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Chapter 10: Introduction to Clinical Chemistry
Turgeon: Linné & Ringsrud’s Clinical Laboratory Science, 7th Edition

MULTIPLE CHOICE

1. Which of the following hormones lowers the blood glucose level by promoting glucose entry
into cells?
a. Cortisol
b. Glucagon
c. Insulin
d. Thyroxine
ANS: C
Insulin, secreted by the pancreas following a meal, facilitates entry of the energy-containing
sugar, glucose, into body cells. Glucagon, also secreted by the pancreas, opposes the action of
insulin, to maintain the blood sugar in the normal range when fasting between meals. The
remaining two hormones, cortisol and thyroxine, also serve to increase blood sugar levels by
promoting gluconeogenesis, the formation of glucose from nonglucose sources.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 247

2. Contributory factors to which form of diabetes include a genetic predisposition and

autoimmune destruction of pancreatic  cells?
a. Type 1
b. Type 2
c. Gestational diabetes mellitus
d. Stress-induced hyperglycemia
ANS: A
Type 1 diabetes is typically diagnosed in children of families with a genetic predisposition to
the disorder. This form of diabetes is characterized by an absolute lack of insulin, a
consequence of autoimmune mechanisms that destroys the  cells of the pancreas. In type 2
diabetes, genetic factors also play a role. Individuals with type 2 diabetes characteristically
develop insulin resistance later in life, which is associated with an unhealthy diet and
sedentary lifestyle. Gestational diabetes is routinely screened for during pregnancy. If
diagnosed, dietary changes can be made to reduce complications experienced with childbirth.
Stress-induced hyperglycemia occurs in both diabetic and nondiabetic individuals. Treatment
of critically ill patients with this condition involves maintaining the blood sugar at normal or
near normal levels, reducing morbidity and mortality rates for this group of individuals.

PTS: 1 DIF: Cognitive Level: 2 REF: p. 248

3. Hypoglycemia is not a consequence of:

a. insulinoma.
b. islet cell hyperplasia.
c. insulin resistance.
d. glycogen storage disease.
ANS: C
 The term insulin resistance refers to the ineffective utilization of insulin by insulin-dependent
cells of the body. This is the situation encountered in type 2 diabetes. As a result, glucose is
less effectively transported into the cell and the patient is hyperglycemic rather than
hypoglycemic. Both insulinoma and islet cell hyperplasia are forms of inappropriate
hyperactivity of pancreatic cells, leading to excessive insulin production, thereby lowering the
blood sugar level. Lowering of blood sugar also occurs in glycogen storage disease. In the
latter case, glycogen, a reserve form of glucose, cannot be broken down and released into the
bloodstream when needed.

PTS: 1 DIF: Cognitive Level: 2 REF: p. 251

4. The anticoagulant of choice for glucose testing when analysis is not performed promptly is:
a. EDTA.
b. sodium fluoride.
c. lithium heparin.
d. sodium citrate.
ANS: B
Sodium fluoride prevents glycolysis, or the breakdown of glucose, in the blood sample.
Without this anticoagulant, if not tested promptly, the blood glucose will decrease with time,
resulting in a falsely low glucose level. The other anticoagulants listed do not prevent
glycolysis and are unacceptable. Glycolysis will also continue to occur in samples collected
with no anticoagulant, if the serum is not separated from the cells following phlebotomy.

PTS: 1 DIF: Cognitive Level: 1 REF: pp. 251-252

5. A major benefit of point-of-care testing (POCT) for blood glucose is that it:
a. allows for immediate intervention.
b. does not require oversight by the laboratory.
c. can only be performed by laboratory personnel.
d. eliminates the need for glucose testing in the laboratory.
ANS: A
POCT allows for immediate action to be taken to normalize the blood sugar level in patients
with diabetes. POCT, performed routinely, improves prognosis. POCT performed in a health
care setting is under the jurisdiction of the laboratory. Other members of the health care team
(e.g., nurses) must be trained before they can perform POCT. Routine screening of individuals
for diabetes is most easily performed as part of a battery of tests, including glucose, in the
laboratory.

PTS: 1 DIF: Cognitive Level: 2 REF: p. 252

6. Which of the following methods is not used to quantitate glucose levels?

a. Glucose oxidase
b. Glucose dehydrogenase
c. Clinitest
d. Hexokinase
ANS: C
 Clinitest is a manual method used to detect reducing substances, including glucose, in the
urine. It is important to note that this test may be positive in some instances, because of the
presence of compounds other than glucose. Clinitest is a semiquantitative test, which
estimates the relative quantity of reducing substance present. The remaining answer choices
are all enzymes, employed in methods to quantitate the glucose level in whole blood, as
performed on POCT instruments, or in the laboratory on automated analyzers.

PTS: 1 DIF: Cognitive Level: 1 REF: pp. 253-254

7. The adult reference range for fasting serum glucose is ____ mg/dL.
a. 40-75
b. 55-105
c. 60-95
d. 70-110
ANS: D
Following a strict fast of 8 to 12 hours, the fasting plasma glucose should be 70-110 mg/dL. A
result on the high side of the reference range should be monitored and additionally testing
such as hemoglobin A1C should be tested. The glucose range in choice C (60-95 mg/dL) is
the corresponding level in a whole blood sample. The lower range accounts for the dilution
factor resulting from the presence of cellular elements, primarily red blood cells. A blood
glucose level below 60 mg/dL is termed hypoglycemia.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 254

8. Estimation of the blood glucose level over the previous 4 to 6 weeks is determined with which
test?
a. HbA1c
b. Ketones
c. Clinitest
d. Microalbumin
ANS: A
HbA1c (glycosylated hemoglobin) is hemoglobin bound to glucose, present in red blood cells.
Because red blood cells have a 120-day life span in the circulation, determination of HbA1c
serves as a measure of the average blood glucose concentration over an extended time period.
Ketones are present in the blood (ketonemia) during diabetic ketoacidosis and during periods
of starvation when the body’s fat stores are utilized for energy. Clinitest is a screening test
once used to detect glucose overflow into the urine when the renal threshold for glucose was
exceeded. Today, direct testing of blood glucose is the preferred method. Microalbumin is a
test performed on urine, invaluable in monitoring renal function in people with diabetes.
Microalbuminuria is an indication of the onset of nephropathy, a common complication of
uncontrolled diabetes.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 251

9. Osmolality measures:
a. the number of sodium ions in plasma.
b. the number of sodium ions in urine or plasma.
c. total concentration of all ions and molecules in serum or urine.
d. total concentration of all ions and molecules in plasma.
 ANS: D
Osmolality is based on the number of dissolved particles in a solution. Osmolality measures
the total concentration of all of the ions and molecules present in serum or urine. Sodium,
glucose, and urea are major contributors to the total osmolality of serum.

PTS: 1 DIF: Cognitive Level: 2 REF: p. 255

10. The term for the condition associated with elevated serum potassium is:
a. hyponatremia.
b. hypernatremia.
c. hypokalemia.
d. hyperkalemia.
ANS: D
The prefix hyper refers to an increased amount of a particular substance. “Kal” signifies
potassium, or K+, and the suffix -emia means condition. Conversely, hypokalemia is lower
than normal serum potassium (the prefix hypo means lack or deficiency). The first two
choices describe the conditions of too little and increased sodium, or Na+, in the blood,
respectively.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 256

11. The term chloride shift refers to the:

a. exchange of chloride with sodium to maintain electrical neutrality.
b. exchange of chloride with bicarbonate between red blood cells and plasma.
c. contribution of chloride to serum osmolality.
d. kidney’s excretion of chloride by the renal tubules.
ANS: B
Chloride and bicarbonate are exchanged at the red blood cell membrane to maintain both
electrical neutrality and acid-base balance. Both chloride and bicarbonate are negatively
charged. Electrical neutrality would become increasingly out of balance if chloride were to be
exchanged with sodium. It is true that chloride is a major contributor to serum osmolality and
that the kidneys may either excrete or retain chloride depending on the body’s needs;
however, these processes are not what is referred to as the chloride shift.

PTS: 1 DIF: Cognitive Level: 2 REF: p. 256

12. An increased anion gap may be due to:

a. lactic acidosis.
b. hypercalcemia.
c. hypermagnesemia.
d. hypoproteinemia.
ANS: A
 The anion gap is increased when negatively charged anions, other than chloride and
bicarbonate, are increased in the plasma. These anions include ketones, present in diabetic
ketoacidosis; lactic acid, an increase indicating inadequate tissue oxygenation; and alcohols,
including ethanol and methanol. An increased anion gap is therefore suggestive of metabolic
disorders or alcohol intoxication. Calcium and magnesium are cations. Elevated levels of
calcium and magnesium—hypercalcemia and hypermagnesemia, respectively—will decrease
the anion gap. The anion gap will also be decreased in hypoproteinemia because less protein
is available to bind plasma cations.

PTS: 1 DIF: Cognitive Level: 2 REF: p. 257

13. Determination of plasma sodium with an ion-selective electrode (ISE) will be altered if the
specimen is lipemic (increased plasma lipids) in which manner?
a. Increased with a direct ISE method
b. Increased with an indirect ISE method
c. Decreased with a direct ISE method
d. Decreased with an indirect ISE method
ANS: D
Direct ISE measurements are those made without sample dilution. Increased levels of lipids
do not alter the result with this type of measurement. With indirect ISE measurements the
sample is prediluted. Because lipids occupy plasma volume, dilution of the specimen will
falsely decrease the concentration of sodium detected by the electrode.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 258

14. The primary form of nonprotein nitrogen in the blood is:

a. urea.
b. creatinine.
c. cystatin C.
d. creatine.
ANS: A
Urea or blood urea nitrogen (BUN) is the major nonprotein, nitrogen-containing compound
that is present in the blood. Urea is the form in which the kidneys excrete excess body
nitrogen, preventing the buildup in the blood plasma of ammonia, the primary metabolite of
protein breakdown. The remaining compounds also contain nitrogen. Both creatine and
creatinine are integral to metabolic reactions in muscle tissue, while cystatin C, a byproduct of
cellular metabolism, may be used to estimate the glomerular filtration rate (GFR).

PTS: 1 DIF: Cognitive Level: 1 REF: p. 260

15. An adult male has a serum BUN of 56 mg/dL and a creatinine of 0.8 mg/dL. These results are
consistent with:
a. decreased GFR.
b. prerenal azotemia.
c. renal azotemia.
d. postrenal azotemia.
ANS: B
 This patient has an elevated BUN and normal creatinine. The BUN-to-creatinine ratio is
greater than 20. Because the creatinine is normal, this is a case of prerenal azotemia. Prerenal
azotemia is due to poor perfusion of the kidneys or an increased rate of protein breakdown.
Postrenal azotemia is also indicated by an elevated BUN to creatinine ratio; however,
creatinine is increased in this case. In renal disease, elevations in both BUN and creatinine
characteristically result in a ratio between 12 and 20. A ratio of less than 12 is present in acute
tubular necrosis. The GFR is used to assess renal function and is most frequently predicted
using the serum creatinine. A decreased GFR is an indicator of renal insufficiency.

PTS: 1 DIF: Cognitive Level: 3 REF: p. 261

16. Which of the following conditions is least likely to contribute to an increased serum uric acid
level?
a. Chemotherapy
b. Renal disease
c. Liver disease
d. Gout
ANS: C
Uric acid is a nitrogen-containing product of purine catabolism. Purines are nucleic acids,
components of DNA, RNA, cofactors, and energy-containing molecules. Plasma increases in
uric acid are therefore seen during chemotherapy when there is increased cell destruction, in a
disorder of purine metabolism referred to as gout, and in renal disease when the clearance of
uric acid is diminished. Another nitrogen-containing compound, ammonia, is a byproduct of
protein catabolism, which occurs primarily in the liver. Liver disease is therefore associated
with an increased plasma ammonia level.

PTS: 1 DIF: Cognitive Level: 2 REF: p. 264

17. The first step in the laboratory determination of serum cholesterol is to ensure that all
cholesterol present is in the free form. This is accomplished with the use of:
a. cholesterol esterase.
b. glycerol.
c. cholesterol oxidase.
d. lipase.
ANS: A
The enzyme cholesterol esterase converts cholesterol esters present in the sample to free
cholesterol. Cholesterol oxidase is used in the second step of the determination of serum
cholesterol. The oxidase catalyzes the formation of hydrogen peroxide. Hydrogen peroxide
then reacts with a chromogen, allowing for spectrophotometric detection. Lipase is an enzyme
employed in the first step of triglyceride quantitation. Glycerol is not an enzyme but a product
of triglyceride hydrolysis.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 265

18. Fasting lipid profile results for a 48-year-old male with diabetes are as follows: total
cholesterol: 298 mg/dL, HDL cholesterol: 26 mg/dL, and triglycerides: 320 mg/dL. The
patient has no evidence of coronary artery disease (CAD). What is the recommended course
of action?
a. The LDL is normal, and no action is indicated.
 b. The LDL is elevated, and the therapeutic goal is to decrease it to less than 100
mg/dL.
c. The LDL is elevated, and the therapeutic goal is to decrease it to less than 130
mg/dL.
d. The LDL is elevated, and the therapeutic goal is to decrease it to less than 160
mg/dL.
ANS: C
For patients without clinical evidence of coronary or other atherosclerotic vascular disease,
the National Cholesterol Education Program (NCEP) recommends health screening, including
measurement of total cholesterol (TC) and HDL cholesterol, at least once every 5 years.
Further evaluation is performed for those patients with a high TC, low HDL cholesterol
(<35 mg/dL), or borderline TC who have at least two CAD risk factors (age >45 for men, age
>55 for women or postmenopausal state without estrogen replacement, high blood pressure,
smoking, diabetes, HDL <35 mg/dL, or family history of CAD before age 55 in male
first-degree relative or before age 65 in female first-degree relative).
The NCEP recommends that treatment decisions be based on the calculated level of LDL.
For patients with an elevated LDL (160 mg/dL) who have fewer than two risk factors in
addition to elevated LDL and who do not have clinical evidence of atherosclerotic disease, the
goal of treatment is an LDL level less than 160 mg/dL. For those who have at least two other
risk factors, the goal of treatment is an LDL level less than 130 mg/dL. When LDL levels
remain higher than 160 mg/dL despite dietary measures, and the patient has two or more risk
factors (in addition to high LDL), or when LDL levels remain higher than 190 mg/dL even
without added risk factors, the addition of drug treatment should be considered.
For those with CAD, peripheral vascular disease, or cerebrovascular disease, the goal of
treatment is an LDL less than 100 mg/dL.
All patients with clinical evidence of coronary or other atherosclerotic disease should be
evaluated with a fasting blood sample for measurement of TC, triglyceride, and HDL. LDL is
calculated.

PTS: 1 DIF: Cognitive Level: 3 REF: p. 266

19. Laboratory diagnosis of an acute myocardial infarction (MI) is most accurately determined
with which of the following two cardiac markers?
a. CK-MB and homocysteine
b. CRP (C-reactive protein) and cardiac troponin
c. Myoglobin and lactate dehydrogenase (LDH)
d. Myoglobin and cardiac troponin
ANS: D
The combination of myoglobin and cardiac troponins is the best choice of markers for acute
MI. With these two markers, elevations (supporting diagnosis of an MI), are seen over a 2- to
10-day window of time. Homocysteine and CRP are both compounds determined to be risk
factors, predicting increased likelihood of acute MI. Both CK-MB and LDH are enzymes,
once utilized as markers of an acute coronary event. Today, the increased specificity of
troponins, combined with early detection of the muscle protein myoglobin, is the preferred
combination of cardiac markers.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 268

20. Which of the following laboratory tests assist in the diagnosis of heart failure?
a. BNP
b. Fibrinogen
c. CRP
d. D-dimer
ANS: A
BNP, or B-type natriuretic peptide, is a powerful regulator of fluid volume released
primarily by cardiac cells in response to ventricular volume increase and pressure overload.
Increased levels of BNP in the blood are diagnostic of congestive heart failure. Fibrinogen and
CRP are acute-phase proteins, which serve as markers of inflammation and therefore
cardiovascular risk. D-dimer, associated with thrombus formation and dissolution, is a
nonspecific marker of active plaque formation in atherosclerotic heart disease.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 269

21. In bilirubin assays, conjugated bilirubin is referred to as ____ reacting bilirubin.

a. unconjugated
b. total
c. indirect
d. direct
ANS: D
Conjugated bilirubin is the water-soluble product of heme degradation formed in the liver.
This form of bilirubin is also referred to as direct or direct-reacting bilirubin because it reacts
with diazo reagent in the bilirubin procedure. Indirect bilirubin, or bilirubin in its
unconjugated form, is detected by a similar procedure; however, a compound such as
methanol is added which accelerates the reaction of indirect bilirubin to result in a measure of
total (both direct and indirect) bilirubin. Consequently, the terms direct and conjugated are
synonymous, as are the terms indirect and unconjugated when referring to the two forms of
bilirubin.

PTS: 1 DIF: Cognitive Level: 2 REF: p. 271

22. Which of the following enzymes is normally found in highest levels in hepatocytes, or liver
cells?
a. ALT
b. AST
c. GGT
d. Alkaline phosphatase
ANS: A
ALT (alanine aminotransferase) is found in the greatest concentration in liver cells. In various
forms of liver disease, including hepatitis and acute liver necrosis, the serum level of ALT is
significantly increased because of liver damage. Although AST (aspartate aminotransferase)
and alkamine phosphatase may be elevated in liver disease, they are not specific to the liver.
For instance, AST is elevated in instances of heart, kidney, and muscle damage, whereas
alkaline phosphatase is also utilized for diagnosis of bone, intestinal, and placental disorders.
Serum elevation of GGT (gamma glutamyltransferase) is an early indicator of liver disease, a
marker of chronic alcoholism, and may also be an indicator of renal damage.
 PTS: 1 DIF: Cognitive Level: 2 REF: p. 272

23. A reversal of the normal serum albumin/globulin (A/G) ratio occurs in ____ disease.
a. heart and lung
b. kidney and bone
c. heart and liver
d. kidney and liver
ANS: D
Kidney and liver disease are the two major causes of decreased serum albumin ratios. The
liver is the site of albumin synthesis such that damage to this organ will decrease serum
albumin, whereas kidney damage results in urinary loss of albumin. In both instances, when
disease has progressed significantly, the ratio becomes less than the normal 2:1. The globulin
component may be increased or decreased in various conditions, including chronic
inflammation and monoclonal immunoglobulin disease. These conditions will also alter the
A/G ratio.

PTS: 1 DIF: Cognitive Level: 2 REF: p. 272

24. The two enzymes used in the diagnosis of acute pancreatitis are:
a. AST and ALT.
b. amylase and lipase.
c. alkaline phosphatase and amylase.
d. GGT and lipase.
ANS: B
Amylase and lipase determinations are central to the diagnosis of acute pancreatitis. Serum
amylase may also originate from the salivary glands; however, a concurrent increase in lipase
in conjunction with abdominal symptoms indicates a diagnosis of pancreatitis. AST and ALT
are most commonly used to diagnose and follow the course of liver disease. Elevation of these
two enzymes is a contraindication for the use of many drugs, such as statins, which may affect
liver function. An elevation of GGT may be an indicator of early renal disease, chronic
alcoholism, or renal damage. Alkaline phosphatase is an enzyme associated with disorders of
the liver, bone, intestine, and placenta.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 274

25. Free T4 is ____ and thyroid stimulating hormone is ____ in hypothyroidism.

a. increased; decreased
b. decreased; increased
ANS: B
Hypothyroidism:
Thyroid Stimulating Hormone: Increased
Free T4 (FT4): Decreased

Hyperthyroidism:
Thyroid Stimulating Hormone: Decreased
Free T4 (FT4): Increased

PTS: 1 DIF: Cognitive Level: 2 REF: p. 275

 26. Which of the following is the least utilized role of a tumor marker?
a. Cancer screening
b. Cancer diagnosis
c. Monitoring of patients for a recurrence of cancer
d. Determination of the extent of tumor burden
ANS: B
Diagnosis of cancer is generally not made with the laboratory finding of an elevated tumor
marker concentration. Tumor markers commonly tested for are associated with a relatively
high rate of false-positive results compared with other diagnostic tests. Diagnosis is made in
conjunction with other testing, such as a biopsy. The value of tumor markers is their use in
screening for cancer, in specific populations, such as PSA (prostate specific antigen) in men
older than age 50 years. Tumor markers are also frequently employed to monitor patients
during therapy to determine its effectiveness, to detect recurrence following treatment, and to
approximate the extent of tumor burden.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 275

TRUE/FALSE

1. It is important to record the exact time and date in relation to the last dose of the drug when
drawing a blood specimen for therapeutic drug monitoring.

ANS: T
It is important to record the exact time and date of the specimen in relation to the last dose of
the drug, with a note of all other drugs prescribed.

PTS: 1 DIF: Cognitive Level: 1 REF: p. 278

MATCHING

Match the following terms with the correct description. Use an answer only once.
a. decreased plasma bicarbonate
b. excess elimination of acid
c. acid-rich fluids are lost
d. decreased elimination of CO2

1. metabolic acidosis
2. metabolic alkalosis
3. respiratory acidosis
4. respiratory alkalosis

1. ANS: A PTS: 1 DIF: Cognitive Level: 2

REF: p. 260
2. ANS: C PTS: 1 DIF: Cognitive Level: 2
REF: p. 260
3. ANS: D PTS: 1 DIF: Cognitive Level: 2
REF: p. 260
4. ANS: B PTS: 1 DIF: Cognitive Level: 2
 REF: p. 260

Match the name of the tumor specific marker assay with an appropriate application.
a. suggests early recurrence of breast cancer
b. secreted in endodermal sinus tumors
c. detected in choriocarcinoma
d. found in 20% of smokers

5. alpha fetoprotein
6. -hCG
7. CA 27.29
8. CEA

5. ANS: B PTS: 1 DIF: Cognitive Level: 2

REF: p. 276
6. ANS: D PTS: 1 DIF: Cognitive Level: 2
REF: p. 276
7. ANS: A PTS: 1 DIF: Cognitive Level: 2
REF: p. 276
8. ANS: D PTS: 1 DIF: Cognitive Level: 2
REF: p. 276
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