratory Sciences PDF

11
Clinicai Chemistry
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 dueto 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
e. at the calculated peak time after a dose
D. one half-life after a dose is administered
The answer is B. lndividuals 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 leveis. The trough levei, 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 moming urine sample
C. Random, mid-stream clean catch
D. Two-hour urine collection following the midday meal, i.e., 2:00-4:00 pm
The answer is A. Vanillylmandelic acid (VMA) is a metabolite of the catechol-

amines: epinephrine, norepinephrine, and dopamine. Dueto 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)
1
2 1. Clinicai Chemistry
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
e. 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 leveis in plasma are stable for 1 week at room tempera-
ture. (Lehmann, pp. 47, 79, 140, 161)
S. 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
CLT Review Questions 3
The answer is D. Because the protein content of cerebrospinal fluid is usually

low, it must be concentrated 80- to 100-fold before electrophoresis. This is com-
monly achieved using commercial concentrator systems. (Brunzel, pp. 376- 377;
Lehmann, p. 32)
8. You need to prepare a 1 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 1 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 núxture is 6.0 mL or 4 parts; hence a 1 to 4 dilution of the sarnple 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+, c1- , HC03 - ). 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?
C D
+ +
·~
A. Component A
B. Component B
C. Component C
D. Component D
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. ln so doing, the path length (b) and
molar absorptivity (a) for a particular analyte become a constant at a given
wavelength. ln which case, the absorbance (A) observed is proportional to the
analyte concentration (c). (Bishop et ai., 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. ernit light used as the internai standard
D. enhance dissociation of calcium phosphate
The answer is D. Because of the requirement of a cool flame in atornic absorp-

tion spectrophotometry, some calcium salts are not broken into their component
atoms; calcium phosphate is ao 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 sarne 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 Biochernistry (IUB) assigns a sys-

tematic name to each enzyme, which defines the substrate, the reaction cat-
alyzed, and the coenzyme involved, if any. ln 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 elirninated. (Bishop et al., pp.
208-209, 218-219)
13. Chromatographic separation of a rnixture of solutes is based on

A. variable solubilities of solutes in the mobile and stationary phases
B. spectral differences of solutes in the mobile and stationary phases
C. selective degradation of solutes by the mobile and stationary phases
D. differential distribution of solutes between the mobile and stationary
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
passes over or through the stationary phase. The solutes interact to differing
degrees with the fixed or stationary phase thereby causing separation. Thus,
solutes that differ in their attraction to the stationary phase can be separated from
one another. (Kaplan and Pesce, p. 107)
14. ln 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. ln the
presence of peroxidase, the hydrogen peroxide produced oxidizes the reduced
dye to forma 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
e. electroendosmosis is avoided
D. heat production is minimized
The answer is A. Proteins are ampholytes whose terminal arnino and carboxyl
groups, as well as ionizable side groups on component arnino 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
arnino group anda 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 ofthe 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
e. free arnino groups in proteins
D. ammonia released from proteins
The answer is A. ln 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 1-globulin
6 1. Clinica! Chemistry
C. Alphaz-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 sarne net charge. (Bishop et al., pp.
189- 192)
18. Which of the following statements about the hexokinase reaction for serum
glucose quantitation is true?
A. The amount of hydrogen peroxide produced is measured

B. During the reaction cupric ions are reduced to cuprous ions
C. The reaction generates a green condensation product with o-toluidine
D. The coupled indicator reaction generates NADPH from glucose-6-phos-
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
e. 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. lt 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)
21. Which of the following formulas can be used to calculate serum osmolality?
A. 2.5 X Na+
B. Na++ K+ + c1- + C02 content
C. (1.86 X Na+)+ (1118 X glucose)+ (112.8 X BUN) + 9
D. (Na++ K+) - (CI- + HC03 - )
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 mrnol/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 ai. ,
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-

1 1 1 1
H - e - NH2 + c=o .--+
_ c=o + H - C - NH2
1 1 1 1
CH2 CH2 CH2 CH2
1 1 1 1
CH2 coo- CH2
coo- 1 1
coo- 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. ln 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). ln 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-

contarrúnation 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 perforrrúng a thin layer chromatography procedure, the solvent front
moved 10.0 centimeters. The substance of interest moved 4.0 centimeters.
What is the Rr for the substance of interest?
A. 0.25
B. 0.40
e. 2.5
D. 4.0
The answer is B. The retention time or Rr of a substance or compound is defined

as the distance of spot rrúgration divided by the distance of the mobile phase
rrúgration. (Burtis and Ashwood, p. 111)
25. Calculate the corrected creatinine clearance using these data obtained from
a person with a 1.73 m 2 body surface area:
Serum creatinine: 1.3 mg/dL

Urine creatinine: 2.4 mg/mL
Urine volume: 1000 mL/24 hour
A. 119 mL/rrún
B. 128 mL/rrún
e. 139 mL/min
D. 167 mL/rrún
The answer is B. The formula for calculating creatinine clearance (CCr) is:
CCr = U • V X 1.73 m2
P SA CCr = creatinine clearance in mL/rrúnute
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 sarne 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) x 1 hour = y in mL/minute

24 hour 60 rrúnutes
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)
26. A serum sample is diluted 1 to 3 (1:3) before analysis and the following
results obtained:
Total protein - 4.1 g/dL
Albumin - 1.5 g/dL
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)?
A. c=A!K
B. b =A• K
C. A= c/K
D. K = a• c
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 e= 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 clinicai 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. ln an adult, a blood glucose leve! of 35 mg/dL is
A. normal
B. dangerously low
e. 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
e. assess pituitary function
D. detect excessive estrogen secretion
The answer is B. ln 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
e. 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
e. 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 levei
B. Vanillylmandelic acid level
C. Thyroid-stimulating hormone level

D. 24-hour creatinine clearance
The answer is A. Both Cushing's syndrome and Cushing's disease are associated
with excessive leveis of cortisol. Hypercortisolism can be dueto tumors of the
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?
400
e 350
8 300
~
00
e
1 250
5IJ
::::1 200
"iiO
m 150
.!!
c:i..
so
30 60 90 120 150 180

Minutes
A. Curves 1 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 levei greater than 140 mg/dL on more than one
occasion, or (2) two or more serum samples with glucose leveis 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 m
mrnol/L.)
Na+ K+ c1- C02 content
A. 125 4.5 100 10
B. 135 3.5 95 28
c. 145 4.0 90 15
D. 150 5.0 110 30
The answer is C. Electrolyte balance is determined by calculating the anion gap

(AG) using the formula: (Na + K) - (Cl + C02 content) or (Na) - (Cl + C0 2
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 mrnol/L. (Lehmann, pp. 138-139)
36. Which set of results is consistent with a diagnosis of respiratory acidosis?
Arterial pH Arterial pC02

A. Decreased Decreased
B. Decreased Increased
e. Increased Decreased
D. lncreased Increased
The answer is B. Respiratory acidosis is characterized by a decreased blood pH

caused by an excess of C02 , i.e., an absolute excess of carbonic acid. This occurs
when the lungs are not able to adequately expel C02 . The carbonic acid (H2 C0 3 )
concentration can be calculated from the pC02 as follows: 0.03 X pC02 =
H 2 C0 3 . When there is ao 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 p0 2 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 .O mg/dL)
These results are most consistent with
A. compromised renal function
B. impaired glucose metabolism
e. 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.
155-1 56)
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 > 2.0
Alpha-fetoprotein: normal normal
Based on these results, if the fetus were delivered today it could have
A . Down's syndrome
B. an open neural tube defect
e. respiratory distress syndrome
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 mrnol/L

K+ = 14.0 mmol/L
c1- = 112 mmol/L
HC03 - = 18 mmol/L
These results are consistent with a specimen that
A. is severely lipernic
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.
Lipernia 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, elirninating 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) (O - 1.1 mg/dL)
A. 0.1 2.1
B. 0.5 1.7
e. LO 1.2
D. 1.6 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
e. 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. ln 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 arnount of glucose in
the urine ultrafiltrate is dependent on the glucose concentration in the plasma,
specimens collected on these individuais 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
e. 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 25ºC

B. Refractometer result obtained using Type 1 water is 1.000
C. Temperature of the refrigerator that stores the QC materiais reads 2ºC
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
perforrning 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. 3~0, 148- 152)
44. The urinalysis reagent strips from four different bottles are evaluated using
the current quality control (QC) materiais. Which bottle of reagent strips is
acceptable for use today?
A. Bottle #1: expiration date is today; QC acceptable

B. Bottle #2: expiration date was yesterday; QC acceptable
C. Bottle #3: expiration date is next week; QC not acceptable
D. Bottle #4: expiration date is tomorrow; QC not acceptable
The answer is A. Quality control materials monitor the performance of a test,

i.e., 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. ln 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 60ºC
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 60ºC and redissolves at lOOºC.
Sulfosalicylic acid is a general protein-precipitating agent and will precipitate ali
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
e. 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 ofurine concentration. Typically, urine is a shade ofyellow 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
B. 1.020 negative 2500 mL
e. 1.005 positive 3500 mL
D. 1.020 positive 2000 mL
The answer is A. Diabetes insipidus, a metabolic disorder, is characterized by

polyuria (excretion of;::: 3 L/d) and polydipsia. Dueto 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. ln contrast, indi-
viduals with uncontrolled diabetes mellitus could produce large volumes of high
specific gravity urine dueto the presence of glucose. (Brunzel, pp. 102, 273, 300)
49. The following results are obtained on a fresh randomly collected urine spec-
1men:
Parameter Result Confirmatory test Result
pH 5.5
SG 1.025 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
5-1 O WBCs per high power field
Which of the following statements regarding these results is true?
A. An abnormal amount of bilirubin is present in the urine
B. Ascorbic acid is causing the positive leukocyte esterase
C. The blood present is causing the protein result to be positive
D. 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
test. Ascorbic acid does not have any effect on the leukocyte esterase test of any
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
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 inflarnmatory process is taking place in the kidney and not in
the lower urinary tract?
A. RBCs
B. Bacteria
e. 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 levei 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
e. nephrotic syndrome
D. acute glomerulonephritis
The answer is D. ln acute glomerulonephritis, glomerular inflamrnation 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. ln 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. ln 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 exarnination of a urine sediment, a clinicai 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
e. 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 .O, protein trace, caleium 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 randornly collected urine specimen
with a pH of 7.0.
The identity of these crystals is most likely

A. cystine
B . uric acid
e. 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. ln which of the glucose tolerances shown in the figure would you expect to
find concurrent glycosuria?
400
350
e
~..e 300
1 z~o
...
~
"
~
200
I~
~
100
30 60 90 120 150 180

Minutes
(Tietz, 3rd., p . 252)
A. Curves 1 and 2
B. Curves 1 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
Urobi linogen 1.0 mg/dL
Nitrite negative
Leukocyte esterase negative
Microscopic Exam: 5-1 O RBCs per high power field
2-5 WBCs per high power field
2-5 fatty casts
0-2 waxy casts
Whích of the following disorders is most consistent with these results?
A. Cystitis
B. Nephrotic syndrome
C. Acute pyelonephritis
D. Acute glomerulonephritis
CLS Review Questions 21
The answer is B. Nephrotic syndrome is characterized by heavy proteinuria.

This results from changes in the permeability of the glomerular filtration barrier
(GFB). Consequently, serum lipids are also able to pass the GFB into the urine
and can appear in the urine sediment as free fat globules, in casts, or in cells
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 ai., pp. 386-388)
2. Which of the following collection tubes is the specimen of choice for the
deterrnination 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 2-5ºC.
(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 ovemight

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 clinicai laboratory scientist (CLS) is summoned to the emergency room

to draw blood on Jane Doe. At the sarne 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 roam 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
retums 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 visitar
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 4ºC 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. ln 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. p0 2 by blood gas analyzer

B. Sodium by potentiometry
C. Ionized calcium by ion selective electrode
D. Creatinine by kinetic alkaline picrate method
The answer is D. The kinetic alkaline picrate or Jaffe method is a spectrophoto-

metric method based on the differential rate of colar formation of noncreatinine
chromogens versus creatinine. This reaction can be performed at room tempera-
ture. ln 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 37ºC. (Kaplan and Pesce, pp. 281- 285)
7. A centrifuge is loaded with patient samples and turned on. It begins to

vibrate and dance across the table top. Which of the following statements
best accounts for this observation?
A. The brake was left "ON"

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 critica! 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 <levices is used in a spectrophotometer to determine

the wavelengths of light that pass through the sample cuvette?
A. Detector
B. Light source
e. 1Y1onochromator
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, i.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 Rf for the substance of interest?
A. 0.25
B. 0.40
e. 2.5
D. 4.0
The answer is A. The retention time or Rr 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-
24 1. Clinical Chemistry
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
e. Sodium
D. Urea
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 leveis 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). ln 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 bílirubin
D. shift the wavelength absorbed by azobilirubin for increased sensitivity
The answer is A. Unconjugated bilirubin reacts very slowly with the aqueous
diazotizing colar 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). lt 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
A. minimize matrix interferences

B. prevent ionization of calcium atoms
e. avoid interference from phosphate in the sample
D. reduce fluctuations from the hollow-cathode lamp
The answer is C. The atoms produced by the fuel-rich flame used in atornic
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
atorns. For example, phosphate can interfere with calcium analysis in specimens
by the formation of calcium phosphate. ln 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 p0 2 meas-
urement used in blood gas analyzers?
A. H+ are generated by a reaction at the electrode surface

B. The amount of 0 2 oxidized to hydrogen peroxide is measured
C. The number of electrons used to reduce 0 2 is measured
D. A voltage between the measuring half-cell and a reference half-cell is
determined
The answer is C. The electrode for p02 measurements is based on arnperometry.

ln amperometry, a current is measured while a fixed potential is applied. ln the
p02 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., 0 2 + 2H+ +
2e- -+ H 20 2 . The amount of current (electron flow) is measured and expressed
as the p02 in mmHg. (Kaplan and Pesce, pp. 277, 287-288)
17. Which of the following methods is not used to quantitate serum albumin?
A. Nephelornetry
B. Electrophoresis at pH 8.6
r
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.
Nephelornetry 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. S 18-519)
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. Alpha1 -globulin
C. Beta-globulin
D. Gamma-globulin
The answer is C. Hemolysis causes an increase primarily in í3-globulins, the

fraction where free hemoglobin migrates. However, a small amount of a hemo-
globin-haptoglobin complex can also appear between the a 2 and fractions. (Bur-
tis and Ashwood, p. 131)
19. LDL cholesterol can be estimated using the Friedewald formula:

triglyceride
LDL =Total cholesterol - HDL -
s
This calculation should not be used when the
A. HDL cholesterol is greater than 40 mg/dL
B. triglyceride levei 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% (1/5 ) 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.
~ 4
~
~ 3
o=
;::
b"' 2
=
~
8 1
Q
e
o~~~~~~~~~-
0123 4 56
Time after oral dose (h)
A. 0.5 h
B. 1.5 h
e. 2.5 h
D. 4h
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. ln the figure, the blood con-
centration is approximately 4 µg/mL at 2 h and approximately 2 µg/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:

Sampie Absorbance
150 mg/dL standard 0.200
Normal control 0.200 (mean: 150 mg/dL; lSD = 15)
Abnormal control 0.400 (mean: 275 mg/dL; lSD = 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: Cu 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
Na+ 140 mmol/L (136-145)
K+ 3.8 mmol/L (3.5-5.0)
c1- 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) BUN (mg/dL)
Serum Osmolality =2 X 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 2
A. 41 mL/min
B. 67 mL/min
e. 92 mL/min
D. 132 mL/min
The answer is C. The formula for calculating a corrected creatinine clearance

(Ccr) is:
C _ U •V X 1.73 m 2 Ccr = creatinine clearance in mL/minute
cr- p SA 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 sarne 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) X 1 hour
= V in 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 arninotransferase (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
B. 126 U/L
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
o 0.020
1 0.200
2 0.315
3 0.395
4 0.435
5 0.480
Select the statement that best summarizes these results.
A. Readings are satisfactory; calculate the enzyme result

B. Substrate depletion; repeat the assay using a serum dilution
C. The 0- 3 min readings are satisfactory; use these for enzyme result cal-
culation
D. The 3- 5 min readings are satisfactory; use these for enzyme result cal-
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-arder 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. Ali protein bands migrated further than usual and the bands were
further apart from each other. Which of the following would accdunt 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
B. 1:1.8
e. 20:1
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 37QC 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
errar of metabolism in which the salvage enzyme of purine catabolism is defi-
cient. This ~esults 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)
"
1
29. Which of the following is nota criterion for the diagnosis of diabetes mellitus?
A. A fasting glucose ;:::: 126 mg/dL

B. A serum 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 dueto disease, the plasma levei 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 li ver. The apolipoprotein B moiety of LDL binds
to specific hepatocyte receptors, the receptors are subsequently intemalized, and
the LDL is catabolized. When these receptors are not present or non-functional,
plasma total cholesterol leveis are increased. (Kaplan and Pesce, pp. 651-652)
31. Which of the following serum protein electrophoresis pattems is most typi-
cal of the nephrotic syndrome?
albumin alpha1 alpha2 beta gamma
A. ! ! ! t !
B. ! ! t t t
C. t t ! normal normal !
D. normal t ! t t t
The answer is A. ln the nephrotic syndrome, an increased permeability of the

glomerular membrane allows proteins, particularly alburnin 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., armacroglobulin)
"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. Troponin I
D. Troponin T
The answer is B. Following an acute MI, myoglobin is the earliest cardiac

marker. lt begins to rise within 2-3 h and peaks at 6-9 h. For comparison, CK-
MB begins to rise at 4-6 h and usually peaks within 12-24 h; the troponins, I
and T, begin to rise at 4-8 h and usually peak within 18 h. (Lehmann, p. 104)
33. Which of the following serum results correlates best with the rapid cell
tumover 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 answer is 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+ c1- HCQ3 -

A. 125 4.5 100 10
B. 135 3.5 95 28
e. 145 4.0 90 15
D. 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. ln 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:
7.28
53 mmHg
75 mmHg
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 pC02 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 (T4 ) and elevated thyroid-stimu-
lating hormone (TSH) compared to reference ranges for that age. These
results are most consistent with
A. congenital hypopituitarism
B. congenital primary hypothyroidism
C. congenital secondary hypothyroidism
D . a normal response to pregnancy-induced changes in maternal thyroid
function
The answer is B. Production ofT4 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 T4
result in a high level of TSH through this feedback loop. The elevated T4 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. ln which of the following situations will the patient have a "normal" urine
levei of human chorionic gonadotropin (HCG)?
A. Ten days following a spontaneous abortion

B. During the 101h 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. ln 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)
39. The following results are obtained from a patient whose admission diagno-
sis is biliary obstruction:
Test Result
Serum: Conjugated bilirubin Increased
Total bilirubin Increased
Urine: Bilirubin Positive
Urobilinogen lncreased
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 remova! 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. ln 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. ln 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 li ver

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 arnino-
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. ln 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. ln 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 perrneability of the blood/brain bar-
rier to plasma proteins can be dueto high intracranial pressure (e.g., brain tumor,
intracerebral hemorrhage) or due to an inflammatory process (e.g., bacterial or
virai 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 moming
D. Midstream clean catch
The answer is D. The specimen type (random, first morning, etc.) is notas 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 dueto proliferation
e. photo-oxidation of bilirubin to biliverdin
D. increased turbidity dueto 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?
A. Calibrator A - SG 1.015
B. Calibrator B - SG 1.025
C. Calibrator C - SG 1.035
D. Calibrator D - SG 1.055
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
rnicroscopic 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
rnicroscope slide and coverslipping
D. transferring, using a calibrated automatic pipette, 20 µL of sediment
onto a microscope slide and coverslipping
The answer is C. A standardized slide should be used for rnicroscopic 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 índex, 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)
49. Ali 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.
ln 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, lndianapolis, IN) are NOT
affected by the presence of ascorbic acid due to a patented iodate scavenger pad
that eliminates this interference. ln 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
pH 5.5
SG l.020
Blood small
Protein 30 mg/dL
Glucose negative
Ketone negative
Bilirubin negative
Nitrite negative
Microscopic Exam: 5-1 O 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?
A. Blood vs. RBCs; test for ascorbic acid
B. Sulfonamide crystals; perform confirmatory test and check patient med-
ications
C. 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)
51. Which of the following crystals can be present in an alkaline urine?
A. Cystine
B. Calcium oxalate
C. Triple phosphate
D. Sodium urate
The answer is C. Tripie 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 ians. The other crystals listed are observed in
their crystalline forros 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
e. 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. ln 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. ln 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 individuais. 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. ln 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?
A. The microscopically identified RBCs are really yeast
B. Myoglobin is causing a false-negative reagent strip blood test
C. Ascorbic acid is causing a false-negative reagent strip blood test
D. The microscopically identified RBCs are really monohydrate calcium
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 1.020
Blood moderate
Protein 500 mg/dL
Glucose negative
Ketone negative
Bilirubin negative
Nitrite negative
Microscopic Exam: 10-25 RBCs per high-power field; dysmorphic

forms present
2-5 WBCs per high-power field
2-5 hyaline casts
2-5 RBC casts
0-2 granular casts
few uric acid crystals
These results are most consistent with a diagnosis of
A. gout
B. glomerulonephritis
e. 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.
LabA LabB
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 micrascopic 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 contrai results are not acceptable?
A. Repeat analysis of QC materiais using a fresh aliquot or different vial

B. Recalibrate the instrument, then reanalyze contrais and patient samples
C. Change reagents, then repeat analysis using a new lot number of QC
materiais
D. Perform periodic maintenance, then recalibrate and reanalyze contrais
and patient samples
The answer is A. Actions necessary to bring a system back into contrai vary.
Traubleshooting should always occur in a stepwise fashion and documentation
must be maintained, e.g., in an "out-of-contral" 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 sarne lot number.
Contrais 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 contrai; 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. Clinica! Chemistry. Philadelphia: WB Saunders
Company, 1993.
Bishop ML, Duben-Engelkirk JL, Fody EP (eds). Clinica! Chemistry: Princi-
pies, Procedures, Correlations (3rd ed). Philadelphia: Lippincott, 1996.
Brunzel NA. Fundamentais of Urine and Body Fluid Analysis. Philadelphia:
WB Saunders Company, 1994.
Burtis CA, Ashwood ER (eds). Fundamentais of Clinica[ Chemistry (5th ed).
Philadelphia: WB Saunders Company, 2001.
Kaplan LA, Pesce AJ. Clinicai Chemistry: Theory, Analysis, and Correlation
(3rd ed). St. Louis: Mosby, 1996.
Lehmann CA (ed). Saunders Manual of Clinicai Laboratory Science. Philadel-
phia: WB Saunders Company, 1998.
Strasinger SK. Urinalysis and Body Fluids (3rd ed). Philadelphia: FA Davis,
1994.
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11

CLT Review Questions

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

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

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

A. just after a dose is administered

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

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

A. 24-hour urine collection

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

Test requested Specimen received Time collected

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

A. Chemistry lab, hematology lab, microbiology lab

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

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

7. Which of the following specimens usually requires concentration before

A. Urine for osmolality

The answer is D. Because the protein content of cerebrospinal fluid is usually

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

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

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

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

A. A series of high anion gaps

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

11. Samples for calcium analysis by atomic absorption spectrophotometry

A. blank for variations in flame temperature

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

pyruvate + NADH ~ lactate + NAD

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

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

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

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

A. all serum proteins will have a net negative charge

A. peptide bonds in proteins

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

A. The amount of hydrogen peroxide produced is measured

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

19. Turbidimetric assays for serum lipase measure the

A. amount of bile acid produced

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

20. Osmolality measurements determine the

A. activity of ions per kilogram of solvent

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

coo- coo- coo- coo-

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

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

A. rinsing the probe between samples

C. using a separate reaction chamber for each sample

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

The answer is B. The retention time or Rr of a substance or compound is defined

Serum creatinine: 1.3 mg/dL

urine volume (mL) x 1 hour = y in mL/minute

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

29. ln an adult, a blood glucose leve! of 35 mg/dL is

The answer is B. True hypoglycemia of this magnitude can cause neurologic

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

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

31. Xanthochromic cerebrospinal fluid is an indicator of

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

A. hepatic blood flow

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

C. Thyroid-stimulating hormone level