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The Medical Laboratory Science (MLS) Review has been designed to provide

a challenging
personal assessment of practical and theoretical knowledge needed by medical lab
scientists and technicians. The MLS Review will help you identify strengths, wea
knesses, and gaps
in your knowledge base. Because taxonomy level is a part of the assessment, you
will also be able
to concentrate on the type of question that causes the most difficulty. The sugg
ested approach to
maximizing use of the MLS Review is to read the explanation that follows each qu
thoroughly, regardless of whether you answered it correctly or not. High- light
the content you
did not know, and study it until com- mitted to memory. This MLS Review was deve
loped as a tool
to facilitate both self-assessment and new learning. The units are arrang
ed in a
logical sequence corresponding to the organization of a textbook, and f
ollow the
pattern of presentation used in laboratory science lectures. The question
s within a unit
are related, and can be used by students as they progress through their courses
in order to
improve understanding. The sections are comprehen- sive, and suitable for all ce
levels although some questions may be more appropriate for one certification lev
el than another.
The MLS Reviewis intended to supple- ment courses in the curriculum and assist t
echnologists and
technicians who are re-entering the laboratory. In addition, it is desi
gned to improve
performance on generalist, categorical, and specialist certification exams. De
sign of Questions
Test questions used in certification examinations are mul- tiple choice. Each co
nsists of a
question, incomplete state- ment, or problem to be solved called the stem and fo
ur alternative
responses. One of the alternatives is the correct response and the remaining thr
ee are incorrect
(these may be wrong, incomplete, partially correct, or less correct than
the most
appropriate response). Incorrect alternatives that appear plausible are called d
istractors. The
difficulty of a question is determined by how close the distractors are to the c
orrect response.
Some questions were written for assessment of your knowledge, and others for lea
rning. For
pedagogic reasons, the latter may contain an all of these options alternative. Thi
s makes such
questions into three true or false statements that are related by the subject (s
tem) of the
question. If you are reasonably sure that two of the responses are true, then th
e correct
response must be all of these options. For this reason, such questions are not use
d on
certification exams. Questions involving combinations of statements (multiple, m
ultiple choice)
are not used on certification examinations or in this book. All of the questions

in this book are

multiple choice. Each question is followed by the test item classification. Alon
gside each
question is the correct answer and an explanation. The test item classific
ation consists of
the subject category, task, and taxonomy level of the question. A question in Bl
ood Banking, for
example, that asks for an interpretation of an ABO problem, may have a test item
Blood Bank/Evaluate laboratory data to recognize problems/ABO discrepancy/3. The t
est item
classification places the question in the major category of blood banking; the
question asks
for an evaluation of data; the subcategory is ABO discrepancy; and the
taxonomy level
classifies the question as problem solving. Taxonomy level 1 questions address r
ecall of
information. Taxonomy 2 questions require calculation, correlation, comprehensio
n, or relation.
Taxonomy 3 questions require problem solving, interpretation, or decision making
. This question
design allows you to compute a score, which helps you to identify strengths and
weaknesses in
various content areas and tasks. You may then focus study time on a particular c
ontent area or on
practicing with questions of a specific taxonomy level. For example, if you answ
er several
mycology questions incorrectly, then you should devote extra time to studying th
is content area.
If, xiii 2828_FM_i-xvi 21/08/12 2:32 PM Page xiii however, you miss severa
l recall
questions (taxonomy 1 level) over several different content areas such as hematology,
chemistry, and immunology, then repetitive review is indicated for all of t
hese sections.
Poor perfor - mance with questions that require mathematical solutions (taxonom
y 2 level)
requires you to review formulas used for lab calculations, and to practice using
them. If interpretation or problem solving (taxonomy 3 level) is iden- tified as a weakness, t
hen the best
approach is to study the explanation that follows each question in order to unde
r- stand the
logic or reasoning behind the answer. Because the answers and explanations appea
r on the same
page as the questions, it is recommended that you tear off the perforated flap a
nd use it as a
blocker to cover the answers while answering the questions. When you have
answered a
question, slide the blocker down the page to reveal the answer and explanat
ion. The
blocker is printed with a compilation of reference ranges for com- mon analyte
s that will
assist you with answering some questions. Prepare for Your Certi cation Examin
ation Ideally,
an examination score should reflect your knowl- edge of the content without
the influence
of other variables. However, variables such as stress, wellness, self- confiden
ce, emotional
state, and alertness all influence performance. In addition, examination skills

often factor into

exam scores and can be decisive. A single question answered correctly can make t
he difference
between pass- ing or failing, the only two meaningful scores for a certi- ficati
on exam.
Certification exams are usually delivered by computer. There are two types of co
examinations, tra- ditional and adaptive. Traditional exams are of fixed
length and
content. Therefore, everyone taking the exam does so at the same time and receiv
es the same set
of ques- tions. Computer adaptive exams may be fixed or variable in length, but
every exam is
different because the difficulty of the next question is determined by whether y
ou answer the
current question correctly. Since the difficulty of the questions answered corre
ctlynot the
number answered correctlydetermines passing or failing, you should always gi
ve your best
answer the first time. Although every examinees question set is different, all qu
estions come
from a common database, and therefore there is some overlap between the
questions used.
The examination is constructed so that the number of questions in each c
ategory (e.g.,
hematology) is within the specifications published for the exam; however, the di
stribution of
ques- tions and the order of questions will vary significantly. Certification ex
ams are criterion
referenced. This means that examination performance is scored passing or failing
of the performance of other candidates taking the examination. The minimum
passing score for
certification examinations is normalized in order to min- imize the variance bet
examinations. However, the xiv Introduction minimum passing score usually falls
within the range
of 65%70% correct responses. A score below 65% on any content area in the MLS Rev
iew is a strong
indicator that you have not mastered the material in this area, and that further
study is
required. Preparation for a certification exam requires a study plan. Begin with
a review of the
exam content outline that is made available by the certification agency. For exa
mple, if 20% of
the exam is Microbiology but only 2% of the exam is Laboratory Management, you s
hould spend significantly more time studying the former. Within each content area will be s
(e.g., Bacteriology and Parasitology under Microbiology). If 60% of the
content is Bacteriology and only 10% is Parasitology, then devote significa
ntly more time to
studying the former. Allow yourself sufficient time prior to the exam to re- vie
w each content
area no less than three times. Begin studying your strongest subject, then
progress to
your weakest. Study your class notes first, then use this review book to test
your knowledge
of the respective content area. Devote time to reading the explanation

for each
question, regardless of whether you answered it correctly or not. Highlight info
rmation you did
not know and re- view it before answering the questions in this book a
second time.
Rarely, will you encounter any of the same questions on your certification exam;
however, you are
likely to encounter variants of the questions, and the explanations will
help prepare you
to answer these cor- rectly. When finished with the second round, take the compr
ehensive exam
included with this book. Evaluate your performance by both subject and taxonomy.
If you score
lower in Clinical Chemistry, devote more time to it in your third round of
study. If you
are weakest in recall-type questions, make note cards with charts and tables,
and study them
regularly until the information on them is committed to memory. Note your progre
ss from the first
to the second round. If your progress is signifi- cant, use the same approac
h on the third
round. If not, devote more time to studying your weakest content areas. Plan y
our third round
of study so that you end with your weakest subject. Then, repeat each chapter in
the MLS Review a
final time. Finish by taking the exam- inations on the CD included with this boo
k. These questions are all different than those in the book, and will give you exposure to ma
ny more based on
interpreting photomicrographs. Test-Taking Skills Before the Exam First, make a
study plan such
as the one suggested earlier. You cannot expect to review all of this material i
n only a few
days. Allow yourself at least 1 month to study all areas completely and carefull
y. Set aside an
allotted time period of at least 1 hour each day when you are alert and can stay
2828_FM_i-xvi 21/08/12 2:32 PM Page xiv Assemble all of your study materials
before you begin
your review. Searching for old notes or textbooks may become time consuming and
frustrating. You
may have a tendency to give up looking for needed materials, if you do not have th
em readily
available. Therefore, you may neglect or not study a major content area. Provide
a study
environment. Choose a quiet, comfort- able area for your study. Find a place whe
re you will not
be distracted or disturbed. Simulate test conditions. Re- gardless of your study
plan, you should
take some portion of the review process, for example, the mock examination, unde
r simulated
test conditions. These examinations should be timed, uninterrupted, and desig
ned to observe
realistic testing practices. For example, you should take the mock examination w
ith only a sheet
of scratch paper, pencil, and a basic calculator at your disposal. A few days
before the
exam, be sure to again read through the instructions sent to you by the cer
agency. Some types of calculators (e.g., graphing or pro- grammable calculators)

may be
prohibited and you should know what you can and cannot bring with you. Make your
arrangements and familiarize yourself with directions to the site. Finally,
go to sleep early
the night before the exam, and leave yourself extra time if you have to travel a
long distance to
the examination site. On Exam Day Eat properly and, if possible, engage in some
light physical
activity such as walking prior to leaving for the exam. Dress comfortab
ly with layered
clothing that you may re- move, if the examination room is too warm. Make sure y
ou bring two
forms of signed identification including 1 photo identification card (drivers lic
ense or state
issued ID card). These must not be expired, and the name on them must match the
name on your
letter of admission to the exam that you should also have with you. Wear a watch
so that you can
keep track of time. Do not take notes or books with you. If you have not pre- pa
red prior to the
examination day, you will not succeed by trying to cram last-minute facts. If yo
u become anxious before or during the exam, close your eyes and breathe deeply fo
r a few
seconds. Perhaps focus on a Introduction xv special activity that you may
have planned as a
reward for yourself after the examination. Have confidence in your abilities. At
this point, you
have successfully completed a rigorous course of classroom and clinical traini
ng and the
examination represents merely the last step in this long process. Tell
yourself that
you have adequately practiced and prepared for the examination and that you are
ready. During the
Exam Read all directions. Make sure you understand how to take the examination.
Read the
questions carefully and note key words. Accept the question as you first read it
; do not read
your own thoughts into the question and do not look for hidden meanings. Quickly
look at all of
the answers. Next, carefully read all choices. You may wish to mentally p
lace a T for
true or an F for false beside each alternative, or to reject outright obviously
wrong choices.
Select your first choice and do not change your answer. Answer all of the questions. There is
no penalty for guessing on certification examinations. Always answer to the best
of your ability
the first time. A computer-adapted exam selects the next question based upon you
r previous
answer. Apply a few simple rules to those questions you cannot answer. Consiste
ntly choose the
same letter on those questions. B is the most common correct answer. Choose on
e of the
longest answers. Pick items that are more specific or detailed than the ot
hers. Do not
overlook words such as not, never, always, most, least, best, worst, except. Sta
tements that
contain unquali- fied absolutes (always, never) are usually incorrect. In con- t

alternatives that are worded to contain exceptions (usually, generally) are ofte
n true. Do not
panic if you do not know an answer. Continue the test and do not allow anxiety t
o make you forget
items that you know. Work steadily and do not spend too much time on qu
estions you do
not know; keep an eye on the time. Try to pace yourself so that sufficient time
remains after
com- pleting the test to review all of your answers. Do not change you
r original answer
unless you are certain that you made a mistake when you answered the question in
2828_FM_i-xvi 21/08/12 2:32 PM Page xv 2828_FM_i-xvi 21/08/12 2:32 PM Page
xvi 1.1 Basic
Hematology Concepts and Laboratory Procedures 1.2 Normocytic and Normochromic An
emias 1.3
Hypochromic and Microcytic Anemias 1.4 Macrocytic and Normochromic Anemias 1.5 Q
ualitative and
Quantitative White Blood Cell Disorders 1.6 Acute Leukemias 1.7 Lymphoproliferat
ive and
Myeloproliferative Disorders 1.8 Hematology Problem Solving CHAPTER 1 Hematology
2828_Ch01_001-040 09/08/12 4:10 PM Page 1 2828_Ch01_001-040 09/08/12 4:10 P
M Page 2 3 1.1
Basic Hematology Concepts and Laboratory Procedures 1. Insu cient centrifugation w
ill result in:
A. A false increase in hematocrit (Hct) value B. A false decrease in Hct value C
. No e ect on Hct
value D. All of these options, depending on the patient Hematology/Apply princip
les of basic
laboratory procedures/Microscopic morphology/Di erential/2 2. Variation in red cel
l size observed
on the peripheral smear is described as: A. Anisocytosis B. Hypochromia C. Poiki
locytosis D.
Pleocytosis Hematology/Apply knowledge of fundamental biological characteristics
morphology/RBCs/1 3. Which of the following is the preferable site for bone marr
ow aspiration and
biopsy in an adult? A. Iliac crest B. Sternum C. Tibia D. Spinous processes of a
Hematology/Apply knowledge of fundamental biological characteristics/Bone marrow
/1 4. Mean cell
volume (MCV) is calculated using the following formula: A. (Hgb RBC) 10 B. (Hct
RBC) 10
C. (Hct Hgb) 100 D. (Hgb RBC) 100 Hematology/Calculate/RBC indices/2 5. What ter
describes the change in shape of erythrocytes seen on a Wrights-stained periphera
l blood smear?
A. Poikilocytosis B. Anisocytosis C. Hypochromia D. Polychromasia Hematology/App
ly knowledge of
fundamental biological characteristics/Microscopic morphology/ RBCs/1 Answers to
Questions 15 1.
A Insu cient centrifugation does not pack down the red blood cells; therefore, the
Hct, which is
the volume of packed cells, will increase. 2. A A mature erythrocyte is approxim
ately 78 m in
diameter. Variation in normal size is denoted by the term anisocytosis. Hypochro
mia is a term
that indicates increased central pallor in erythrocytes, and poikilocytosis deno

tes variation in
red cell shape. 3. A The iliac crest is the most frequently used site for bone m
arrow aspiration
and biopsy. This site is the safest and most easily accessible, with the bone ju
st beneath the
skin, and neither blood vessels nor nerves are in the vicinity. 4. B MCV is the
average volume
of the red cells. This is obtained by dividing the Hct or packed cell volume (PC
V) by the red
blood cell (RBC) count in millions per microliter of blood and multiplying by 10
. The MCV is
expressed in cubic microns (m 3 ) or femtoliters (fL). 5. A Variation in shape of
erythrocytes on a peripheral blood smear is poikilocytosis. Anisocytosis refers
to a change in
size. Hypochromia is an increase in central pallor in erythrocytes. Polychromasi
a describes the
bluish tinge of the immature erythrocytes (reticulocytes) circulating in the per
ipheral blood.
2828_Ch01_001-040 09/08/12 4:10 PM Page 3 6. Calculate the mean cell hemoglob
in concentration
(MCHC) using the following values: Hgb: 15 g/dL (150 g/L) Hct: 47 mL/dL (0.47) R
BC: 4.50 10 6
L (4.50 10
A. 9.5% (.095) B. 10.4% (.104) C. 31.9% (.319) D. 33.3% (.333) Hematolog
indices/2 7. A manual white blood cell (WBC) count was performed. A total of 36
cells were
counted in all 9-mm 2 squares of a Neubauer-ruled hemacytometer. A 1:10 dilution
was used. What
is the WBC count? A. 0.4 10 9
B. 2.5 10 9
C. 4.0 10 9
D. 8.0 10 9
Hematology/Calculate/Manual WBCs/2 8. When an erythrocyte containing iro
n granules is stained
with Prussian blue, the cell is called a: A. Spherocyte B. Leptocyte C. Schistoc
yte D. Siderocyte
Hematology/Apply knowledge of fundamental biological characteristics/RBCs micros
morphology/Stain/1 9. A 7.0-mL ethylenediaminetetraacetic acid (EDTA) tube is re
ceived in the
laboratory containing only 2.0 mL of blood. If the laboratory is using manual te
chniques, which
of the following tests will most likely be erroneous? A. RBC count B. Hemoglobin
(Hgb) C. Hct D.
WBC count Hematology/Apply knowledge to identify sources of error/Specimen colle
ction and
handling/CBCs/2 10. A 1:200 dilution of a patients sample was made and 336 red ce
lls were
counted in an area of 0.2 mm 2 . What is the RBC count? A. 1.68 10 12
B. 3.36 10 12

C. 4.47 10 12
D. 6.66 10 12
Hematology/Calculate/Manual RBCs/2 Answers to Questions 611 6. C MCHC is
the average
concentration of Hgb in red cells expressed as a percentage. It expresses the ra
tio of the weight
of Hgb to the volume of erythrocytes and is calculated by dividing Hgb by the Hc
t, and then
multiplying by 100. A decreased MCHC indicates that cells are hypochromic. In th
is example, (15
47) 100 = 31.9%. The reference range for MCHC is 32%36%. 7. A The formula used fo
r calculating
manual cell counts using a hemacytometer is: Number of cells counted dilution fa
ctor depth
factor (10) divided by the area. In this example, 36 10 10 = 3600 9 = 400/mm 3 o
r 0.4 10 9
8. D Siderocytes are red cells containing iron granules and are visible
when stained with
Prussian blue. 9. C Excessive anticoagulant causes shrinkage of cells; thus, the
Hct will be
a ected. RBC and WBC counts remain the same, as does the Hgb content. 10. B RBC co
unt = number of
cells counted dilution factor depth factor (10), divided by the area. In this ex
ample, 336
200 10 = 672,000 0.2 = 3.36 10 6
3 = 3.36 10 12
11. D Neutrophils are highly phagocytic and release lysozymes, peroxidas
e, and pyrogenic
proteins. Eosinophils migrate to sites where there is an allergic reaction or pa
infestation, releasing peroxidase, pyrogens, and other enzymes, including an oxi
dase that
neutralizes histamine. They are poorly phagocytic and do not release lysozyme. 4
Chapter 1 |
Hematology 11. What phagocytic cells produce lysozymes that are bacteriocidal? A
. Eosinophils B.
Lymphocytes C. Platelets D. Neutrophils Hematology/Apply knowledge of fundamenta
l biological
characteristics/Leukocytes/1 2828_Ch01_001-040 09/08/12 4:10 PM Page 4 12. If
a patient has a
reticulocyte count of 7% and an Hct of 20%, what is the corrected reticulocyte c
ount? A. 1.4% B.
3.1% C. 3.5% D. 14% Hematology/Apply principles of basic laboratory
procedures/Calculate/Reticulocytes/2 13. A decreased osmotic fragility test woul
d be associated
with which of the following conditions? A. Sickle cell anemia B. Hereditary sphe
rocytosis C.
Hemolytic disease of the newborn D. Acquired hemolytic anemia Hematology/Apply p
rinciples of
basic laboratory procedures/RBCs/Osmotic fragility/2 14. What e ect would using a
bu er at pH 6.0
have on a Wrights-stained smear? A. Red cells would be stained too pink B. White
cell cytoplasm
would be stained too blue C. Red cells would be stained too blue D. Red cells wo
uld lyse on the

slide Hematology/Evaluate laboratory data to recognize problems/Microscopic morp

15. Which of the following erythrocyte inclusions can be visualized with supravi
tal stain but
cannot be detected on a Wrights-stained blood smear? A. Basophilic stippling B. H
einz bodies C.
HowellJolly bodies D. Siderotic granules Hematology/Apply principles of basic lab
procedures/Microscopic morphology/RBC inclusions/2 16. A falsely elevated Hct is
obtained. Which
of the following calculated values will not be a ected? A. MCV B. MCH C. MCHC D. R
ed cell
distribution width (RDW) Hematology/Evaluate sources of error/Microhematocrit/2
17. A Miller disk
is an ocular device used to facilitate counting of: A. Platelets B. Reticulocyte
s C. Sickle cells
D. Nucleated red blood cells (NRBCs) Hematology/Apply knowledge of standard oper
procedures/Manual counts/1 Answers to Questions 1217 12. B In anemic states, the
percentage is not a true measure of reticulocyte production. The following formu
la must be
applied to calculate the corrected (for anemia) reticulocyte count. Corrected re
ticulocyte count
= reticulocytes (%) Hct 45, the average normal Hct. In this case, 7 (20 45) = 3.
1. 13. A
Osmotic fragility is decreased when numerous sickle cells and target cells are p
resent and is
increased in the presence of spherocytes. Spherocytes are a prominent feature of
spherocytosis (HS), hemolytic disease of the newborn, and acquired hemolytic ane
mia. The osmotic
fragility test is increased in the presence of spherocytes, whereas this test is
decreased when
sickle cells, target cells, and other poikilocytes are present. 14. A The pH of
the bu er is
critical in Romanowsky stains. When the pH is too low (<6.4), the red cells take
up more acid dye
(eosin), becoming too pink. Leukocytes also show poor nuclear detail when the pH
is decreased.
15. B Heinz bodies are irregular, refractile, purple inclusions that are not vis
ible with
Wrights stain but show up with supravital staining. The other three inclusions ca
n be detected
with Wrights stain. 16. B The MCH = Hgb 10/RBC count and is not a ected by the Hct.
The MCV =
Hct 10/RBC count, and MCHC = Hgb 100/Hct; therefore, an erroneous Hct will a ect t
parameters. Centrifugal force for microhematocrit determination should be 12,000
g for 5 min in
order to avoid error caused by trapped plasma. The red cell distribution width (
RDW) is
calculated by electronic cell counters and re ects the variance in the size of the
red cell
population. Electronic cell counters calculate Hct from the MCV and RBC count. T
herefore, the RDW
would be a ected by an erroneous MCV. 17. B The manual reticulocyte count involves
the counting
of 1,000 RBCs. The Miller disk is a reticle (grid) that is placed in the eyepiec
e of the

microscope and divides the eld into two squares, one being nine times larger in s
ize than the
other. Reticulocytes are enumerated in both the squares. Mature red cells are co
unted in the
smaller one. 1.1 | Basic Hematology Concepts and Laboratory Procedures 5 2828_
09/08/12 4:10 PM Page 5 6 Chapter 1 | Hematology Answers to Questions 1823 18.
and MCHC are all within the reference interval (normal range); hence, the erythr
ocytes should be
of normal size and should re ect normal concentrations of Hgb. Therefore, the anem
ia is
normocytic normochromic. 19. A EDTA and sodium citrate can be used without any e e
ct on the ESR.
Anisocytosis and poikilocytosis may impede rouleaux formation, thus causing a lo
w ESR. Plasma
proteins, especially brinogen and immunoglobulins, enhance rouleaux, increasing t
he ESR.
Reference ranges must be established for di erent caliber tubes. 20. B The reticul
um within the
reticulocytes consists of ribonucleic acid (RNA), which cannot be stained with W
rights stain.
Supravital staining with new methylene blue is used to identify the reticulocyte
s. 21. A
Electronic cell (Coulter) counters use the principle of electrical impedance. Tw
o electrodes
suspended in isotonic solutions are separated by a glass tube having a small ape
rture. A vacuum
is applied, and as a cell passes through the aperture it impedes the ow of curren
t and generates
a voltage pulse. 22. C The automated hematology analyzers enumerate all nucleate
d cells. NRBCs
are counted along with WBCs, falsely elevating the WBC count. To correct the WBC
count, determine
the number of NRBCs per 100 WBCs. Corrected WBC count = (uncorrected WBC count [
NRBCs + 100])
100. 23. B The RDW parameter correlates with the degree of anisocytosis seen on
morphological examination. The reference range is 11.5%14.5%. 18. SITUATION: RBC
obtained on an anemic patient are as follows: MCV 88 m 3 (fL); MCH 30 pg; MCHC 34
% (.340). Te
RBCs on the peripheral smear would appear: A. Microcytic, hypochromic B. Microcy
tic, normochromic
C. Normocytic, normochromic D. Normocytic, hypochromic Hematology/Evaluate labor
atory data to
recognize health and disease states/RBC indices/2 19. All of the following facto
rs may in uence
the erythrocyte sedimentation rate (ESR) except: A. Blood drawn into a sodium ci
trate tube B.
Anisocytosis, poikilocytosis C. Plasma proteins D. Caliber of the tube Hematolog
principles of basic laboratory procedures/ESRs/2 20. What staining method is use
d most frequently
to stain and manually count reticulocytes? A. Immuno uorescence B. Supravital stai
ning C.
Romanowsky staining D. Cytochemical staining Hematology/Apply knowledge of stand
ard operating
procedures/Reticulocytes/1 21. Te Coulter principle for counting of cells is bas
ed upon the fact

that: A. Isotonic solutions conduct electricity better than cells do B. Conducti

vity varies
proportionally to the number of cells C. Cells conduct electricity better than s
aline does D.
Isotonic solutions cannot conduct electricity Hematology/Apply principles of bas
ic laboratory
procedures/Instrumentation/Cell counters/2 22. A correction is necessary for WBC
counts when
nucleated RBCs are seen on the peripheral smear because: A. Te WBC count would b
e falsely lower
B. Te RBC count is too low C. Nucleated RBCs are counted as leukocytes D. Nuclea
ted RBCs are
confused with giant platelets Hematology/Evaluate laboratory data to take correc
tive action
according to predetermined criteria/Leukocytes/2 23. Using an electronic cell co
unter analyzer,
an increased RDW should correlate with: A. Spherocytosis B. Anisocytosis C. Leuk
ocytosis D.
Presence of NRBCs Hematology/Correlate laboratory data with other laboratory dat
a to assess test
results/RBC microscopic morphology/2 2828_Ch01_001-040 09/08/12 4:10 PM Page
6 1.1 | Basic
Hematology Concepts and Laboratory Procedures 7 Answers to Questions 2429 24. C
have a decreased cell diameter and volume, which results in loss of central pall
or and discoid
shape. The index most a ected is the MCHC, usually being in excess of 36%. 25. C S
deviation(s) describes the distribution of a sample of observations. It depends
upon both the
mean (average value) and dispersion of results and is most in uenced by reproducib
ility or
precision. Because s is in uenced by the mean and expressed as a percentage of the
mean, the
coe cient of variation ([s mean] 100) can be used to compare precision of tests wi
th di erent
means (e.g., WBC and RBC counts or low vs. high controls). 26. D Deoxyhemoglobin
is the
physiological Hgb that results from the unloading of oxygen by Hgb. This is acco
mpanied by the
widening of the space between chains and the inding of 2,3-diphosphoglycerate (2,
3-DPG) on a
mole-for-mole asis. 27. A Acidosis is associated with a shift to the right of t
he oxyhemoglo in
dissociation curve and, therefore, increased oxygen release (decreased a nity of H
g for oxygen).
Alkalosis does the opposite. Multiple lood transfusions shift the curve to the
left ecause the
transfused lood is low in 2,3-DPG. Hg S and Hg C do not change the a nity of ox
ygen for
hemoglo in; however, many hemoglo inopathies do. For example, Hg Kansas causes
a right shift and
Hg Chesapeake causes a left shift of the oxyhemoglo in dissociation curve. 28.
B Lymphocytes
constitute the majority of the nucleated cells seen. The one marrow in aplastic
anemia is spotty
with patches of normal cellularity. A solute granulocytopenia is usually present
; however,
lymphocyte production is less a ected. 29. C The normal adult percentage of lympho
cytes in a

white cell di erential is etween 20% and 44%, although normal ranges vary y inst
patient population, and testing methodology. This range is higher in the pediatr
ic population.
24. Given the following values, which set of red lood cell indices suggests sph
erocytosis? A.
MCV 76 m 3 MCH 19.9 pg MCHC 28.5% B. MCV 90 m 3 MCH 30.5 pg MCHC 32.5% C. MCV 80 m
3 MCH 36.5
pg MCHC 39.0% D. MCV 81 m 3 MCH 29.0 pg MCHC 34.8% Hematology/Evaluate la oratory
data to
recognize health and disease states/RBC indices/3 25. Which of the following sta
tistical terms
re ects the est index of precision when comparing two CBC parameters? A. Mean B.
Median C.
Coe cient of variation D. Standard deviation Hematology/Correlate la oratory data
with other
la oratory data to assess test results/QC/Statistics/2 26. Which of the followin
g is considered a
normal hemoglo in? A. Car oxyhemoglo in B. Methemoglo in C. Sulfhemoglo in D. De
oxyhemoglo in
Hematology/Apply knowledge of fundamental iological characteristics/Hemoglo in/
1 27. Which
condition will shift the oxyhemoglo in dissociation curve to the right? A. Acido
sis B. Alkalosis
C. Multiple lood transfusions D. Increased quantities of hemoglo in S or C Hema
la oratory data with other la oratory data to assess test results/RBCs/ Meta oli
sm/2 28. What is
the major type of leukocyte seen in the peripheral smear of a patient with aplas
tic anemia? A.
Segmented neutrophil B. Lymphocyte C. Monocyte D. Eosinophil Hematology/Correlat
e clinical and
la oratory data/ Leukocytes/Aplastic anemia/1 29. What is the normal WBC di erenti
al lymphocyte
percentage (range) in the adult population? A. 5%10% B. 10%20% C. 20%44% D. 50%70%
Hematology/Correlate asic la oratory values/ Di erentials/1 2828_Ch01_001-040 09
/08/12 4:10 PM
Page 7 30. In which age group would 60% lymphocytes e a normal nding? A. 6 mont
hs2 years B.
46 years C. 1115 years D. 4060 years Hematology/Evaluate la oratory data/Di erentials
/2 31.
Which of the following results on an automated di erential suggests that a periphe
ral smear
should e reviewed manually? A. Segs = 70% B. Band = 6% C. Mono = 15% D. Eos = 2
Hematology/Correlate la oratory data/Instrumentation/2 32. Which is the rst stage
erythrocytic maturation in which the cytoplasm is pink due to the formation of h
emoglo in? A.
Reticulocyte B. Pronormo last C. Basophilic normo last D. Polychromatic normo la
Hematology/Apply knowledge of fundamental iological characteristics/Microscopic
morphology/1 33.
Which of the following can shift the hemoglo in oxygen dissociation curve to the
right? A.
Increases in 2,3 DPG B. Acidosis C. Hypoxia D. All of these options Hematology/E
la oratory data to recognize health and disease states/O 2 dissociation curves/2
34. Which of the
following Hg con gurations is characteristic of Hg H? A. 4 B. 2 - 2 C. 4 D. 2 - 2

Hemtoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Hemolo in/

2 35.
Autolutintion of red cells t room temperture cn cuse which of the follow
in  norml test
results? A. Low RBC count B. Hih MCV C. Low hemtocrit D. All of these options
Hemtoloy/Correlte l ortory dt with other l ortory dt to ssess test r
Answers to Questions 3035 30. A There is  reltive neutropeni in children from
es 4 months
to 4 yers. Becuse of this, the percente of lymphocytes is incresed in this
popultion. This
is commonly referred to s  reversl in the norml di erentil percente (or inv
di erentil). 31. C A reltive monocyte count of 15% is  norml, iven tht the
monocyte count in  norml di erentil is etween 1% nd 8%. An incresed monocyte
count my
sinl  myeloprolifertive process such s chronic myelomonocytic leukemi, n
in mmtory
response, or  norml lymphocytes tht my hve een counted s monocytes y n
utomted cell
counter. 32. D In norml erythrocytic mturtion, H formtion in the lte poly
normo lst ste ives the cytoplsm  prominent pink colortion. The red cell c
ontinues to
produce H throuhout the reticulocyte ste of development. 33. D Increses in
cidosis, hypoxi, nd  rise in ody temperture ll shift the hemolo in-oxye
n dissocition
curve to the riht. In nemi, lthouh the num er of RBCs is reduced, the cells
re more e cient
t oxyen delivery ecuse there is n increse in red cell 2,3-DPG. This cuses
oxyhemolo in dissocition curve to shift to the riht, llowin more oxyen to
e relesed to
the tissues. 34. C The structure of H H is 4 . H H disese is  severe clini
cl expression
of thlssemi in which only one ene out of four is functionin. 35. D Autolutin
tion t
room temperture my cuse  low RBC count nd hih MCV from n electronic count
er. The Hct will
e low ecuse it is clculted from the RBC count. Low RBC count nd low Hct c
use flsely hih
clcultions of MCH nd MCHC, respectively. 8 Chpter 1 | Hemtoloy 2828_Ch01_0
01-040 09/08/12
4:10 PM Pe 8 Answers to Questions 16 1. C Hypersplenic conditions re enerll
y descri ed y
the followin four criteri: (1) cytopenis of one or more peripherl cell lines
, (2)
splenomely, (3) one mrrow hyperplsi, nd (4) resolution of cytopeni y sp
lenectomy. 2. B
The spleen is the supreme lter of the ody, pittin imperfections from the erythr
ocyte without
destroyin the interity of the mem rne. 3. D Spherocytes lose their deform il
ity owin to the
defect in spectrin,  mem rne protein, nd re therefore prone to splenic seque
strtion nd
hemolysis. 4. C Clssic fetures of intrvsculr hemolysis such s hemolo inem
hemolo inuri, or hemosiderinuri do not occur in hereditry spherocytosis. The

hemolysis seen
in hereditry spherocytosis is n extrvsculr rther thn n intrvsculr pro
cess. 5. D
Spherocytic cells hve decresed tolernce to swellin nd, therefore, hemolyze
t  hiher
concentrtion of sodium slt compred with norml red cells. 6. C Sickle cell di
sese is 
chronic hemolytic nemi clssi ed s  normocytic, normochromic nemi. 6. Te ne
mi seen in
sickle cell disese is usully: A. Microcytic, normochromic B. Microcytic, hypoc
hromic C.
Normocytic, normochromic D. Normocytic, hypochromic Hemtoloy/Apply knowlede o
f fundmentl
ioloicl chrcteristics/RBC microscopic morpholoy/ Hemolo inopthy/1 1. Hyp
ersplenism is
chrcterized y: A. Polycythemi B. Pncytosis C. Leukopeni D. Myelodysplsi
Hemtoloy/Correlte clinicl nd l ortory dt/ WBCs/Hypersplenism/2 2. Which
of the followin
orns is responsi le for the pittin process for RBCs? A. Liver B. Spleen C. Kidn
ey D. Lymph
nodes Hemtoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Physi
oloy/1 3.
Spherocytes di er from norml red cells in ll of the followin except: A. Decres
ed surfce to
volume B. No centrl pllor C. Decresed resistnce to hypotonic sline D. Incre
deform ility Hemtoloy/Apply knowlede of fundmentl ioloicl chrcteristi
microscopic morpholoy/2 4. Which of the followin is not ssocited with heredi
spherocytosis? A. Incresed osmotic frility B. An MCHC reter thn 36% C. Int
hemolysis D. Extrvsculr hemolysis Hemtoloy/Correlte clinicl nd l ortor
y dt/
Hereditry spherocytosis/2 5. Which of the followin disorders hs n increse i
n osmotic
frility? A. Iron de ciency nemi B. Hereditry elliptocytosis C. Hereditry sto
mtocytosis D.
Hereditry spherocytosis Hemtoloy/Evlute l ortory dt to reconize helth
nd disese
sttes/Specil tests/Osmotic frility/2 1.2 Normocytic nd Normochromic Anemis
2828_Ch01_001-040 09/08/12 4:10 PM Pe 9 Answers to Questions 713 7. D The m
jor hemolo in
in sickle cell trit is H A, which constitutes 50%70% of the totl. H S compr
ises 20%40%,
nd H A 2 nd H F re present in norml mounts. 8. B The structurl muttio
n for H S is
the su stitution of vline for lutmic cid t the sixth position of the -chin.
lutmic cid is netively chred, this decreses its rte of mirtion towrd
the node t pH
8.6. 9. D Su stitution of  positively chred mino cid for  netively chr
ed mino cid in
H C disese results in  slow electrophoretic mo ility t pH 8.6. 10. C At pH
8.6, severl
hemolo ins mirte toether. These include H A 2 , H C, H E, H 0 Ar ,
nd H C Hrlem
. These re locted nerest the cthode t pH 8.6. 11. B Electrophoresis t lk
line pH usully

shows 50% 70% H A, 20%40% H S, nd norml levels of H A 2 in  ptient with

the sickle
cell trit. 12. D Autosplenectomy occurs in sickle cell nemi s  result of re
peted infrcts
to the spleen cused y the overwhelmin sicklin phenomenon. 13. A PNH is  rr
e cquired stem
cell disorder tht results in  normlities of the red cell mem rne. This cuse
s the red cells
to e hihly sensitive to complement-medited hemolysis. Becuse this is  stem
cell disorder,
 normlities re seen in leukocytes nd pltelets, s well s in red cells. PNH
is chrcterized
y recurrent, episodic intrvsculr hemolysis, hemolo inuri, nd venous throm
osis. 13. Which
of the followin is most true of proxysml nocturnl hemolo inuri (PNH)? A. I
t is  rre
cquired stem cell disorder tht results in hemolysis B. It is inherited s  se
x-linked trit C.
It is inherited s n utosoml dominnt trit D. It is inherited s n utosom
l recessive trit
Hemtoloy/Apply knowlede of fundmentl ioloicl chrcteristics/PNH/1 10 Ch
pter 1 |
Hemtoloy 7. Which is the mjor H found in the RBCs of ptients with sickle c
ell trit? A. H
S B. H F C. H A 2 D. H A Hemtoloy/Apply knowlede of fundmentl ioloi
chrcteristics/Anemi/Hemolo inopthy/1 8. Select the mino cid su stitution
tht is
responsi le for sickle cell nemi. A. Lysine is su stituted for lutmic cid 
t the sixth
position of the -chin B. Vline is su stituted for lutmic cid t the sixth po
sition of the
-chin C. Vline is su stituted for lutmic cid t the sixth position of the -ch
in D.
Glutmine is su stituted for lutmic cid t the sixth position of the -chin He
knowlede of fundmentl ioloicl chrcteristics/Hemolo inopthy/1 9. All of
the followin
re usully found in H C disese except: A. H C crystls B. Tret cells C.
su stituted for lutmic cid t the sixth position of the chin D. Fst mo ility
of H C t
pH 8.6 Hemtoloy/Apply knowlede of fundmentl ioloicl
chrcteristics/Anemi/Hemolo inopthy/1 10. Which of the followin hemolo ins
mirtes to the
sme position s H A 2 t pH 8.6? A. H H B. H F C. H C D. H S Hemtolo
clinicl nd l ortory dt/ Hemolo in electrophoresis/1 11. Which of the foll
electrophoretic results is consistent with  dinosis of sickle cell trit? A.
H A: 40% H S:
35% H F: 5% B. H A: 60% H S: 40% H A 2
C. H A: 0% H A 2
5% H F: 95%
D. H A: 80% H S: 10% H A2: 10% Hemtoloy/Evlute l ortory dt
to reconize helth
nd disese/Specil tests/Electrophoresis/2 12. In which of the followin condit
ions will
utosplenectomy most likely occur? A. Tlssemi mjor B. H C disese C. H S

C disese D.
Sickle cell disese Hemtoloy/Apply knowlede of fundmentl ioloicl
chrcteristics/Anemi/Hemolo inopthy/1 2828_Ch01_001-040 09/08/12 4:10 PM
Pe 10 1.2 |
Normocytic nd Normochromic Anemis 11 14. Hemolytic uremic syndrome (HUS) is
chrcterized y
ll of the followin except: A. Hemorrhe B. Trom ocytopeni C. Hemolo inuri
Reticulocytopeni Hemtoloy/Correlte clinicl nd l ortory dt/ HUS/2 15. A
n utohemolysis
test is positive in ll the followin conditions except: A. Glucose-6-phosphte
(G6PD) de ciency B. Hereditry spherocytosis (HS) C. Pyruvte kinse (PK) de ciency
D. Proxysml
nocturnl hemolo inuri (PNH) Hemtoloy/Correlte clinicl nd l ortory test
s/ Specil
tests/2 16. Which nti ody is ssocited with proxysml cold hemolo inuri (PC
H)? A. Anti-I B.
Anti-i C. Anti-M D. Anti-P Hemtoloy/Apply knowlede of fundmentl ioloicl
chrcteristics/Anemi/PCH/1 17. All of the followin re ssocited with intrv
sculr hemolysis
except: A. Methemolo inemi B. Hemolo inuri C. Hemolo inemi D. Decresed h
ptolo in
Hemtoloy/Correlte clinicl nd l ortory dt/ Anemi/Hemolytic/2 18. Autoim
mune hemolytic
nemi is est chrcterized y which of the followin? A. Incresed levels of p
lsm C3 B.
Spherocytic red cells C. Decresed osmotic frility D. Decresed unconjuted
iliru in
Hemtoloy/Correlte clinicl nd l ortory dt/ Anemi/Hemolytic/2 19. Bite ce
lls re
usully seen in ptients with: A. Rh null trit B. Chronic rnulomtous disese
de ciency D. PK de ciency Hemtoloy/Correlte clinicl nd l ortory dt/RBC micr
morpholoy/1 Answers to Questions 1419 14. D The hemolytic nemi of HUS is ssoc
ited with
reticulocytosis. The nemi seen in HUS is multifctoril, with chrcteristic s
chistocytes nd
polychromsi commensurte with the nemi. 15. D The utohemolysis test is posi
tive in G6PD nd
PK de ciencies nd in HS, ut is norml in PNH ecuse lysis in PNH requires sucro
se to enhnce
complement indin. The ddition of lucose, sucrose, or denosine triphosphte
(ATP) corrects
the utohemolysis of HS. Autohemolysis of PK cn e corrected y ATP. 16. D PCH
is cused y the
nti-P nti ody,  cold utonti ody tht inds to the ptients RBCs t low tempe
rtures nd
xes complement. In the clssic DonthLndsteiner test, hemolysis is demonstrted i
n  smple
plced t 4C tht is then wrmed to 37C. 17. A Methemolo in occurs when iron is o
xidized to
the ferric stte. Normlly, iron is predominntly in the ferrous stte in the he
molo in tht
circultes. Durin intrvsculr hemolysis, the red cells rupture, relesin hem
olo in directly
into the loodstrem. Hptolo in is  protein tht inds to free H . The incre
sed free H in
intrvsculr hemolysis cuses depletion of hptolo in. As hptolo in is deple

ted, un ound
hemolo in dimers pper in the plsm (hemolo inemi) nd re ltered throuh th
e kidneys nd
re sor ed y the renl tu ulr cells. The renl tu ulr uptke cpcity is ppr
oximtely 5  per
dy of ltered hemolo in. Beyond this level, free hemolo in ppers in the urine
(hemolo inuri). Hemolo inuri is ssocited with hemolo inemi. 18. B Sphero
cytes re
chrcteristic of utoimmune hemolytic nemi nd result in n incresed osmotic
frility. In
utoimmune hemolytic nemis (AIHAs), production of utonti odies inst ones o
wn red cells
cuses hemolysis or phocytic destruction of RBCs. A positive direct ntilo ul
in (DAT or
Coom s) test identi es in vivo nti ody-coted nd complement-coted red cells. A p
ositive DAT
distinuishes AIHA from other types of hemolytic nemi tht produce spherocytes
. 19. C In
ptients with G6PD de ciency, the red cells re un le to reduce nicotinmide den
dinucleotide phosphte (NADP) to NADPH; consequently, H is dentured nd Heinz
odies re
formed. Bite cells pper in the peripherl circultion s  result of splenic pit
tin of Heinz
odies. 2828_Ch01_001-040 09/08/12 4:10 PM Pe 11 12 Chpter 1 | Hemtoloy
Answers to
Questions 2025 20. C RBC indices clssify the nemi morpholoiclly. Anemis cn
e clssi ed
morpholoiclly y the use of l ortory dt; physioloiclly, sed upon the m
echnism; nd
cliniclly, sed upon n ssessment of symptoms. 21. C Aplstic nemi hs mny
cuses, such s
chemicl, dru, or rdition poisonin; conenitl plsi; nd Fnconis syndrome
. All result in
depletion of hemtopoietic precursors of ll cell lines, ledin to peripherl
pncytopeni. 22. A There re four clssi ctions of CDAs, ech chrcterized y i
ne ective
erythropoiesis, incresed unconjuted iliru in, nd izrre multinucleted ery
precursors. 23. D Microniopthic hemolytic nemi is  condition resultin fro
m sher stress to
the erythrocytes. Fi rin strnds re lid down within the microcircultion, nd
red cells ecome
frmented s they contct
rin throuh the circultion process, formin schistoc
ytes. 24. D
Chlormphenicol is the dru most often implicted in cquired plstic nemi. A
out hlf of the
cses occur within 30 dys fter therpy nd  out hlf of the cses re reversi
le. Penicillin,
tetrcycline, nd sulfonmides hve een implicted in  smll num er of cses.
25. A Sickle cell
disorders re intrcorpusculr red cell defects tht re hereditry nd result i
n defective H s
ein produced. The ene for sickle cell cn e inherited either homozyously or
20. Te morpholoicl clssi ction of nemis is sed on which of the followin?
A. M:E
(myeloid:erythroid) rtio B. Prussin lue stin C. RBC indices D. Reticulocyte

Hemtoloy/Correlte clinicl nd l ortory diseses/ RBC microscopic morpholo

y/1 21. Which of
the followin is  common ndin in plstic nemi? A. A monoclonl disorder B. T
in ltrtion C. Peripherl lood pncytopeni D. Defective DNA synthesis Hemtoloy
knowlede of fundmentl ioloicl chrcteristics/Aplstic nemi/1 22. Conen
dyserythropoietic nemis (CDAs) re chrcterized y: A. Bizrre multinucleted
erythro lsts B.
Cytoenetic disorders C. Melo lstic erythropoiesis D. An elevted M:E rtio H
knowlede of fundmentl ioloicl chrcteristics/Anemi/Chrcteristics/2 23.
hemolytic nemi is chrcterized y: A. Tret cells nd C ot rins B. Toxic 
rnultion nd
Dhle odies C. Pppenheimer odies nd sophilic stipplin D. Schistocytes nd n
ucleted RBCs
Hemtoloy/Correlte clinicl nd l ortory dt/ RBC microscopic morpholoy/An
emi/2 24. Which
nti iotic(s) is (re) most often implicted in the development of plstic nem
i? A.
Sulfonmides B. Penicillin C. Tetrcycline D. Chlormphenicol Hemtoloy/Correl
te clinicl nd
l ortory dt/ Aplstic nemi/1 25. Sickle cell disorders re: A. Hereditry,
RBC defects B. Hereditry, extrcorpusculr RBC defects C. Acquired, intrcorpus
culr RBC defects
D. Acquired, extrcorpusculr RBC defects Hemtoloy/Apply knowlede of fundmen
tl ioloicl
concepts/2 2828_Ch01_001-040 09/08/12 4:10 PM Pe 12 1.2 | Normocytic nd No
Anemis 13 Answers to Questions 2630 26. C Spherocytes re produced in utoimmu
ne hemolytic
nemi. Spherocytes my e produced y one of three mechnisms. First, they re
morpholoicl phse of norml red cell senescence. Second, they re produced whe
n the cell
surfce-to-volume rtio is decresed, s seen in hereditry spherocytosis. And t
hird, they my e
produced s  result of nti ody cotin of the red cells. As the nti ody-cote
d red cells
trvel throuh the spleen, the nti odies nd portions of the red cell mem rne
re removed y
mcrophes. The mem rne repirs itself; hence, the red cells morpholoy chnes
iconcve disk to  spherocyte. 27. C This ptients  norml peripherl smer ind
ictes mrked
red cell reenertion, cusin mny reticulocytes to e relesed from the mrrow
. Becuse
reticulocytes re lrer thn mture RBCs, the MCV will e slihtly elevted. 28
. B As  result
of splenectomy, HowellJolly odies my e seen in ret num ers. One of the min
functions of
the spleen is the pittin function, which llows inclusions to e removed from t
he red cell
without destroyin the cell mem rne. 29. D Reticulocytes re polychromtophilic
mcrocytes, nd
the presence of reticulocytes indictes red cell reenertion. The one mrrows 

response to nemi is to deliver red cells premturely to the peripherl circul

tion. In this
wy, reticulocytes nd possi ly nucleted red cells my e seen in the peripher
l smer. 30. C HP
is  mem rne defect chrcterized y  spectrin  normlity nd therml inst i
lity. The MCV is
decresed nd the red cells pper to e uddin nd frmented. 26. Which of th
e followin
conditions my produce spherocytes in  peripherl smer? A. PelerHut nomly B.
nemi C. Autoimmune hemolytic nemi D. Sidero lstic nemi Hemtoloy/Evlut
e l ortory dt
to reconize helth nd disese sttes/Morpholoy/2 27. A ptients peripherl sme
r revels
numerous NRBCs, mrked vrition of red cell morpholoy, nd pronounced polychro
msi. In
ddition to  decresed H nd decresed Hct vlues, wht other CBC prmeters
my e
nticipted? A. Reduced pltelets B. Incresed MCHC C. Incresed MCV D. Decrese
d red-cell
distri ution width (RDW) Hemtoloy/Correlte l dt with clinicl picture/ Co
mplete lood
counts/3 28. Wht red cell inclusion my e seen in the peripherl lood smer o
f  ptient
postsplenectomy? A. Toxic rnultion B. HowellJolly odies C. Mlril prsites
D. Siderotic
rnules Hemtoloy/Correlte clinicl l ortory dt/ Inclusions/1 29. Reticul
ocytosis usully
indictes: A. Response to in mmtion B. Neoplstic process C. Aplstic nemi D.
Red cell
reenertion Hemtoloy/Correlte l ortory dt for clinicl conditions/Morpho
loy/2 30.
Hereditry pyropoikilocytosis (HP) is  red cell mem rne defect chrcterized
y: A. Incresed
pencil-shped cells B. Incresed ovl mcrocytes C. Misshpen uddin frmented
cells D. Bite
cells Hemtoloy/Evlute l ortory dt to reconize helth nd disese sttes
/Red cell
mem rne/2 2828_Ch01_001-040 09/08/12 4:10 PM Pe 13 1. Te osmotic frility
test result in 
ptient with thlssemi mjor would most likely e: A. Incresed B. Decresed C
. Norml D.
Decresed fter incu tion t 37C Hemtoloy/Correlte clinicl nd l ortory d
t/ Microscopic
morpholoy/Osmotic frility/1 2. All of the followin re chrcteristic ndins
in  ptient
with iron de ciency nemi except: A. Microcytic, hypochromic red cell morpholoy
B. Decresed
serum iron nd ferritin levels C. Decresed totl iron- indin cpcity (TIBC) D
. Incresed RBC
protoporphyrin Hemtoloy/Correlte clinicl nd l ortory dt/ Anemi/Iron de c
iency/2 3. Iron
de ciency nemi my e distinuished from nemi of chronic infection y: A. Seru
m iron level B.
Red cell morpholoy C. Red cell indices D. Totl iron- indin cpcity Hemtolo
l ortory dt to reconize helth nd disese sttes/Anemi/3 4. Which nemi
hs red cell
morpholoy similr to tht seen in iron de ciency nemi? A. Sickle cell nemi B.

syndrome C. Pernicious nemi D. Hereditry spherocytosis Hemtoloy/Correlte l

 ortory dt
with other l ortory dt to ssess test results/Anemi/RBC microscopic morphol
oy/2 5. Iron
de ciency nemi is chrcterized y: A. Decresed plsm iron, decresed % stur
tion, incresed
totl iron- indin cpcity (TIBC) B. Decresed plsm iron, decresed plsm fe
rritin, norml
RBC porphyrin C. Decresed plsm iron, decresed % sturtion, decresed TIBC D
. Decresed
plsm iron, incresed % sturtion, decresed TIBC Hemtoloy/Evlute l orto
ry dt to
reconize helth nd disese sttes/Anemi/Iron de ciency/2 1.3 Hypochromic nd Mi
Anemis 14 Answers to Questions 16 1. B The osmotic frility is decresed ecus
e numerous
tret cells re present nd hve incresed surfce volume in thlssemi mjor
ptients. 2. C In
iron de ciency nemi (IDA), there is n increse in TIBC nd in RBC protoporphyri
n. The serum
iron nd ferritin levels re decresed. IDA is chrcterized y  microcytic hyp
ochromic nemi.
3. D In iron de ciency nemi, the serum iron nd ferritin levels re decresed n
d the totl
iron- indin cpcity nd RBC protoporphyrin re incresed. In chronic disese,
serum iron nd
TIBC re oth decresed ecuse the iron is trpped in reticuloendothelil (RE)
cells, nd is
unvil le to the red cells for hemolo in production. 4. B Iron de ciency nemi
thlssemi re oth clssi ed s microcytic, hypochromic nemis. Iron de ciency n
emi is
cused y defective heme synthesis; wheres thlssemi is cused y decresed 
lo in chin
synthesis. 5. A Iron de ciency nemi is chrcterized y decresed plsm iron, i
ncresed TIBC,
decresed % sturtion, nd microcytic, hypochromic nemi. Iron de ciency occurs
in three
phses: iron depletion, iron-de cient erythropoiesis, nd iron de ciency nemi. 6.
D Ferritin
enters the serum from ll ferritin-producin tissues, nd therefore is considere
d to e  ood
indictor of ody store iron. Becuse iron stores must e depleted efore nem
i develops, low
serum ferritin levels precede the fll in serum iron ssocited with iron de cienc
y nemi. 6.
Store iron is usully est determined y: A. Serum trnsferrin levels B. H v
lues C.
Myolo in vlues D. Serum ferritin levels Hemtoloy/Apply knowlede of sic l
procedures/Iron/1 2828_Ch01_001-040 09/08/12 4:10 PM Pe 14 1.3 | Hypochromi
c nd Microcytic
Anemis 15 7. All of the followin re ssocited with sidero lstic nemi ex
cept: A.
Incresed serum iron B. Rined sidero lsts C. Dimorphic lood picture D. Incre
sed RBC
protoporphyrin Hemtoloy/Evlute l ortory dt to reconize helth nd dise
sttes/Anemi/Sidero lstic/3 8. Wht is the sic hemtoloicl defect seen in
ptients with

thlssemi mjor? A. DNA synthetic defect B. H structure C. -Chin synthesis D

. H
phosphoryltion Hemtoloy/Apply knowlede of fundmentl ioloicl
chrcteristics/Hemolo inopthy/1 9. Which of the followin is the primry H
in ptients with
thlssemi mjor? A. H D B. H A C. H C D. H F Hemtoloy/Correlte clin
icl nd
l ortory diseses/ Hemolo in/Hemolo inopthy/2 10. A ptient hs n Hct of 3
0%,  hemolo in
of 8 /dL, nd n RBC count of 4.0 10 12
L. Wht
is the morpholoicl clssi ction of this nemi? A. Normocytic normochro
mic B. Mcrocytic
hypochromic C. Microcytic hypochromic D. Normocytic hyperchromic Hemtoloy/Evl
ute l ortory
dt to reconize helth nd disese sttes/Hemolo inopthy/ Chrcteristics/3
11. In which of
the followin conditions is H A 2 elevted? A. H H B. H SC disese C. -Tl
ssemi minor D.
H S trit Hemtoloy/Correlte l ortory results with disese sttes/2 12. Wh
ich of the
followin prmeters my e similr for the nemi of in mmtion nd iron de ciency
nemi? A.
Normocytic indices B. Decresed serum iron concentrtion C. Rined sidero lsts
D. Pppenheimer
odies Hemtoloy/Correlte l ortory dt to reconize helth nd disese stt
es/2 Answers to
Questions 712 7. D Sidero lstic nemi hs  decresed red cell protoporphyrin.
The defect in
sidero lstic nemi involves ine ective erythropoiesis. The filure to produce RB
protoporphyrin occurs ecuse the nonheme iron is trpped in the mitochondri n
d is unvil le
to e recycled. 8. C In thlssemi mjor, there is little or no production of t
he -chin,
resultin in severely depressed or no synthesis of H A. Severe nemi is seen,
lon with
skeletl  normlities nd mrked splenomely. The ptient is usully supported
with trnsfusion
therpy. 9. D Ptients with thlssemi mjor re un le to synthesize the -chin
; hence, little
or no H A is produced. However, -chins continue to e synthesized nd led to
vri le
elevtions of H F in these ptients. 10. C The indices will provide  morpholo
clssifiction of this nemi. The MCV is 75 fL (reference rne 80100 fL), the M
CH is 20.0 p
(reference rne 2731 p), nd the MCHC is 26.6% (reference rne 32%36%). Therefo
re, the
nemi is microcytic hypochromic. 11. C H A 2 is prt of the norml complement
of dult H .
This H is elevted in -thlssemi minor ecuse the individul with this condi
tion hs only
one norml -ene; consequently, there is  sliht elevtion of H A 2 nd H F.
12. B Thirty
to fty percent of the individuls with the nemi of chronic in mmtion demonstrt
microcytic hypochromic lood picture with decresed serum iron. Serum iron is de
cresed ecuse
it is un le to escpe from the RE cells to e delivered to the nucleted red ce

lls in the one

mrrow. 2828_Ch01_001-040 09/08/12 4:10 PM Pe 15 Answers to Questions 15 1.
D Melo lstic
mcrocytic nemi is normochromic ecuse there is no defect in the H synthesi
s. These nemis
comprise  roup of synchronized nemis chrcterized y defective nucler mt
urtion due to
defective deoxyri onucleic cid (DNA) synthesis. This  normlity ccounts for t
he melo lstic
fetures in the one mrrow nd the mcrocytosis in the peripherl lood. 2. D P
ernicious nemi
is cused y  lck of intrinsic fctor, which prevents vitmin B 12  sorption.
3. B
Melo lstic nemis re ssocited with n ine ective erythropoiesis nd therefo
re  decrese
in the reticulocyte count. 4. B Administrtion of folic cid to  ptient with v
itmin B 12
de ciency will improve the hemtoloicl  normlities; however, the neuroloicl
pro lems will
continue. This helps to con rm the correct dinosis of vitmin B 12 de ciency. 5. D
Ine ective
erythropoiesis is cused y destruction of erythroid precursor cells prior to th
eir relese from
the one mrrow. Pernicious nemi results from defective DNA synthesis; it is s
uested tht the
synchronous development of red cells renders them more li le to intrmedullry
destruction. 16
1.4 Mcrocytic nd Normochromic Anemis 1. Which morpholoicl clssi ction is ch
rcteristic of
melo lstic nemi? A. Normocytic, normochromic B. Microcytic, normochromic C.
hypochromic D. Mcrocytic, normochromic Hemtoloy/Correlte clinicl nd l or
dt/Microscopic morpholoy/RBCs/2 2. Which nemi is chrcterized y  lck of
intrinsic fctor
tht prevents B 12  sorption? A. Tropicl sprue B. Trnsco lmin de ciency C. Bl
ind loop
syndrome D. Pernicious nemi Hemtoloy/Evlute l ortory dt to reconize h
elth nd disese
sttes/2 3. All of the followin re chrcteristics of melo lstic nemi exc
ept: A.
Pncytopeni B. Elevted reticulocyte count C. Hypersemented neutrophils D. Mc
erythrocyte indices Hemtoloy/Correlte clinicl nd l ortory dt/ Anemi/Me
lo lstic/2 4.
A ptient with  vitmin B 12 nemi is iven  hih dose of folte. Which of
the followin is
expected s  result of this tretment? A. An improvement in neuroloicl pro le
ms B. An
improvement in hemtoloicl  normlities C. No expected improvement D. Toxicit
y of the liver
nd kidneys Hemtoloy/Select course of ction/Anemi/Terpy/3 5. Which of the f
disorders is ssocited with ine ective erythropoiesis? A. G6PD de ciency B. Liver d
isese C. H
C disese D. Melo lstic nemi Hemtoloy/Evlute l ortory dt to reconi
ze helth nd
disese sttes/RBC physioloy/2 2828_Ch01_001-040 09/08/12 4:10 PM Pe 16 6.
A 50-yer-old
ptient is su erin from pernicious nemi. Which of the followin l ortory dt

re most
likely for this ptient? A. RBC = 2.5 10 12
L; WBC =12,500/L (12.5
10 9
L); PLT = 250,000/L (250 10
B. RBC = 4.5 10 12
L; WBC = 6,500/L (6.5
10 9
L); PLT = 150,000/L (150 10
C. RBC = 3.0 10 12
L; WBC = 5,000/L (5.0
10 9
L); PLT = 750,000/L (750 10
D. RBC = 2.5 10 12
L; WBC = 2,500/L (2.5
10 9
L); PLT = 50,000/L (50 10
Hemtoloy/Correlte clinicl nd l ortory dt/ Anemis/2 7. Which of
the followin my e
seen in the peripherl lood smer of  ptient with o structive liver disese?
A. Schistocytes
B. Mcrocytes C. HowellJolly odies D. Microcytes Hemtoloy/Apply principles of
l ortory procedures/Microscopic morpholoy/2 8. Te mcrocytes typiclly seen i
n melo lstic
processes re: A. Crescent-shped B. Terdrop-shped C. Ovlocytic D. Pencil-sh
Hemtoloy/Apply principles of sic l ortory procedures/Microscopic morpholo
y/Di erentils/2
9. Which of the followin re most chrcteristic of the red cell indices ssoci
ted with
melo lstic nemis? A. MCV 99 , MCH 28 p, MCHC 31% B. MCV 62 fL, MCH 27 p, M
CHC 30% C. MCV
125 fL, MCH 36 p, MCHC 34% D. MCV 78 fL, MCH 23 p, MCHC 30% Hemtoloy/Correl
te clinicl nd
l ortory dt/ Melo lstic nemi/2 10. A ptient hs 80 nucleted red lood
cells per 100
leukocytes. In ddition to incresed polychromsi on the peripherl smer, wht
other ndin my
e present on the CBC? A. Incresed pltelets B. Incresed MCV C. Incresed Hct
D. Incresed red
lood cell count Hemtoloy/Correlte clinicl nd l ortory dt/ Melo lsti
c nemi/2 1.4 |
Mcrocytic nd Normochromic Anemis 17 Answers to Questions 610 6. D Ptients w
ith pernicious
nemi demonstrte  pncytopeni with low WBC, PLT, nd RBC counts. Becuse thi
s is 
melo lstic process nd  DNA mturtion defect, ll cell lines re  ected. In
the one
mrrow, this results in  normlly lre precursor cells, mturtion synchrony,
hyperplsi of
ll cell lines, nd  low M:E rtio. 7. B Ptients with o structive liver dises

e my hve red

lood cells tht hve n incresed tendency towrd the deposition of lipid on th
e surfce of the
red cell. Consequently, the red cells re lrer or more mcrocytic thn norml
red cells. 8. C
Mcrocytes in true melo lstic conditions re ovl mcrocytes s opposed to th
e round
mcrocytes tht re usully seen in lcoholism nd o structive liver disese. 9.
C The red cell
indices in  ptient with melo lstic nemi re mcrocytic nd normochromic.
The mcrocytosis
is prominent, with n MCV rnin from 100 to 130 fL. 10. B The ptient will hv
e n incresed
MCV. One of the cuses of  mcrocytic nemi tht is not melo lstic is n in
reticulocyte count, here noted s incresed polychromsi. Reticulocytes re pol
mcrocytes; therefore, the MCV is slihtly incresed. 2828_Ch01_001-040 09/08/1
2 4:10 PM Pe
17 18 1.5 Qulittive nd Quntittive White Blood Cell Disorders 1. Which of th
e followin is n
unusul compliction tht my occur in infectious mononucleosis? A. Splenic inf
rctions B.
Dctylitis C. Hemolytic nemi D. Gint pltelets Hemtoloy/Evlute l ortory
dt to
reconize helth nd disese sttes/Infectious mononucleosis/2 2. In  ptient w
ith humn
immunode ciency virus (HIV) infection, one should expect to see: A. Shift to the l
eft in WBCs B.
Tret cells C. Rective lymphocytes D. Peleroid cells Hemtoloy/Evlute l o
rtory dt to
reconize helth nd disese sttes/AIDS/Microscopic morpholoy/1 3. Which inclu
sions my e seen
in leukocytes? A. Dhle odies B. Bsophilic stipplin C. Mlril prsites D. Ho
odies Hemtoloy/Apply knowlede of fundmentl chrcteristics/WBC inclusions/
1 4. Which of the
followin is contined in the primry rnules of the neutrophil? A. Lctoferrin
Myeloperoxidse C. Histmine D. Alkline phosphtse Hemtoloy/Apply knowlede
of fundmentl
ioloicl chrcteristics/WBC kinetics/2 5. Wht is the typicl rne of relti
ve lymphocyte
percente in the peripherl lood smer of  1-yer-old child? A. 1%6% B. 27%33%
C. 35%58% D.
50%70% Hemtoloy/Evlute l ortory dt to reconize helth nd disese sttes
/Di erentil
norml vlues/2 Answers to Questions 15 1. C Occsionlly ptients with infectiou
s mononucleosis
develop  potent cold lutinin with nti-I speci city. This cold utonti ody c
n cuse stron
hemolysis nd  hemolytic nemi. 2. C HIV infection rins  out severl hemto
 normlities seen on peripherl smer exmintion; most ptients demonstrte re
lymphocytes nd hve rnulocytopeni. 3. A Dhle odies re RNA-rich res within
polymorphonucler neutrophils (PMNs) tht re ovl nd liht lue in color. Alth
ouh often
ssocited with infectious sttes, they re seen in  wide rne of conditions 
nd toxic

rections, includin hemolytic nd pernicious nemis, chronic rnulocytic leuk

emi, nd therpy
with ntineoplstic drus. The other inclusions re ssocited with erythrocytes
. 4. B
Myeloperoxidse, lysozyme, nd cid phosphtse re enzymes tht re contined i
n the primry
rnules of neutrophils. The contents of secondry nd tertiry rnules include
collense, NADPH oxidse, nd lkline phosphtse. 5. D The men reltive lym
percente for  1-yer-old child is 61% compred to the men lymphocyte percent
e of 35% for n
dult. 2828_Ch01_001-040 09/08/12 4:10 PM Pe 18 6. Qulittive nd quntit
tive neutrophil
chnes noted in response to infection include ll of the followin except: A. N
eutrophili B.
Peleroid hyposementtion C. Toxic rnultion D. Vcuoliztion Hemtoloy/Appl
y knowlede of
fundmentl ioloicl chrcteristics/WBC microscopic morpholoy/2 7. Neutropen
i is present in
ptients with which  solute neutrophil counts? A. <1.5 10 9
B. <5.0 10 9
C. <10.0 10 9
D. <15.0 10 9
Hemtoloy/Evlute l ortory dt to reconize helth nd disese stt
es/Di erentil norml
vlues/2 8. Te morpholoicl chrcteristic(s) ssocited with the ChdikHishi s
yndrome is
(re): A. Ple lue cytoplsmic inclusions B. Gint lysosoml rnules C. Smll,
rnules nd condensed nuclei D. Nucler hyposementtion Hemtoloy/Reconize m
chnes ssocited with diseses/WBC inclusions/2 9. Te fmilil condition of Pe
lerHut nomly
is importnt to reconize ecuse this disorder must e di erentited from: A. Inf
mononucleosis B. MyHelin nomly C. A shift-to-the-left increse in immture 
rnulocytes D.
G6PD de ciency Hemtoloy/Reconize morpholoicl chnes ssocited with diseses
inclusions/2 10. SITUATION: A di erentil shows rective lymphocytes, nd the phys
icin suspects
 virl infection is the cuse. Wht is the expected l ortory ndin in  ptien
t with 
cytomelovirus (CMV) infection? A. Heterophile nti ody: positive B. EpsteinBrr
(EBV)immunolo ulin (IM): positive C. Direct ntilo ulin test (DAT): positive D
positive Hemtoloy/Evlute l ortory dt to reconize helth nd disese
sttes/Di erentils/2 1.5 | Qulittive nd Quntittive White Blood Cell Disorder
s 19 Answers
to Questions 610 6. B Neutrophil chnes ssocited with infection my include ne
shift to the left, toxic rnultion, Dhle odies, nd vcuoliztion. Peleroid h
is noted in neutrophils from individuls with the conenitl PelerHut nomly nd

s  n
cquired nomly induced y dru inestion or secondry to conditions such s le
ukemi. 7. A
Neutropeni is de ned s n  solute decrese in the num er of circultin neutrop
hils. This
condition is present in ptients hvin neutrophil counts of less thn 1.5 10 9
8. B ChdikHishi syndrome is  disorder of neutrophil phocytic dysfunc
tion cused y
depressed chemotxis nd delyed dernultion. The dernultion distur nce is
ttri uted to
interference from the int lysosoml rnules chrcteristic of this disorder.
9. C PelerHut
nomly is  enin fmilil condition reported in 1 out of 6,000 individuls. C
re must e tken
to di erentite PelerHut cells from the numerous nd neutrophils nd metmyelocyte
s tht my
e o served durin severe infection or  shift-to-the-left of immturity in rn
ulocyte stes.
10. D If oth the heterophile nti ody test nd the EBV-IM tests re netive i
n  ptient with
rective lymphocytosis nd  suspected virl infection, the serum should e nl
yzed for IM
nti odies to CMV. CMV elons to the herpes virus fmily nd is endemic worldwi
de. CMV infection
is the most common cuse of heterophile-netive infectious mononucleosis. 2828_
09/08/12 4:10 PM Pe 19 11. Neutrophil phocytosis nd prticle inestion r
e ssocited with
n increse in oxyen utiliztion clled respirtory urst. Wht re the two mos
t importnt
products of this iochemicl rection? A. Hydroen peroxide nd superoxide nion
B. Lctoferrin
nd NADPH oxidse C. Cytochrome
nd collense D. Alkline phosphtse nd s
cor ic cid
Hemtoloy/Apply knowlede of fundmentl ioloicl chrcteristics/WBC kinetic
s/3 12. Which of
the morpholoicl ndins re chrcteristic of rective lymphocytes? A. Hih nucl
rtio B. Prominent nucleoli C. Bsophilic cytoplsm D. All of these options Hem
morpholoicl chnes ssocited with diseses/WBC morpholoy/2 20 Chpter 1 | H
emtoloy Answers
to Questions 1112 11. A The iochemicl products of the respirtory urst tht r
e involved with
neutrophil prticle inestion durin phocytosis re hydroen peroxide nd supe
roxide nion. The
ctivted neutrophil dischres the enzyme NADPH oxidse into the pholysosome,
where it
converts O 2 to superoxide nion (O 2 ), which is then reduced to hydroen perox
ide (H 2 O 2 ).
12. D Both rective lymphocytes nd lsts my hve sophilic cytoplsm,  hih
N:C rtio, nd
the presence of prominent nucleoli. Blsts, however, hve n extremely ne nucler
stinin pttern s viewed on  WrihtsGiemssstined smer. 2828_Ch01_001-040 09/0
4:10 PM Pe 20 1. Auer rods my e seen in ll of the followin except: A. Acu
te myelomonocytic
leukemi (M4) B. Acute lympho lstic leukemi C. Acute myeloid leukemi without

mturtion (M1)
D. Acute promyelocytic leukemi (M3) Hemtoloy/Apply knowlede of fundmentl
chrcteristics/Acute leukemi/1 2. Which type of nemi is usully present in 
ptient with
cute leukemi? A. Microcytic, hyperchromic B. Microcytic, hypochromic C. Normoc
normochromic D. Mcrocytic, normochromic Hemtoloy/Correlte clinicl nd l or
tory dt/RBC
microscopic morpholoy/Anemi/2 3. In leukemi, which term descri es  peripher
l lood ndin of
leukocytosis with  shift to the left, ccompnied y nucleted red cells? A. My
elophthisis B.
Dysplsi C. Leukoerythro lstosis D. Melo lstosis Hemtoloy/Apply knowlede
of fundmentl
ioloicl chrcteristics/WBC di erentils/2 4. Te sic pthophysioloicl mech
responsi le for producin sins nd symptoms in leukemi include ll of the foll
owin except: A.
Replcement of norml mrrow precursors y leukemic cells cusin nemi B. Decr
ese in
functionl leukocytes cusin infection C. Hemorrhe secondry to throm ocytope
ni D. Decresed
erythropoietin production Hemtoloy/Correlte clinicl nd l ortory dt/ Leu
kemi/2 1.6 Acute
Leukemis 21 Answers to Questions 14 1. B Auer rods re not seen chrcteristicl
ly in
lympho lsts. They my e seen in myelo lsts, promyelocytes, nd mono lsts. 2.
C Acute leukemi
is usully ssocited with  normocytic normochromic nemi. Anemi in cute leu
kemi is usully
present from the onset nd my e severe; however, there is no inherent nutritio
nl de ciency
ledin to either  microcytic, hypochromic, or melo lstic process. 3. C The
presence of
immture leukocytes nd nucleted red cells is clled leukoerythro lstosis nd
denotes  mlinnt or myeloprolifertive process. Myelophthisis refers to repl
cement of one
mrrow y  disese process such s  neoplsm. The development of  norml tiss
ue is clled
dysplsi. 4. D A norml physioloicl response to nemi would e n increse i
n the kidneys
production of erythropoietin. The ccumultion of leukemic cells in the one mr
row leds to
mrrow filure, which is mnifested y nemi, throm ocytopeni, nd rnulocyto
2828_Ch01_001-040 09/08/12 4:10 PM Pe 21 Answers to Questions 59 5. D Acute
leukemi hs n incidence of etween 1%8% of ll cute leukemis. It hs  distin
ctive clinicl
mnifesttion of monocytic involvement resultin in skin nd um hyperplsi. Th
e WBC count is
mrkedly elevted, nd pronosis is poor. 6. A Acute lympho lstic leukemi (ALL
) usully  ects
children from es 115 nd is the most common type of cute leukemi in this e
roup. In
ddition, ALL constitutes the sinle most prevlent mlinncy in peditric pti
ents. 7. B The
zurophilic rnules in the leukemic promyelocytes in ptients with cute promye

locytic leukemi
contin throm oplstic su stnces. These ctivte solu le coultion fctors, w
hich when
relesed into the lood, cuse DIC. 8. B A disproportionte increse in the myel
oid component of
the one mrrow is usully the result of  leukemic stte. The norml M:E rtio
is pproximtely
4:1 in dults with norml cellulrity. 9. A Auer rods re  liner projection of
zurophilic rnules, nd re present in the cytoplsm of myelo lsts nd mono l
sts in ptients
with cute leukemi. 22 Chpter 1 | Hemtoloy 5. Which type of cute myeloid le
ukemi is clled
the true monocytic leukemi nd follows n cute or su cute course chrcterize
d y mono lsts,
promonocytes, nd monocytes? A. Acute myeloid leukemi, minimlly di erentited B.
Acute myeloid
leukemi without mturtion C. Acute myelomonocytic leukemi D. Acute monocytic
Hemtoloy/Evlute l ortory dt to mke identi ctions/Leukemi/2 6. In which
e roup does
cute lympho lstic leukemi occur with the hihest frequency? A. 115 yers B. 203
5 yers C.
4560 yers D. 6075 yers Hemtoloy/Correlte clinicl nd l ortory dt/ Leukem
i/1 7.
Disseminted intrvsculr coultion (DIC) is most often ssocited with which
of the followin
types of cute leukemi? A. Acute myeloid leukemi without mturtion B. Acute p
leukemi C. Acute myelomonocytic leukemi D. Acute monocytic leukemi Hemtoloy
l ortory dt to reconize helth nd disese sttes/Leukemi/DIC/2 8. An M:E
rtio of 10:1 is
most often seen in: A. Tlssemi B. Leukemi C. Polycythemi ver D. Myelo rosis
Hemtoloy/Evlute l ortory dt to reconize helth nd disese sttes/Bone
mrrow/M:E/2 9.
Which of the followin is  chrcteristic of Auer rods? A. Tey re composed of
rnules B. Tey stin periodic cidSchi (PAS) positive C. Tey re predominntly se
en in chronic
myeloenous leukemi (CML) D. Tey re nonspeci c esterse positive Hemtoloy/Appl
y knowlede of
fundmentl ioloicl chrcteristics/Leukocytes/Auer rods/1 2828_Ch01_001-040
09/08/12 4:10
PM Pe 22 1.6 | Acute Leukemis 23 Answers to Questions 1014 10. C In cute e
leukemi, more thn 50% of nucleted one mrrow cells re erythroid nd more th
n 30%
nonerythroid cells re lsts. Pernicious nemi results in pncytopeni nd low
vitmin B 12
concentrtions. 11. D Common sins of cute lymphocytic leukemi re heptosplen
omely (65%),
lymphdenopthy (50%), nd fever (60%). Anemi nd throm ocytopeni re usully
present nd the
WBC count is vri le. The numerous lympho lsts re enerlly PAS positive. 12.
A AML lsts
stin positive for Sudn Blck B nd peroxidse. Usully, fewer thn 10% lsts
re found in the
peripherl smer of ptients with CML, unless there hs een  trnsition to l
st crisis. The

ornelles in the cells of AUL re not mture enouh to stin positive for SBB o
r peroxidse.
Blsts in ALL re chrcteristiclly netive with these stins. 13. C Phospholi
pids, neutrl
fts, nd sterols re stined y Sudn Blck B. The PAS rection stins intrcel
lulr lycoen.
Myeloperoxidse is n enzyme present in the primry rnules of myeloid cells n
d to  lesser
deree in monocytic cells. Terminl deoxynucleotidyl trnsferse is  DNA polyme
rse found in
thymus- derived nd some one mrrow-derived lymphocytes. 14. B NASDA stins mon
ocytes (nd
mono lsts) nd rnulocytes (nd myelo lsts). The ddition of uoride renders th
e monocytic
cells (nd lsts) netive, thus llowin for di erentition from the rnulocyti
c cells, which
remin positive. WBC Differentil Bone Mrrow 6% PMNs 40% myelo lsts 40% lymph
ocytes 60%
promelo lsts 4% monocytes 40 melo lstoid NRBCs/100 WBCs 50% lsts 10. SIT
followin l ortory vlues re seen: WBCs = 6.0 10 9
L H = 6.0 /dL
RBCs = 1.90 10 12
L Hct = 18.5%
Pltelets = 130 10 9
Serum vitmin B 12 nd folic cid: norml Tese results re most chrcte
ristic of: A.
Pernicious nemi B. Acute myeloid leukemi without mturtion C. Acute erythroi
d leukemi D.
Acute myelomonocytic leukemi Hemtoloy/Evlute l ortory dt to mke
identi ctions/Leukemi/3 11. A 24-yer-old mn with Down syndrome presents with 
fever, pllor,
lymphdenopthy, nd heptosplenomely. His CBC results re s follows: WBCs =
10.8 10 9
L RBCs = 1.56 10
8% PMNs H = 3.3 /dL 25% lymphocytes Hct = 11% 67% PAS-positive lsts
Pltelets = 2.5 10
Tese ndins re suestive of: A. Hodkins lymphom B. Myeloprolifertive
disorder C.
Leukemoid rection D. Acute lymphocytic leukemi Hemtoloy/Evlute l ortory
dt to reconize
helth nd disese sttes/Leukemi/3 12. SITUATION: A peripherl smer shows 75%
lsts. Tese
stin positive for oth Sudn Blck B (SBB) nd peroxidse. Given these vlues,
which of the
followin disorders is most likely? A. Acute myelocytic leukemi (AML) B. CML C.
undi erentited leukemi (AUL) D. Acute lymphocytic leukemi (ALL) Hemtoloy/Evl
ute l ortory
dt to reconize helth nd disese sttes/Leukemi/Cytochemicl stins/3 13. I
n myeloid cells,
the stin tht selectively identi es phospholipid in the mem rnes of oth primry
nd secondry
rnules is: A. PAS B. Myeloperoxidse C. Sudn Blck B stin D. Terminl deoxyn

trnsferse (TdT) Hemtoloy/Apply principles of specil procedures/ Leukemi/Cy

stins/3 14. Sodium uoride my e dded to the nphthyl ASD cette (NASDA) ester
se rection.
Te uoride is dded to inhi it  positive rection with: A. Mekryocytes B. Mono
cytes C.
Erythrocytes D. Grnulocytes Hemtoloy/Apply principles of specil procedures/
Leukocytes/Cytochemicl stins/2 2828_Ch01_001-040 09/08/12 4:10 PM Pe 23 1
5. Leukemic
lympho lsts rectin with nti-CALLA re chrcteristiclly seen in: A. B-cell
ALL B. T-cell ALL
C. Null-cell ALL D. Common ALL Hemtoloy/Evlute l ortory dt to reconize
helth nd
disese sttes/Leukemi/Immunochemicl rections/2 16. Which of the followin re
ctions re often
positive in ALL ut re netive in AML? A. Terminl deoxynucleotidyl trnsfers
e nd PAS B.
Chlorocette esterse nd nonspeci c esterse C. Sudn Blck B nd peroxidse D.
New methylene
lue nd cid phosphtse Hemtoloy/Apply principles of specil procedures/ Leu
tests/2 17. A ptients peripherl lood smer nd one mrrow oth show 70% lst
s. Tese cells
re netive for Sudn Blck B stin. Given these dt, which of the followin i
s the most likely
dinosis? A. Acute myeloid leukemi B. Chronic lymphocytic leukemi C. Acute pr
leukemi D. Acute lymphocytic leukemi Hemtoloy/Apply principles of specil pr
Leukemi/Cytochemicl stins/2 18. Which of the followin leukemis re included
in the 2008
World Helth Orniztion clssi ction of myeloprolifertive neoplsms? A. Chroni
c myeloenous
leukemi (CML) B. Chronic neutrophilic leukemi (CNL) C. Chronic eosinophilic le
ukemi (CEL) D.
All of these options re clssi ed s myeloprolifertive neoplsms (MPN)
Hemtoloy/Leukemis/Apply knowlede of specil procedures/Clssi ctions/2 19. In
ddition to
morpholoy, cytochemistry, nd immunophenotypin, the WHO clssi ction of myelond
lymphoprolifertive disorders is sed upon which chrcteristic? A. Proteomics
B. Cytoenetic
 normlities C. Cr ohydrte-ssocited tumor ntien production D. Cell sinl
in nd dhesion
mrkers Hemtoloy/Leukemis/Apply knowlede of specil procedures/Clssi ctions/
1 24 Chpter 1
| Hemtoloy Answers to Questions 1520 15. D The mjority of non-T, non-B ALL l
st cells
disply the common ALL ntien (CALLA) mrker. Lympho lsts of common ALL re Td
T positive nd
CALLA positive ut do not hve surfce mem rne IM or chains and are pre-B lymp
Common ALL has a lower relapse rate and better prognosis than other immunologic
subtypes of
B-cell ALL. 16. A PAS is positive in about 50% of ALL with L1 and L2 morphology
but is negative
in ALL with L3 morphology (B-cell ALL). Terminal deoxynucleotidyl transferase is
positive in all
types of ALL except L3. Both terminal deoxynucleotidyl transferase and PAS are n
egative in AML.

17. D Sudan Black B stains phospholipids and other neutral fats. It is the most
sensitive stain
for granulocytic precursors. Lymphoid cells rarely stain positive for it. Becaus
e 70%
lymphoblasts would never be seen in CLL, the correct response is ALL. 18. D The
2008 WHO
classification system includes the following disorders under the myeloproliferat
ive neoplasms
(MPN): chronic myelogenous leukemia (CML), chronic neutrophilic leukemia (CNL),
eosinophilic leukemia (CEL), essential thrombocythemia (ET), polycythemia vera (
PV), primary
(idiopathetic) myelofibrosis, hypereosinophilic syndrome, mast cell disease, and
unclassified. 19. B In addition to morphology, cytochemical stains, and ow cytome
try, the WHO
classi cation relies heavily on chromosomal and molecular abnormalities. 20. B The
classi cation of AML requires that 20% of nucleated bone marrow cells be blasts, wh
ile the FAB
classi cation generally requires 30%. WHO classi es AML into ve subgroups: These are a
myeloid leukemias with recurrent genetic disorders; acute myeloid leukemia with
dysplasia; acute myeloid leukemia and myelodysplastic syndromes, therapy related
; acute myeloid
leukemia not otherwise categorized; and acute leukemia of ambiguous lineage. 20.
classi cation requires what percentage for the blast count in the blood or bone ma
rrow for the
diagnosis of AML? A. At least 30% B. At least 20% C. At least 10% D. Any percent
Hematology/Apply knowledge of special procedures/ Leukemias/Classi cations/2 2828_
09/08/12 4:10 PM Page 24 21. What would be the most likely designation by the
WHO for the FAB
AML M2 by the FrenchAmericanBritish classi cation? A. AML with t(15;17) B. AML with
lineage C. AML with t(8;21) D. AML with inv(16) Hematology/Apply knowledge of sp
ecial procedures/
Leukemias/Classi cations/3 22. What would be the most likely designation by the WH
O for the FAB
AML M3 by the FrenchAmericanBritish classi cation? A. AML with t(15;17) B. AML with
lineage C. AML with t(8;21) D. AML with inv(16) Hematology/Apply knowledge of sp
ecial procedures/
Leukemias/Classi cations/3 23. Which AML cytogenetic abnormality is associated wit
h acute
myelomonocytic leukemia with marrow eosinophilia under the WHO classi cation of AM
L with
recurrent genetic abnormalities? A. AML with t(15;17) B. AML with mixed lineage
C. AML with
t(8;21) D. AML with inv(16) Hematology/Apply knowledge of special procedures/
Leukemias/Classi cations/3 24. What would be the most likely classi cation by the WH
O for the FAB
AML M7 by the FrenchAmericanBritish classi cation? A. Acute myeloid leukemias with r
genetic abnormalities B. Acute myeloid leukemia with multilineage dysplasia C. A
cute myeloid
leukemia not otherwise categorized D. Acute leukemias of ambiguous lineage Hemat

knowledge of special procedures/ Leukemias/Classi cations/3 1.6 | Acute Leukemias
25 Answers to
Questions 2124 21. C AML with t(8;21) is classi ed under the category of AML with R
Genetic Abnormalities by the WHO. This translocation occurs in up to 15% of case
s of AML and may
be the most common translocation. The AML1ETO translocation occurs chie y in younge
r patients
and often in cases of acute myeloblastic leukemia with maturation, FAB M2. The t
involves the fusion of the AML1 gene on chromosome 21 with the ETO gene on chrom
osome 8. 22. A
AML with t(15;17) is classi ed under the category of AML with Recurrent Genetic Ab
normalities by
the WHO. Acute promyelocytic leukemia (PML; known as M3 under the FAB system) is
composed of
abnormal promyelocytes with heavy granulation, sometimes obscuring the nucleus,
and abundant
cytoplasm. Acute promyelocytic leukemia (APL) contains a translocation that resu
lts in the fusion
of a transcription factor called PML on chromosome 15 with the alpha ()-retinoic
cid receptor
ene (RAR) on chromosome 17. 23. D AML with inv(16) hs pericentric inversion of
chromosome 16,
nd is ssocited with cute myelomonocytic leukemi with mrrow eosinophili, M
4eo under the FAB
system. The inv(16) results in the fusion of the CBF ene on 16q22 with the MYH11
ene on 16p13.
24. C Acute mekryo lstic leukemi, which is equivlent to FAB M7, is  relt
ively uncommon
form of leukemi chrcterized y neoplstic prolifertion of mekryo lsts n
d typicl
mekryocytes. Reconition of this entity ws ided y the use of pltelet pero
xidse (PPO)
ultrstructurl studies. PPO, which is distinct from myeloperoxidse, is speci c f
or the
mekryocytic cell line. Acute mekryo lstic leukemi is de ned s n cute le
ukemi in which
reter thn or equl to 50% of the lsts re of mekryocytic linee. 2828_C
09/08/12 4:10 PM Pe 25 Answers to Questions 15 1. C The most common tretment
utilized in PV is phle otomy. Reduction of lood volume (usully 1 unit of whole
lood450 cc),
cn e performed weekly or even twice weekly in youner ptients to control symp
toms. The Hct
tret rne is less thn 45% for men, less thn 42% for women. Iron de ciency ne
mi is 
predict le compliction of therpeutic phle otomy ecuse pproximtely 250 m
of iron is
removed with ech unit of lood. 2. A In essentil throm ocythemi, the pltelet
count is
extremely elevted. These pltelets re  norml in function, ledin to oth l
eedin nd
throm otic dithesis. 3. D The morpholoicl common denomintor in Hodkins lymph
om is the
ReedStern er (RS) cell. It is  lre, inucleted cell with  dense nucleolus s
urrounded y
cler spce. These chrcteristics ive the RS cell n owls eye ppernce. NiemnnP

ick cells
(fom cells) re histiocytes continin phocytized sphinolipids tht stin p
le lue nd
imprt  fomlike texture to the cytoplsm. Flme cells re plsm cells with di
stinctive red
cytoplsm. They re sometimes seen in the one mrrow of ptients with multiple
myelom. 4. C The
mrked mount of rosis, oth medullry nd extrmedullry, ccounts for the irre
versi le red
cell morpholoicl chne to  terdrop shpe. The red cells re tered s they t
tempt to pss
throuh the rotic tissue. 5. D The dinosis of PV requires the demonstrtion of
n increse in
red cell mss. Pncytosis my lso e seen in  out two thirds of PV cses. The
plsm volume is
norml or slihtly reduced, nd the rteril oxyen sturtion is usully norml
. 1. Repeted
phle otomy in ptients with polycythemi ver (PV) my led to the development o
f: A. Folic cid
de ciency B. Sidero lstic nemi C. Iron de ciency nemi D. Hemolytic nemi
Hemtoloy/Evlute l ortory dt to reconize helth nd disese sttes/Anemi
/2 2. In
essentil throm ocythemi, the pltelets re: A. Incresed in num er nd functio
nlly  norml B.
Norml in num er nd functionlly  norml C. Decresed in num er nd functionl
D. Decresed in
num er nd functionlly  norml Hemtoloy/Evlute l ortory dt to reconiz
e helth nd
disese sttes/CBCs/Pltelets/2 3. Which of the followin cells is considered p
thonomonic for
Hodkins disese? A. NiemnnPick cells B. Rective lymphocytes C. Flme cells D. R
eedStern er
cells Hemtoloy/Evlute l ortory dt to reconize helth nd disese sttes
/Lymphom/1 4. In
myelo rosis, the chrcteristic  norml red lood cell morpholoy is tht of: A.
Tret cells
B. Schistocytes C. Terdrop cells D. Ovlocytes Hemtoloy/Correlte clinicl n
d l ortory
dt/RBC microscopic morpholoy/1 5. PV is chrcterized y: A. Incresed plsm
volume B.
Pncytopeni C. Decresed oxyen sturtion D. A solute increse in totl red ce
ll mss
Hemtoloy/Evlute l ortory dt to reconize helth nd disese sttes/RBCs/
Leukemis/2 1.7
Lymphoprolifertive nd Myeloprolifertive Disorders 26 2828_Ch01_001-040 09/08
/12 4:10 PM
Pe 26 Answers to Questions 611 6. A Splenomely is  feture of PV ut not ch
rcteristic of
secondry polycythemi. The red cell mss is incresed in oth primry polycythe
mi (PV) nd
secondry polycythemi. Erythropoietin is incresed nd oxyen sturtion is dec
resed in
secondry polycythemi. 7. B Reltive polycythemi is cused y  reduction of p
lsm rther thn
n increse in red lood cell volume or mss. Red cell mss is incresed in oth
PV nd secondry
polycythemi, ut erythropoietin levels re hih only in secondry polycythemi.
8. B PV is 
myeloprolifertive disorder chrcterized y uncontrolled prolifertion of eryth
roid precursors.

However, production of ll cell lines is usully incresed. Pnhyperplsi is 

term used to
descri e the cellulrity of the one mrrow in PV. 9. C One hundred mture neutr
ophils re
counted nd scored. The LAP score is clculted s: (the num er of 1+ cells 1) +
(2+ cells 2)
+ (3+ cells 3) + (4+ cells 4). Tht is, 48 + 76 + 9 + 4 = 137. The reference rn
e is
pproximtely 20130. 10. A CML cuses  low LAP score, wheres n elevted or nor
ml score
occurs in  leukemoid rection. CML cnnot e distinuished y WBC count ecuse
oth CML nd
leukemoid rection hve  hih count. 11. D Anemi,
rosis, myeloid metplsi, t
hrom ocytosis,
nd leukoerythro lstosis occur in idiopthic myelo rosis. 1.7 | Lymphoprolifert
ive nd
Myeloprolifertive Disorders 27 6. Fetures of secondry polycythemi include
ll of the
followin except: A. Splenomely B. Decresed oxyen sturtion C. Incresed re
d cell mss D.
Incresed erythropoietin Hemtoloy/Evlute l ortory dt to reconize helth
nd disese
sttes/RBC disorders/2 7. Te erythrocytosis seen in reltive polycythemi occurs
ecuse of: A.
Decresed rteril oxyen sturtion B. Decresed plsm volume of circultin
lood C. Incresed
erythropoietin levels D. Incresed erythropoiesis in the one mrrow Hemtoloy/
clinicl nd l ortory dt/RBC disorders/2 8. In PV, wht is chrcteristicll
y seen in the
peripherl lood? A. Pnmyelosis B. Pncytosis C. Pncytopeni D. Pnhyperplsi
knowlede of fundmentl ioloicl chrcteristics/Polycythemi/1 9. Te leukocy
te lkline
phosphtse (LAP) stin on  ptient ives the followin results 10(0) 48(1+) 38
(2+) 3(3+) 1(4+)
Clculte the LAP score. A. 100 B. 117 C. 137 D. 252 Hemtoloy/Clculte/LAP sc
ore/2 10. CML is
distinuished from leukemoid rection y which of the followin? A. CML: low LAP
; leukemoid: hih
LAP B. CML: hih LAP; leukemoid: low LAP C. CML: hih WBC; leukemoid: norml WBC
D. CML: hih
WBC; leukemoid: hiher WBC Hemtoloy/Evlute l ortory nd clinicl dt to s
pecify dditionl
tests/Leukemis/2 11. Which of the followin occurs in idiopthic myelo rosis (IM
F)? A. Myeloid
metplsi B. Leukoerythro lstosis C. Fi rosis of the one mrrow D. All of the
se options
Hemtoloy/Evlute l ortory dt to reconize helth nd disese sttes/Myelo
neoplsms/3 2828_Ch01_001-040 09/08/12 4:10 PM Pe 27 12. Wht in uence does t
he Phildelphi
(Ph 1 ) chromosome hve on the pronosis of ptients with chronic myelocytic leu
kemi? A. It is
not predictive B. Te pronosis is etter if Ph 1 is present C. Te pronosis is w
orse if Ph 1 is
present D. Te disese usully trnsforms into AML when Ph 1 is present Hemtolo
l ortory dt to reconize helth nd disese sttes/Genetic theory nd princi
ples/CML/2 13.

Which of the followin is (re) commonly found in CML? A. Mny terdrop-shped c

ells B. Intense
LAP stinin C. A decrese in rnulocytes D. An increse in sophils Hemtolo
l ortory dt to reconize helth nd disese sttes/CML/3 14. In which of the
conditions does LAP show the lest ctivity? A. Leukemoid rections B. Idiopthi
c myelo rosis C.
PV D. CML Hemtoloy/Correlte clinicl nd l ortory dt/LAP score/1 15. A st
rikin feture of
the peripherl lood of  ptient with CML is : A. Profusion of izrre lst c
ells B. Norml
num er of typicl rnulocytes C. Presence of rnulocytes t di erent stes of d
evelopment D.
Pncytopeni Hemtoloy/Evlute l ortory dt to reconize helth nd disese
sttes/WBCs/CML/2 16. Which of the followin is often ssocited with CML ut no
t with AML? A.
Infections B. WBCs reter thn 20.0 10 9
C. Hemorrhe D. Splenomely Hemtoloy/Correlte clinicl nd l orto
ry dt/
CML/Chrcteristics/2 17. Multiple myelom nd Wldenstrms mcrolo ulinemi hve
ll the
followin in common except: A. Monoclonl mmopthy B. Hyperviscosity of the l
ood C.
BenceJones protein in the urine D. Osteolytic lesions Hemtoloy/Evlute l ort
ory dt to
reconize helth nd disese sttes/Myelom/Chrcteristics/2 28 Chpter 1 | Hem
toloy Answers
to Questions 1217 12. B Ninety percent of ptients with CML hve the Phildelphi
This ppers s  lon rm deletion of chromosome 22, ut is ctully  trnsloc
tion etween the
lon rms of chromosomes 22 nd 9. The ABL oncoene from chromosome 9 forms  hy
rid ene with
the cr reion of chromosome 22. This results in production of  chimeric protei
n with tyrosine
kinse ctivity tht ctivtes the cell cycle. The pronosis for CML is etter i
f the
Phildelphi chromosome is present. Often,  second chromosoml  normlity occu
rs in CML efore
lst crisis. 13. D CML is mrked y n elevted WBC count demonstrtin vrious
stes of
mturtion, hypermet olism, nd  miniml LAP stinin. An increse in sophil
s nd eosinophils
is  common ndin. PseudoPeler-Hut cells nd throm ocytosis my e present. The m
rrow is
hypercellulr with  hih M:E rtio (e.., 10:1). 14. D Chronic myeloenous leuk
emi shows the
lest LAP ctivity, wheres the LAP score is slihtly to mrkedly incresed in e
ch of the other
sttes. 15. C The WBC count in CML is often hiher thn 100 10 9
L, nd the peripherl smer shows  rnulocyte
proression from myelo lst to semented neutrophil. 16. D Splenomely
is seen in more thn
90% of CML ptients, ut it is not  chrcteristic ndin in AML. Infections, hem
orrhe, nd
elevted WBC counts my e seen in oth CML nd AML. 17. D Osteolytic lesions in
destruction of the one s evidenced y rdiorphy re seen in multiple myelom

ut not in
Wldenstrms mcrolo ulinemi. In ddition, Wldenstrms ives rise to  lymphocytosi
s tht
does not occur in multiple myelom nd di ers in the morpholoy of the mlinnt c
2828_Ch01_001-040 09/08/12 4:10 PM Pe 28 18. Wht is the chrcteristic ndin
 seen in the
peripherl smer of  ptient with multiple myelom? A. Microcytic hypochromic c
ells B.
Intrcellulr inclusion odies C. Rouleux D. Hypersemented neutrophils Hemtol
knowlede of fundmentl ioloicl chrcteristics/Myelom/Microscopic morpholo
y/1 19. All of
the followin re ssocited with the dinosis of multiple myelom except: A. M
plsmcytosis B. Lytic one lesions C. Serum nd/or urine M component (monoclon
l protein) D.
Phildelphi chromosome Hemtoloy/Correlte clinicl nd l ortory dt/ Myelo
m/2 20. Multiple
myelom is most di cult to distinuish from: A. Chronic lymphocytic leukemi B. Ac
ute myeloenous
leukemi C. Benin monoclonl mmopthy D. Benin denom Hemtoloy/Apply know
lede of
fundmentl ioloicl chrcteristics/Myelom/2 21. Te ptholoy of multiple my
elom includes
which of the followin? A. Expndin plsm cell mss B. Overproduction of monoc
immunolo ulins C. Production of osteoclst ctivtin fctor (OAF) nd other cy
tokines D. All of
these options Hemtoloy/Apply knowlede of fundmentl ioloicl chrcteristi
mnifesttion of disese/Immunolo ulins/2 22. Wldenstrms mcrolo ulinemi is 
mlinncy of
the: A. Lymphoplsmcytoid cells B. Adrenl cortex C. Myelo lstic cell lines D.
Erythroid cell
precursors Hemtoloy/Apply knowlede of fundmentl ioloicl chrcteristics/
mnifesttion of disese/2 1.7 | Lymphoprolifertive nd Myeloprolifertive Diso
rders 29
Answers to Questions 1822 18. C Rouleux is o served in multiple myelom ptients
s  result of
incresed viscosity nd decresed l umin/lo ulin rtio. Multiple myelom is 
plsm cell
dyscrsi tht is chrcterized y n overproduction of monoclonl immunolo uli
n. 19. D The Ph 1
chromosome is  dinostic mrker for CML. Osteolytic lesions, monoclonl mmop
thy, nd one
mrrow in ltrtion y plsm cells constitute the trid of dinostic mrkers for
myelom. 20. C Benin monoclonl mmopthies hve peripherl lood ndins simil
r to those in
myelom. However,  lower concentrtion of monoclonl protein is usully seen. T
here re no
osteolytic lesions, nd the plsm cells comprise less thn 10% of nucleted cel
ls in the one
mrrow. A out 30% ecome mlinnt, nd therefore the term monoclonl mmopthy
of undetermined
sini cnce (MGUS) is the desintion used to descri e this condition. 21. D Mutt
ed plsm lsts
in the one mrrow undero clonl repliction nd expnd the plsm cell mss. N

orml one mrrow

is rdully replced y the mlinnt plsm cells ledin to pncytopeni. Mos
t mlinnt
plsm cells ctively produce immunolo ulins. In multiple myelom, the normlly
controlled nd
purposeful production of nti odies is replced y the inpproprite production
of even lrer
mounts of useless immunolo ulin molecules. The normlly equl production of li
ht chins nd
hevy chins my e im lnced. The result is the relese of excess free liht c
hins or free
hevy chins. The immunolo ulins produced y  clone of myelom cells re ident
icl. Any
 norml production of identicl nti odies is referred to y the enerl nme o
f monoclonl
mmopthy. Osteoclsts re one cells ctive in loclly resor in one nd rele
sin clcium
into the lood. Ner y osteo lsts re eqully ctive in utilizin clcium in th
e lood to form
new one. Multiple myelom interrupts this lnce y the secretion of t lest
two su stnces.
These re interleukin-6 (IL-6) nd osteoclst-ctivtin fctor (OAF). As its n
me implies, OAF
stimultes osteoclsts to increse one resorption nd relese of clcium, which
leds to lytic
lesions of the one. 22. A Wldenstrms mcrolo ulinemi is  mlinncy of the
lymphoplsmcytoid cells, which mnufcture IM. Althouh the cells secrete immu
nolo ulin, they
re not fully di erentited into plsm cells nd lck the chrcteristic perinucl
er hlo, deep
sophili, nd eccentric nucleus chrcteristic of clssic plsm cells. 2828_C
09/08/12 4:10 PM Pe 29 23. Cells tht exhi it  positive stin with cid pho
sphtse nd re
not inhi ited with trtric cid re chrcteristiclly seen in: A. Infectious m
ononucleosis B.
Infectious lymphocytosis C. Hiry cell leukemi D. T-cell cute lympho lstic le
Hemtoloy/Apply principles of specil procedures/Cytochemicl stins/2 24. Te J
muttion my e positive in ll of the followin chronic myeloprolifertive diso
rders except: A.
Essentil throm ocythemi B. Idiopthic myelo rosis C. PV D. CML Hemtoloy/Corre
lte clinicl
nd l ortory dt/ CML/Chrcteristics/3 25. All of the followin re mjor cr
iteri for the
2008 WHO dinostic criteri for essentil throm ocythemi except: A. Pltelet c
ount >450 10 9
B. Mekryocyte prolifertion with lre nd mture morpholoy, nd no
or little rnulocyte
or erythroid prolifertion C. Demonstrtion of JAK2(V617F) or other clonl mrke
r D. Sustined
pltelet count >600 10 9
Hemtoloy/Apply knowlede of specil procedures/ Myeloprolifertive
diseses/Clssi ctions/3 30 Chpter 1 | Hemtoloy Answers to Questions 2325 23. C
A vri le
num er of mlinnt cells in hiry cell leukemi (HCL) will stin positive with

resistnt cid phosphtse (TRAP+). Althouh this cytochemicl rection is firl

y speci c for
HCL, TRAP ctivity hs occsionlly een reported in B-cell nd rrely T-cell le
ukemi. 24. D The
JAK2(V617F) muttion is netive in ptients with CML. It my e positive in pt
ients with
idiopthic myelo rosis (35%57%), polycythemi ver (65%97%), nd essentil throm oc
(23%57%). 25. D The criterion for the 2001 WHO dinosis of essentil throm ocyth
emi (ET) ws 
pltelet count 600 x 10 9
L. This ws chned in the 2008 WHO
criteri to 450 x 10 9
L. Dinosis of essentil
throm ocythemi requires meetin ll four mjor 2008 WHO dinostic crit
eri, which lso
includes: mekryocyte prolifertion with lre nd mture morpholoy nd no or
rnulocyte or erythroid prolifertion; not meetin WHO criteri for CML, PV, IM
F, MDS, or other
myeloid neoplsm; nd demonstrtion of JAK2(V617F) muttion or other clonl mrk
er, or no
evidence of rective throm ocytosis. 2828_Ch01_001-040 09/08/12 4:10 PM Pe
30 Answers to
Questions 13 1. B The formul for correctin the WBC count for the presence of NR
BCs is: Totl
WBC 100 or (21.0 100) 126 = 16.7 10 9
where totl WBC = WBCs 10 9
L, 100 is the
num er of WBCs counted in the di erentil, nd 126 is the sum of NRBCs plu
s WBCs counted in
the di erentil. 2. C The formul for clcultin mnul cell counts usin  hemc
ytometer is:
cells counted 10 (depth fctor)
dilution fctor divided y the re counted in mm 2 , or (80 10 100) 4 =
20,000/L or
20.0 10 9
3. D Regardless of the cell or uid type, the formula for calculating manu
al cell counts
using a hemacytometer is:
cells counted 10 (depth factor)
dilution factor divided by the area counted in mm 2 , or (125 10 200) 1
= 250,000/L or
250.0 10 9
1. A 19-year-old man came to the emergency department with severe joint
pain, fatigue, cough,
and fever. Review the following laboratory results: WBCs 21.0 10 9
RBCs 3.23 10 12
Hgb 9.6 g/dL PLT 252 10 9
Di erential: 17 band neutrophils; 75 segmented neutrophils; 5 lymphocytes;
2 monocytes; 1
eosinophil; 26 NRBCs What is the corrected WBC count? A. 8.1 10 9
B. 16.7 10 9

C. 21.0 10 9
D. 80.8 10 9
Hematology/Calculate/WBCs corrected for NRBCs/2 2. A manual WBC count is
performed. Eighty
WBCs are counted in the four large corner squares of a Neubauer hemacytometer. T
e dilution is
1:100. What is the total WBC count? A. 4.0 10 9
B. 8.0 10 9
C. 20.0 10 9
D. 200.0 10 9
Hematology/Calculate/Cell count/2 3. A manual RBC count is performed on
a pleural uid. Te
RBC count in the large center square of the Neubauer hemacytometer is 125, and t
he dilution is
1:200. What is the total RBC count? A. 27.8 10 9
B. 62.5 10 9
C. 125.0 10 9
D. 250.0 10 9
Hematology/Calculate/Cell count/2 1.8 Hematology Problem Solving 31 2828
09/08/12 4:10 PM Page 31 4. Review the scatterplot of white blood cells shown.
Which section of
the scatterplot denotes the number of monocytes? 32 Chapter 1 | Hematology Answe
rs to Questions
45 4. A White blood cell identi cation is facilitated by analysis of the impedance,
and light-scattering properties of the WBCs. The scatterplot represents the rela
tionship between
volume (x axis) and light scatter (y axis). Monocytes account for the dots in se
ction A,
neutrophils are represented in section B, eosinophils in section C, and lymphocy
tes are denoted
in section D. 5. C When an automated WBC count is performed using a hematology a
nalyzer, the RBCs
are lysed to allow enumeration of the WBCs. Sickle cells are often resistant to
lysis within the
limited time frame (less than 1 minute), during which the RBCs are exposed to th
e lysing reagent
and the WBCs are subsequently counted. As a result, the nonlysed RBCs are counte
d along with the
WBCs, thus falsely increasing the WBC count. When an automated cell counting ana
lyzer indicates a
review ag for the WBC count, and sickle cells are noted on peripheral smear analy
sis, a manual
WBC count must be performed. The manual method allows optimal time for sickle ce
ll lysis and
accurate enumeration of the WBCs. W BC V O L U M E DF 1 A D B C A. A B. B C. C
D. D
Hematology/Apply basic principles to interpret results/ Automated cell counting/

2 5. Review the
following automated CBC values. WBCs = 17.5 10 9
L ( agged) MCV = 86.8 fL
RBCs = 2.89 10 12
L MCH = 28.0 pg
Hgb = 8.1 g/dL MCHC = 32.3% Hct = 25.2% PLT = 217 10 9
Many sickle cells were observed upon review of the peripheral blood smea
r. Based on this
nding and the results provided, what automated parameter of this patient is most
inaccurate and what follow-up test should be done to accurately assess this para
meter? A.
MCV/perform reticulocyte count B. Hct/perform manual Hct C. WBC/perform manual W
BC count D.
Hgb/perform serum:saline replacement Hematology/Apply knowledge to identify sour
ces of
error/Instrumentation/3 2828_Ch01_001-040 09/08/12 4:10 PM Page 32 6. Review
the following CBC
results on a 2-day-old infant: WBCs = 15.2 10 9
L MCV = 105 fL
RBCs = 5.30 10 12
L MCH = 34.0 pg
Hgb = 18.5 g/dL MCHC = 33.5% Hct = 57.9% PLT = 213 10 9
Tese results indicate: A. Macrocytic anemia B. Microcytic anemia C. Live
r disease D. Normal
values for a 2-day-old infant Hematology/Apply knowledge of fundamental biologic
characteristics/Normal values/2 7. Review the following scatterplot, histograms,
and automated
values on a 21-year-old college student. 1.8 | Hematology Problem Solving 33 A
nswers to
Questions 67 6. D During the rst week of life, an infant has an average Hct of 55
mL/dL. This
value drops to a mean of 43 mL/dL by the rst month of life. The mean MCV of the rs
t week is 108
fL; after 2 months, the average MCV is 96 fL. The mean WBC count during the rst w
eek is
approximately 18 10 9
L, and this drops to
an average of 10.8 10 9
L after the rst month. The
platelet count of newborns falls within the same normal range as adults.
7. A Lymphocytosis
with numerous atypical lymphocytes is a hallmark nding consistent with the diagno
sis of
infectious mononucleosis. The automated results demonstrated abnormal WBC subpop
speci cally lymphocytosis as well as monocytosis. However, on peripheral smear exa
mination, 60
atypical lymphocytes and only 6 monocytes were noted. Atypical lymphocytes are o
ften misclassi ed
by automated cell counters as monocytes. Therefore, the automated analyzer di eren
tial must not
be released and the manual di erential count must be relied upon for diagnostic in
WBC di erential: 5 band neutrophils; 27 segmented neutrophils; 60 atypical lymphoc
ytes; 6
monocytes; 1 eosinophil; 1 basophil What is the presumptive diagnosis? A. Infect

mononucleosis B. Monocytosis C. Chronic lymphocytic leukemia D. -Tlssemi Hemt
knowlede to identify sources of error/Instrumenttion/3 2828_Ch01_001-040 09/0
8/12 4:10 PM
Pe 33 WBC di erentil: 14 nd neutrophils; 50 semented neutrophils; 7 lymphocy
tes; 4
monocytes; 10 metmyelocytes; 8 myelocytes; 1 promyelocyte; 3 eosinophils; 3 s
ophils; 2
NRBCs/100 WBCs Wht is the presumptive dinosis? A. Leukemoid rection B. Chron
ic myelocytic
leukemi C. Acute myelocytic leukemi D. Melo lstic leukemi Hemtoloy/Evlu
te l ortory
dt to reconize helth nd disese sttes/Instrumenttion/3 9. Review the uto
mted results
from the previous question. Which prmeters cn e relesed without further fol
veri ction procedures? A. WBC nd reltive percentes of WBC popultions B. RBCs
nd PLTs C.
H nd Hct D. None of the utomted counts cn e relesed without follow-up ve
ri ction
Hemtoloy/Apply knowlede to identify sources of error/Instrumenttion/3 Answer
s to Questions
89 8. B The +++++ on the printout indictes tht the WBC count exceeds the upper
linerity of
the nlyzer (>99.9 10 9
L). This mrkedly elevted WBC count,
com ined with the spectrum of immture rnulocytic cells seen on periph
erl smer
exmintion, indictes the dinosis of chronic myelocytic leukemi. 9. D All of
the utomted
results hve R or review s indicted; none cn e relesed without veri ction pr
ocedures. The
specimen must e diluted to rin the WBC count within the linerity rne of th
e nlyzer. When
enumertin the RBC count, the nlyzer does not lyse the WBCs nd ctully coun
ts them in with
the RBC count. As such, the RBC count is flsely elevted ecuse of the incres
ed num er of
WBCs. Therefore, fter n ccurte WBC count hs een o tined, this vlue cn
e su trcted from
the RBC count to o tin  true RBC count. For exmple, usin the vlues for this
ptient: Step 1:
O tin n ccurte WBC count y dilutin the smple 1:10. WBC = 41.0 10 (dilutio
n) = 410 10 9
Step 2: Convert this vlue to cells per 10 12 in order to su trct from
the RBC count. 410
10 9
L = 0.41 10
Step 3: Su trct the WBC count from the RBC count to et n ccurte RBC
count. 3.28
(oriinl RBC) 0.41 (true WBC) = 2.87 10 12
L = ccurte RBC
The Hct my e o tined y microhemtocrit centrifution. The true MCV
my e o tined usin
the stndrd formul. MCV = (Hct RBC) 10 where RBC = RBC count in millions per m

Additionlly, the pltelet count must e veri ed y smer estimte or performed m

nully. 34
Chpter 1 | Hemtoloy 8. Review the followin sctterplot, historms, nd uto
mted vlues on 
61-yer-old womn. 2828_Ch01_001-040 09/08/12 4:10 PM Pe 34 A. Redrw lood
smple usin 
sodium citrte tu e; multiply PLTs 1.11 B. Dilute the WBCs 1:10; multiply 10 C.
plsm lnk H to correct for lipemi D. Wrm specimen t 37C for 15 minutes; r
erun specimen
Hemtoloy/Apply knowlede to identify sources of error/Instrumenttion/3 Answer
to Question 10
10. A The pltelet clumpin phenomenon is often induced in vitro y the ntico
ulnt EDTA.
Redrwin  smple from the ptient usin  sodium citrte tu e usully corrects
this phenomenon
nd llows ccurte pltelet enumertion. The pltelet count must e multiplied
y 1.11 to djust
for the mount of sodium citrte. Pltelet clumps cuse  spurious decrese in t
he pltelet count
y utomted methods. The WBC vlue hs n R (review)  ecuse the pltelet clu
mps hve een
flsely counted s WBCs; therefore,  mnul WBC count is indicted. 1.8 | Hemt
oloy Pro lem
35 10. Refer to the followin sctterplot, historms, nd utomted v
lues on 
45-yer-old mn. Wht follow-up veri ction procedure is indicted efore relesin
results? 2828_Ch01_001-040 09/08/12 4:10 PM Pe 35 A. Redrw specimen usin
 sodium citrte
tu e; multiply PLT 1.11 B. Dilute the WBCs 1:10; multiply 10 C. Perform plsm
lnk H to
correct for lipemi D. Wrm the specimen t 37C for 15 minutes; rerun the specime
Hemtoloy/Apply knowlede to identify sources of error/Instrumenttion/3 Answer
to Question 11
11. D The presence of  hih titer cold lutinin in  ptient with cold utoim
mune hemolytic
nemi will interfere with utomted cell countin. The most remrk le ndins r
e  flsely
elevted MCV, MCH, nd MCHC s well s  flsely decresed RBC count. The ptien
ts red lood
cells will quickly lutinte in vitro when exposed to m ient tempertures el
ow ody
temperture. To correct this phenomenon, incu te the EDTA tu e t 37C for 1530 mi
nutes nd
then rerun the specimen. 36 Chpter 1 | Hemtoloy 11. Refer to the followin sc
historms, nd utomted vlues on  52-yer-old womn. Wht follow-up veri ctio
n procedure is
indicted efore relesin these results? 2828_Ch01_001-040 09/08/12 4:10 PM
Pe 36 A.
Perform  mnul hemtocrit nd redrw the smple usin  sodium citrte tu e; m
ultiply PLT
1.11 B. Dilute the WBC 1:10; multiply 10 C. Perform plsm lnk H to correct
for lipemi D.
Wrm the specimen t 37C for 15 minutes; rerun the specimen Hemtoloy/Apply know
lede to
identify sources of error/Instrumenttion/3 Answer to Question 12 12. C The rule
of thum

rerdin the H /Hct correltion dicttes tht H 3 Hct ( 3). This rule is viol
ted in
this ptient; therefore,  follow-up veri ction procedure is indicted. Addition
lly, the MCHC
is mrkedly elevted in these results, nd n explntion for  flsely increse
d H should e
investited. Lipemi cn e visulized y centrifuin the EDTA tu e nd o serv
in for  milky
white plsm. To correct for the presence of lipemi,  plsm H vlue ( seli
ne H ) should e
scertined usin the ptients plsm nd su sequently su trcted from the oriin
l flsely
elevted H vlue. The followin formul cn e used to correct for lipemi. Wh
ole lood H
[(Plsm H ) (1 Hct/100)] = Corrected H 1.8 | Hemtoloy Pro lem Solvin
12. Refer to
the followin sctterplot, historms, nd utomted vlues on  33-yer-old wom
n. Wht
follow-up veri ction procedure is indicted efore relesin these results? 2828_
09/08/12 4:10 PM Pe 37 A. Dilute WBCs 1:10; multiply 10 B. Redrw the smple
usin  sodium
citrte tu e; multiply WBC 1.11 C. Prepre u y cot peripherl lood smers nd p
mnul di erentil D. Wrm specimen t 37C for 15 minutes; rerun specimen Hemtolo
course of ction/Instrumenttion/3 14. Review the followin CBC results on  70yer-old mn:
WBCs = 58.2 10 9
L MCV = 98 fL
RBCs = 2.68 10 12
L MCH = 31.7 p
H = 8.5 /dL MCHC = 32.6% Hct = 26.5 mL/dL% PLT = 132 10 9
Di erentil: 96 lymphocytes; 2 nd neutrophils; 2 semented neutrophils;
25 smude cells/100
WBCs Wht is the most likely dinosis sed on these vlues? A. Acute lymphocyt
ic leukemi B.
Chronic lymphocytic leukemi (CLL) C. Infectious mononucleosis D. Myelodysplsti
c syndrome
Hemtoloy/Evlute l ortory dt to reconize helth nd disese sttes/2 Ans
wers to Questions
1314 13. C The mrkedly decresed WBC count (0.2 10 9
indictes tht  mnul di erentil is necessry nd very few leukocytes w
ill e vil le
for di erentil cell countin. To increse the yield nd there y fcilitte counti
n, di erentil
smers should e prepred usin the u y cot technique. 14. B CLL is  disese of
the elderly,
clssiclly ssocited with n elevted WBC count nd reltive nd  solute lymp
hocytosis. CLL is
twice s common in men, nd smude cells (WBCs with little or no surroundin cyt
oplsm) re
usully present in the peripherl lood smer. CLL my occur with or without ne
mi or
throm ocytopeni. The ptients e nd lck of lsts rule out cute lymphocytic
Similrly, the ptients e nd the lck of typicl lymphocytes mke infectious

unlikely. Myelodysplstic syndromes my involve the erythroid, rnulocytic, or

cell lines ut not the lymphoid cells. 38 Chpter 1 | Hemtoloy 13. Refer to th
e followin
sctterplot, historms, nd utomted vlues on  48-yer-old mn. Wht followup veri ction
procedure is indicted efore relesin the ve-prt WBC di erentil results? 2828_C
09/08/12 4:10 PM Pe 38 A. Disseminted intrvsculr coultion (DIC) B. He
elliptocytosis (ovlocytosis) C. Cirrhosis D. H C disese Hemtoloy/Evlute
l ortory dt
to reconize helth nd disese sttes/2 1.8 | Hemtoloy Pro lem Solvin
39 1
5. Refer to the
followin sctterplot, historms, nd utomted vlues on  28-yer-old womn w
ho hd
preopertive l ortory testin. A mnul WBC di erentil ws requested y her phy
sicin. Te WBC
di erentil ws not sini cntly di erent from the utomted ve-prt di erentil; however
, the
technoloist noted 3+ elliptocytes/ovlocytes while reviewin the RBC morpholoy
. Wht is the
most likely dinosis for this ptient? Answers to Questions 1516 15. B The ndin
of ovlocytes
s the predominnt RBC morpholoy in peripherl lood is consistent with the di
nosis of
hereditry elliptocytosis (HE), or ovlocytosis. This disorder is reltively com
mon nd cn rne
in severity from n symptomtic crrier to homozyous HE with severe hemolysis.
The most common
clinicl su type is ssocited with no or miniml hemolysis. Therefore, HE is us
ully ssocited
with  norml RBC historm nd cell indices nd will o unnoticed without micro
scopic evlution
of the peripherl smer. 16. A The osmotic frility test is indicted s  con rm
tory test for
the presence of numerous spherocytes, nd individuls with hereditry spherocyto
sis (HS) hve n
incresed osmotic frility. The MCHC is elevted in more thn 50% of ptients w
spherocytosis, nd this prmeter cn e used s  clue to the presence of HS. S
pherocytes hve 
decresed surfce-to-volume rtio, pro  ly resultin from mild cellulr dehydr
tion. 16. A
25-yer-old womn sw her physicin with symptoms of jundice, cute cholecystit
is, nd n
enlred spleen. On investition, numerous llstones were discovered. Review t
he followin CBC
results: WBCs = 11.1 10 9
L MCV = 100 fL
RBCs = 3.33 10 12
L MCH = 34.5 p
H = 11.5 /dL MCHC = 37.5% Hct = 31.6 mL/dL PLT = 448 10 9
WBC di erentil: 13 nd neutrophils; 65 semented neutrophils; 15 lymphoc
ytes; 6 monocytes;
1 eosinophil RBC morpholoy: 3+ spherocytes, 1+ polychromsi Wht follow-up l
ortory test
would provide vlu le informtion for this ptient? A. Osmotic frility B. H

C. G6PD ssy D. Methemolo in reduction test Hemtoloy/Evlute l ortory dt

 to reconize
helth nd disese sttes/2 2828_Ch01_001-040 09/08/12 4:10 PM Pe 39 A. Iro
n de ciency
nemi (IDA) B. Polycythemi ver (PV) C. Sidero lstic nemi D. -Tlssemi min
Hemtoloy/Evlute l ortory dt to reconize helth nd disese sttes/2 18.
Review the
followin CBC results: WBCs = 11.0 10 9
L MCV = 85.0 fL
RBCs = 3.52 10 12
L MCH = 28.4 p
H = 10.0 /dL MCHC = 33.4% Hct = 29.9 mL/dL PLT = 155 10 9
12 NRBCs/100 WBCs RBC morpholoy: Moderte polychromsi, 3+ tret cell
s, few schistocytes
Which of the followin dditionl l ortory tests would yield informtive din
ostic informtion
for this ptient? A. Osmotic frility B. H electrophoresis C. Sur wter tes
t D. Bone mrrow
exmintion Hemtoloy/Correlte l ortory dt with other l ortory dt to 
ssess test
results/3 Answers to Questions 1718 17. D -Thlssemi minor cn esily e detecte
d y notin
n  normlly elevted RBC count, n Hct tht does not correlte with the elevt
ed RBC count, in
conjunction with  decresed MCV. Althouh thlssemi nd IDA re oth microcyt
ic, hypochromic
processes, thlssemi cn e di erentited from IDA ecuse in IDA the RBC count,
H , nd Hct
vlues re usully decresed lon with the MCV. Althouh the RBC count is incre
sed in PV, the
Hct must lso e hiher thn 50% to consider  dinosis of PV. 18. B The ndins
of  moderte
nemi, numerous tret cells seen on  peripherl lood smer, s well s the p
resence of NRBCs,
re often ssocited with hemolo inopthies. Hemolo in electrophoresis t lk
line pH is 
commonly performed test to correctly dinose the type of hemolo inopthy. 40 C
hpter 1 |
Hemtoloy 17. Refer to the followin sctterplot, historms, nd utomted vl
ues on 
53-yer-old mn who hd preopertive l ortory testin. Wht is the most likely
dinosis for
this ptient? BI BL I OGRAPHY 1. Greer J, Foerster J, Roders GM, Prskevs F,
Glder B, Ar er
DA, nd Mens RT Jr. Wintro es Clinicl Hemtoloy. 12th edition, 2009. Lippincot
t Willims &
Wilkins, Phildelphi. 2. Hrmenin D. Clinicl Hemtoloy nd Fundmentls of H
emostsis. 5th
edition, 2009. F.A. Dvis, Phildelphi. 3. Hillmn R, Ault K, Leporrier M, Rind
er HM, nd Rinder
H. Hemtoloy in Clinicl Prctice. 5th edition, 2011. McGrw-Hill, New York. 4.
Ho mn R,
Sil erstein LE, Shttil SJ, Furie B, nd McGlve P. Hemtoloy: Bsic Principles
nd Prctices,
Expert Consult. 5th edition, 2009. Churchhill Livinstone Elsevier, Phildelphi
. 5. Kushnsky
K, Lichtmn M, Beutler E, Kipps T, Prchl J, nd Selisohn U. Willims Hemtolo
y. 8th edition,

2010. McGrw-Hill, New York. 6. Roders GP nd Youn NS. Te Bethesd Hnd ook of
Hemtoloy. 2010. Lippincott Willims & Wilkins, Phildelphi. 7. S  HI nd Mu
fti G. Advnces
in Mlinnt Hemtoloy. 2011. Wiley-Blckwell, Chichester, West Sussex, UK. 282
09/08/12 4:10 PM Pe 40 2.1 Coultion nd Fi rinolytic Systems/ Reents n
d Methods 2.2
Pltelet nd Vsculr Disorders 2.3 Coultion System Disorders 2.4 Inhi itors,
Trom otic
Disorders, nd Anticoulnt Drus 2.5 Hemostsis Pro lem Solvin CHAPTER 2 41 H
2828_Ch02_041-074 06/08/12 11:09 AM Pe 41 2828_Ch02_041-074 06/08/12 11:0
9 AM Pe 42 43
2.1 Coultion nd Fi rinolytic Systems/Reents nd Methods 1. Which of the fo
llowin initites
in vivo coultion y ctivtion of fctor VII? A. Protein C B. Tissue fctor C
. Plsmin
ctivtor D. Trom omodulin Hemostsis/Apply knowlede of fundmentl ioloicl
chrcteristics/Coultion/2 Answer to Question 1 1. B In vivo, ctivtion of c
oultion occurs
on the surfce of ctivted pltelets or cells tht hve tissue fctor. Tissue f
ctor is found on
the surfce of mny cells outside the vsculr system (extrinsic). Upon vsculr
injury, TF is
exposed to the vsculr system. TF hs hih  nity for fctors VII nd VII. TF c
tivtes fctor
VII to VII nd forms TF-VII complex. TF-VII complex in the presence of C +2
nd pltelet
phospholipid ctivtes fctors IX to IX nd X to X. Fctor X forms  complex
with cofctor V
(X-V) on the surfce of the ctivted pltelets. Fctor X-V complex in the p
resence of C +2
nd pltelet phospholipid converts prothrom in (fctor II) to throm in (II). Th
rom in cts on
solu le plsm rinoen to form 
rin clot, which is st ilized y ctivted fct
(XIII). In ddition, ctivted fctor IX (IX) forms  complex with ctivted c
ofctor VIII
(VIII) on the surfce of the ctivted pltelets. Fctor IXVIII complex in the
presence of C
+2 nd pltelet phospholipid converts fctor X to X with the end products of th
rom in nd rin
clot s discussed previously. The clssicl description of intrinsic, extrinsic,
nd common
pthwys does not tke plce in vivo. The concept of these three pthwys is use
d to explin clot
formtion in l ortory tests. The ctivted throm oplstin time (APTT) is deter
mined y the
intrinsic nd common pthwys, while the prothrom in time (PT) is determined y
the extrinsic nd
common pthwys. The extrinsic pthwy is so nmed ecuse the tissue fctor is
derived from
extrvsculr cells. 2828_Ch02_041-074 06/08/12 11:09 AM Pe 43 2. Which of
the followin
clottin fctors plys  role in clot formtion in vitro, ut not in vivo? in vi
tro clot
formtion nd not in vivo coultion? A. VII B. II C. XII D. X Hemostsis/A
pply knowlede of
fundmentl ioloicl chrcteristics/Coultion/2 3. Te nticoulnt of choi

ce for most
routine coultion studies is: A. Sodium oxlte B. Sodium citrte C. Heprin D
Ethylenediminetetrcetic cid (EDTA) Hemostsis/Select methods/Reents/Specim
en collection nd
hndlin/Specimen/1 4. Which rtio of nticoulnt-to- lood is correct for co
procedures? A. 1:4 B. 1:5 C. 1:9 D. 1:10 Hemostsis/Select methods/Reents/Spec
imen collection
nd hndlin/Specimen/1 5. Which results would e expected for the prothrom in t
ime (PT) nd
ctivted prtil throm oplstin time (APTT) in  ptient with polycythemi? A.
Both proloned B.
Both shortened C. Norml PT, proloned APTT D. Both norml Hemostsis/Correlte
clinicl nd
l ortory dt/Coultion tests/3 6. Wht reents re used in the PT test? A.
Trom oplstin
nd sodium chloride B. Trom oplstin nd potssium chloride C. Trom oplstin nd
clcium D. Actin
nd clcium chloride Hemostsis/Select methods/Reents/Coultion tests/1 7. W
hich test would
e  norml in  ptient with fctor X de ciency? A. PT only B. APTT only C. PT n
Trom in time Hemostsis/Correlte clinicl nd l ortory dt/ Coultion test
s/2 44 Chpter 2
| Hemostsis Answers to Questions 27 2. C Fctor XII does not ply  role in co
ultion in
vivo; however, in vitro, the de ciency of this fctor cuses  proloned APTT resu
lt. In vitro,
fctor XII is ctivted y su stnces such s lss, Kolin, nd ellic cid, 
nd in vivo it my
e ctivted y exposure to  netively chred cell surfce mem rne such coll
en s well s
kllikrein (n ctivted form of prekllikrein) nd hih moleculr weiht kinino
en (HMWK). In
vivo, fctor XII plys n importnt role in the rinolytic system y ctivtin
plsminoen to
plsmin. Plsmin derdes the
rin clot t the site of injury. De ciency of fctor
XII is
ssocited with throm osis nd not leedin. Fctors VII, X, nd II ply  ro
le in vivo nd in
vitro. 3. B The nticoulnt of choice for most coultion procedures is sodiu
m citrte (3.2%).
Becuse fctors V nd VIII re more l ile in sodium oxlte, heprin neutrlize
s throm in, nd
EDTA inhi its throm ins ction on rinoen, these nticoulnts re not used for
coultion studies. 4. C The optimum rtio of nticoulnt to lood is one pr
t nticoulnt
to nine prts of lood. The nticoulnt supplied in this mount is su cient to
ind ll the
vil le clcium, there y preventin clottin. 5. A The volume of lood in  po
ptient contins so little plsm tht excess nticoulnt remins nd is vil
 le to ind to
reent clcium, there y resultin in prolontion of the PT nd APTT. For more
ccurte results,
the plsm:nticoulnt rtio cn e modi ed y decresin the mount of ntico
ulnt in the
collection tu e usin the followin formul: (0.00185)(V)(100H) = C, where V = l

ood volume in
mL; H = ptients Hct; nd C = volume (mL) of nticoulnt. A new smple should
e drwn to
rerun the PT nd APTT. 6. C Throm oplstin nd clcium (com ined into  sinle r
eent) replce
the tissue throm oplstin nd clcium necessry in vivo to ctivte fctor VII t
o fctor VII.
This ultimtely enertes throm in from prothrom in vi the coultion cscde.
7. C Fctor X is
involved in the common pthwy of the coultion cscde; therefore, its de cienc
y prolons oth
the PT nd APTT. Activted fctor X lon with fctor V in the presence of clci
um nd pltelet
fctor III (PF3) converts prothrom in (fctor II) to the ctive enzyme throm in
(fctor II).
2828_Ch02_041-074 06/08/12 11:09 AM Pe 44 8. Which clottin fctor is not m
esured y PT nd
APTT tests? A. Fctor VIII B. Fctor IX C. Fctor V D. Fctor XIII Hemostsis/Ap
ply principles of
sic l ortory procedures/Coultion tests/1 9. A modi ction of which procedur
e cn e used
to mesure rinoen? A. PT B. APTT C. Trom in time D. Fi rin derdtion products
Hemostsis/Apply principles of sic l ortory procedures/Coultion tests/2 1
0. Which of the
followin chrcterizes vitmin K? A. It is required for ioloicl ctivity of
rinolysis B.
Its ctivity is enhnced y heprin therpy C. It is required for cr oxyltion
of lutmte
residues of some coultion fctors D. It is mde y the endothelil cells Hemo
knowlede of fundmentl ioloicl chrcteristics/Vitmin K/2 11. Which sttem
ent  out the
rinoen/ rin derdtion product test is correct? A. It detects erly derdtion
products (X
nd Y) B. It is decresed in disseminted intrvsculr coultion (DIC) C. It
evlutes the
coultion system D. It detects lte derdtion products (D nd E) Hemostsis/
Apply principles
of sic l ortory procedures/FDPs/2 12. Which of the followin clottin fctor
s re mesured y
the APTT test? A. II, VII, IX, X B. VII, X, V, II, I C. XII, XI, IX, VIII, X, V,
VII, X, V, II, I Hemostsis/Correlte clinicl nd l ortory dt/ Coultion
tests/2 13. Which
coultion test(s) would e  norml in  vitmin Kde cient ptient? A. PT only B.
C. Fi rinoen level D. Trom in time Hemostsis/Correlte clinicl nd l ortory
Coultion tests/2 2.1 | Coultion nd Fi rinolytic Systems/Reents nd Meth
ods 45 Answers
to Questions 814 8. D Fctor XIII is not mesured y the PT or APTT. Fctor XIII
( rin
st ilizin fctor) is  trnsmidse. It cretes covlent onds etween rin mon
omers formed
durin the coultion process to produce  st le rin clot. In the  sence of f
ctor XIII, the
hydroen onded
rin polymers re solu le in 5M ure or in 1% monochlorocetic c
id. 9. C
Fi rinoen cn e quntittively mesured y  modi ction of the throm in time y
dilutin the

plsm, ecuse the throm in clottin time of diluted plsm is inversely propor
tionl to the
concentrtion of
rinoen (principle of Cluss method). 10. C Vitmin K is necess
ry for
ctivtion of vitmin K dependent clottin fctors (II, VII, IX, nd X). This ct
ivtion is
ccomplished y cr oxyltion of lutmic cid residues of the inctive clottin
fctors. The
ctivity of vitmin K is not enhnced y heprin therpy. Vitmin K is present i
n  vriety of
foods nd is lso the only vitmin mde y the ornisms livin in the intestine
. 11. D The
derdtion product (FDP) test detects the lte derdtion products (frments
D nd E) nd not
the erly ones (frments X nd Y). 12. C The APTT test evlutes the clottin f
ctors in the
intrinsic pthwy (XII, XI, IX, nd VIII) s well s the common pthwy (X, V, I
I, nd I). 13. B
Ptients with vitmin K de ciency exhi it decresed production of functionl proth
rom in proteins
(fctors II, VII, IX, nd X). Decresed levels of these fctors prolon oth the
PT nd APTT. 14.
B INR is used to stndrdize PT results to djust for the di erence in throm opls
tin reents
mde y di erent mnufcturers nd used y vrious institutions. The INR clculti
on uses the
Interntionl Sensitivity Index (ISI) vlue, nd is used to monitor n orl nti
coulnt such s
wrfrin. INR is not used to stndrdize APTT testin. 14. Which of the followin
 is correct
rerdin the interntionl normlized rtio (INR)? A. It uses the Interntionl
Rtio (ISR) B. It stndrdizes PT results C. It stndrdizes APTT results D. It
is used to
monitor heprin therpy Hemostsis/Apply knowlede of fundmentl ioloicl
chrcteristics/INR/2 2828_Ch02_041-074 06/08/12 11:09 AM Pe 45 15. Which o
f the followin
is referred to s n endoenous ctivtor of plsminoen? A. Streptokinse B. Tr
nsmidse C.
Tissue plsminoen ctivtor D. Tissue plsminoen ctivtor inhi itor Hemostsi
s/Apply knowlede
of fundmentl ioloicl chrcteristics/Plsminoen/2 16. Which protein is the
inhi itor of the rinolytic system? A. Protein C B. Protein S C. 2 -Antiplsmin D
. 2
-Mcrolo ulin Hemostsis/Apply knowlede of fundmentl ioloicl chrcterist
ics/Plsmin/1 17.
Which of the followin sttements is correct rerdin the D-dimer test? A. Leve
ls re decresed
in DIC B. Test detects polypeptides A nd B C. Test detects frments D nd E D.
Test hs 
netive predictive vlue Hemostsis/Apply principles of sic l ortory proced
18. A protein tht plys  role in oth coultion nd pltelet retion is:
A. Fctor I B.
Fctor VIII C. Fctor IX D. Fctor XI Hemostsis/Apply knowlede of fundmentl
chrcteristics/Clottin fctors/2 19. A stndrd 4.5-mL lue-top tu e lled with
3.0 mL of lood
ws su mitted to the l ortory for PT nd APTT tests. Te smple is from  ptie

nt underoin
surery the followin mornin for  tonsillectomy. Which of the followin is the
necessry course
of ction y the technoloist? A. Run oth tests in duplicte nd report the ve
re result B.
Reject the smple nd request  new smple C. Report the PT result D. Report the
APTT result
Hemostsis/Select methods/Reents/Specimen collection nd hndlin/Specimens/3
20. Which
sttement is correct rerdin smple store for the prothrom in time test? A.
St le for 24
hours if the smple is cpped B. St le for 24 hours if the smple is refriert
ed t 4C C.
St le for 4 hours if the smple is stored t 4C D. Should e run within 8 hours
Hemostsis/Select methods/Reents/Specimen collection nd hndlin/Specimens/2
46 Chpter 2 |
Hemostsis Answers to Questions 1520 15. C Tissue plsminoen ctivtor (tPA) is
n endoenous
(produced in the ody) ctivtor of plsminoen. It is relesed from the endothe
lil cells y the
ction of protein C. It converts plsminoen to plsmin. Streptokinse is n exo
enous (not mde
in the ody) ctivtor of plsminoen. 16. C 2 -Antiplsmin is the min inhi ito
r of plsmin.
It inhi its plsmin y formin  1:1 stoichiometric complex with ny free plsmi
n in the plsm
nd, therefore, prevents the indin of plsmin to rin nd rinoen. 17. D The Ddimer ssy
evlutes rin derdtion. It is  nonspeci c screenin test tht is incresed in
conditions in which
rinolysis is incresed, such s DIC nd rinolytic therpy. T
he D-dimer
test is widely used to rule out throm osis nd throm otic ctivities. The neti
ve predictive
vlue of  test is the pro  ility tht  person with  netive result is free
of the disese
the test is ment to detect. Therefore,  netive D-dimer test rules out throm
osis nd hence
further l ortory investitions re not required. 18. A Fctor I ( rinoen) is
necessry for
pltelet retion lon with the lycoprotein II /III complex. Fctor I is 
lso  su strte
in the common pthwy of coultion. Throm in cts on rinoen to form
rin clots
. 19. B A
4.5-mL lue-top tu e contins 4.5 mL lood + 0.5 mL sodium citrte. The tu e sho
uld e 90% full.
A tu e with 3.0 mL lood should e rejected s quntity not sufficient (QNS). QN
S smples lter
the necessry lood to n nticoulnt rtio of 9:1. The excess nticoulnt i
n  QNS smple
inds to the reent clcium, there y resultin in prolontion of the PT nd AP
TT. 20. A
Accordin to Clinicl L ortory Stndrds Institute (CLSI, formerly NCCLS) uid
elines, plsm
smples for PT testin re st le for 24 hours t room temperture if cpped. Re
friertin the
smple cuses cold ctivtion of fctor VII nd, therefore, shortened PT results
. The APTT
smples re st le for 4 hours if stored t 4C. 2828_Ch02_041-074 06/08/12 11:0
9 AM Pe 46

21. In primry rinolysis, the rinolytic ctivity results in response to: A. Incr
esed rin
formtion B. Spontneous ctivtion of
rinolysis C. Incresed rin monomers D. DI
Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/Fi rinolysi
s/2 22.
Plsminoen de ciency is ssocited with: A. Bleedin B. Trom osis C. Incresed
nolysis D.
Incresed coultion Hemostsis/Correlte clinicl nd l ortory dt/Plsmino
en/2 23. Which
of the followin clottin fctors re ctivted y throm in tht is enerted y
tissue pthwy
(TF-VII)? A. XII, XI B. XII, I C. I, II D. V, VIII Hemostsis/Apply knowlede o
f fundmentl
ioloicl chrcteristics/Trom in/2 24. Wht su strte is used in  chromoenic
fctor ssy? A.
p-nitronline B. Chloropheonol red C. Prussin lue D. Ferricynide Hemostsis/
methods/Reents/Chromoenic ssys/1 25. Which of the followin nti odies is u
sed in the
D-dimer ssy? A. Polyclonl directed inst X nd Y frments B. Polyclonl di
rected inst
D-dimer C. Monoclonl inst D nd E frments D. Monoclonl inst D-dimer He
methods/Reents/D-dimer ssy/2 2.1 | Coultion nd Fi rinolytic Systems/Re
ents nd Methods
47 Answers to Questions 2125 21. B Primry rinolysis is  rre ptholoicl cond
ition in
which  spontneous systemic rinolysis occurs. Plsmin is formed in the  sence
of coultion
ctivtion nd clot formtion. Primry rinolysis is ssocited with incresed pr
oduction of
plsminoen nd plsmin, decresed plsmin removl from the circultion, nd spo
leedin. 22. B Plsminoen de ciency is ssocited with throm osis. Plsminoen i
s n importnt
component of the rinolytic system. Plsminoen is ctivted to plsmin, which is
necessry for
derdtion of
rin clots to prevent throm osis. When plsminoen is de cient, pls
min is not
formed, cusin  defect in the clot lysin processes. 23. D Fctors V nd VIII
re ctivted y
the throm in tht is enerted y the ction of TF-VII on fctor X to form fct
or X. Fctor X
forms  complex with fctor V on the pltelet surfces. FX V complex in the pr
esence of
phospholipid nd C +2 trnsform more prothrom in to throm in. 24. A The chromo
enic, or
midolytic, ssys use  color-producin su stnce known s  chromophore. The c
hromophore used
for the coultion l ortory is p-nitroniline (pN). The pN is ound to  sy
oliopeptide su strte. The protese cleves the chromoenic su strte t the si
te indin the
oliopeptide to the pNA, which results in relese of pNA. Free pNA hs  yellow
color; the color
intensity of the solution is proportionl to the protese ctivity nd is mesur
ed y 
photodetector t 405 nm. 25. D The D-dimer is the rin derdtion product ener
ted y the

ction of plsmin on cross-linked rin formed y XIII. The ptient plsm is mix
ed with ltex
prticles coted with monoclonl nti odies inst D-domins. The test cn e 
utomted or
performed mnully on  lss slide, lookin mcroscopiclly for lutintion.
ELISA methods re
lso vil le. Norml D-dimer in plsm is less thn 2 n/mL. Incresed levels
of D-dimer re
ssocited with DIC, throm olytic therpy, venous throm osis, nd throm oem olic
disorders. The
D-dimer ssy hs  90%95% netive predictive vlue, nd hs een used to rule o
ut throm osis
nd throm oem olic disorders. 2828_Ch02_041-074 06/08/12 11:09 AM Pe 47 48
2.2 Pltelet nd
Vsculr Disorders 1. Trom otic throm ocytopenic purpur (TTP) is chrcterized
y: A. Proloned
PT B. Incresed pltelet retion C. Trom ocytosis D. Proloned APTT Hemosts
clinicl nd l ortory dt/ Pltelets/2 2. Trom ocytopeni my e ssocited w
ith: A.
Postsplenectomy B. Hypersplenism C. Acute lood loss D. Incresed prolifertion
of pluripotentil
stem cells Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/
Pltelets/2 3.
Aspirin prevents pltelet retion y inhi itin the ction of which enzyme?
A. Phospholipse
B. Cyclo-oxyense C. Trom oxne A 2 synthetse D. Prostcyclin synthetse Hemos
knowlede of fundmentl ioloicl chrcteristics/Pltelets/1 4. Norml pltel
et dhesion
depends upon: A. Fi rinoen B. Glycoprotein I C. Glycoprotein II , III complex
D. Clcium
Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/Pltelets/1
5. Which of the
followin test results is norml in  ptient with clssic von Wille rnds dises
e? A. Bleedin
time B. Activted prtil throm oplstin time C. Pltelet count D. Fctor VIII:C
nd von
Wille rnds fctor (VWF) levels Hemostsis/Correlte clinicl nd l ortory dt
/ Pltelet
disorders/3 Answers to Questions 16 1. B Throm otic throm ocytopenic purpur (TTP
) is 
quntittive pltelet disorder ssocited with incresed intrvsculr pltelet
ctivtion nd
retion resultin in throm ocytopeni. The PT nd APTT results re norml in
TTP. 2. B
Hypersplenism is ssocited with throm ocytopeni. In this condition, up to 90%
of pltelets cn
e sequestered in the spleen, cusin decreses in circultory pltelets. Postsp
lenectomy, cute
lood loss, nd incresed prolifertion of pluripotentil stem cells re ssoci
ted with
throm ocytosis. 3. B Aspirin prevents pltelet retion y inhi itin the ct
ivity of the
enzyme cyclo-oxyense. This inhi ition prevents the formtion of throm oxne A
2 (TXA2), which
serves s  potent pltelet retor. 4. B Glycoprotein I is  pltelet recep
tor for VWF.
Glycoprotein I nd VWF re oth necessry for  norml pltelet dhesion. Other
proteins tht

ply  role in pltelet dhesion re lycoproteins V nd IX. 5. C Von Wille rnds
disese is n
inherited, qulittive pltelet disorder resultin in incresed leedin, prolon
ed APTT, nd
decresed fctor VIII:C nd VWF levels. The pltelet count nd morpholoy re e
nerlly norml in
von Wille rnds disese, ut retion in the pltelet function ssy is  norm
l. 6. C
BernrdSoulier syndrome is ssocited with throm ocytopeni nd int pltelets.
It is 
qulittive pltelet disorder cused y the deficiency of lycoprotein I . In Be
syndrome, pltelet retion to ADP is norml. Aretion in the pltelet fun
ction ssy is
 norml. Fctor VIII ssy is not indicted for this dinosis. 6. BernrdSoulie
r syndrome is
ssocited with: A. Decresed leedin time B. Decresed fctor VIII ssy C. Tr
om ocytopeni nd
int pltelets D. A norml pltelet retion to ADP Hemostsis/Correlte cli
nicl nd
l ortory dt/Pltelet disorders/3 2828_Ch02_041-074 06/08/12 11:09 AM Pe
48 7. When
performin pltelet retion studies, which set of pltelet retion resul
ts would most
likely e ssocited with BernrdSoulier syndrome? A. Norml pltelet retion
to collen,
ADP, nd ristocetin B. Norml pltelet retion to collen, ADP, nd epineph
rine; decresed
retion to ristocetin C. Norml pltelet retion to epinephrine nd rist
ocetin; decresed
retion to collen nd ADP D. Norml pltelet retion to epinephrine, r
istocetin, nd
collen; decresed retion to ADP Hemostsis/Correlte clinicl nd l ort
ory dt/
Pltelet disorders/3 8. Which set of pltelet responses would e most likely ss
ocited with
Glnzmnns throm stheni? A. Norml pltelet retion to ADP nd ristocetin;
retion to collen B. Norml pltelet retion to collen; decresed 
retion to ADP
nd ristocetin C. Norml pltelet retion to ristocetin; decresed reti
on to collen,
ADP, nd epinephrine D. Norml pltelet retion to ADP; decresed retio
n to collen nd
ristocetin Hemostsis/Correlte clinicl nd l ortory dt/ Pltelet disorders
/3 9. Which of
the followin is  chrcteristic of cute immune throm ocytopenic purpur? A. S
remission within  few weeks B. Predominntly seen in dults C. Nonimmune pltel
et destruction D.
Insidious onset Hemostsis/Apply knowlede of fundmentl ioloicl chrcteris
disorders/2 10. TTP di ers from DIC in tht: A. APTT is norml in TTP ut prolone
d in DIC B.
Schistocytes re not present in TTP ut re present in DIC C. Pltelet count is
decresed in TTP
ut norml in DIC D. PT is proloned in TTP ut decresed in DIC Hemostsis/Corr
elte clinicl
nd l ortory dt/ Pltelet disorders/3 2.2 | Pltelet nd Vsculr Disorders
49 Answers to

Questions 711 7. B BernrdSoulier syndrome is  disorder of pltelet dhesion cus

ed y
de ciency of lycoprotein I . Pltelet retion is norml in response to coll
en, ADP, nd
epinephrine ut  norml in response to ristocetin. 8. C Glnzmnns throm stheni
 is  disorder
of pltelet retion. Pltelet retion is norml in response to ristoceti
n, ut  norml
in response to collen, ADP, nd epinephrine. 9. A Acute immune throm ocytopeni
c purpur is n
immune-medited disorder found predominntly in children. It is commonly ssoci
ted with
infection (primrily virl). It is chrcterized y  rupt onset, nd spontneou
s remission
usully occurs within severl weeks. 10. A Throm otic throm ocytopenic purpur i
s  pltelet
disorder in which pltelet retion increses, resultin in throm ocytopeni.
Schistocytes re
present in TTP s  result of microniopthic hemolytic nemi; however, the PT
nd APTT re
oth norml. In DIC, the PT nd APTT re oth proloned, the pltelet count is d
ecresed, nd
schistocytes re seen in the peripherl smer. 11. C Neontl lloimmune throm o
cytopeni is
similr to the hemolytic disese of the fetus nd new orn. It results from immun
iztion of the
mother y fetl pltelet ntiens. The o endin nti odies re commonly nti HPA-1

llonti odies tht re directed inst lycoproteins II /III, I /IX, I/II ,
nd CD 109. The
mternl nti odies cross the plcent, resultin in throm ocytopeni in the fet
us. 11. Severl
hours fter irth,   y oy develops petechie nd purpur nd  hemorrhic d
ithesis. Te
pltelet count is 18 10 9
L. Wht is
the most likely explntion for the low pltelet count? A. Dru-induced
throm ocytopeni B.
Secondry throm ocytopeni C. Neontl lloimmune throm ocytopeni D. Neontl D
Hemostsis/Correlte clinicl nd l ortory dt/Pltelet disorders/3 2828_Ch02
06/08/12 11:09 AM Pe 49 12. Which of the followin is ssocited with post-t
purpur (PTP)? A. Nonimmune throm ocytopeni/llonti odies B. Immune-medited t
hrom ocytopeni/
llonti odies C. Immune-medited throm ocytopeni/ utonti odies D. Nonimmunemedited
throm ocytopeni/ utonti odies Hemostsis/Apply knowlede of fundmentl iolo
chrcteristics/Pltelet disorders/2 13. Hemolytic uremic syndrome (HUS) is sso
cited with: A.
Fever, throm ocytosis, nemi, nd renl filure B. Fever, rnulocytosis, nd t
hrom ocytosis C.
Escherichi coli 0157:H7 D. Leukocytosis nd throm ocytosis Hemostsis/Apply kno
wlede of
fundmentl ioloicl chrcteristics/Pltelet disorders/2 14. Store pool de ci
encies re
defects of: A. Pltelet dhesion B. Pltelet retion C. Pltelet rnules D.

production Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/

disorders/1 15. Lumi-retion mesures: A. Pltelet retion only B. Plte
let retion
nd ATP relese C. Pltelet dhesion D. Pltelet lycoprotein I Hemostsis/Sele
methods/Reents/Specimen collection nd hndlin/Areometry/1 16. Neuroloic
l ndins my e
commonly ssocited with which of the followin disorders? A. HUS B. TTP C. ITP
Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/Pltelet fu
nction/1 17.
Which of the followin is correct rerdin cquired throm otic throm ocytopenic
purpur? A.
Autoimmune disese B. Decresed VWF C. Decresed pltelet retion D. Decres
ed pltelet
dhesion Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/Pl
disorders/2 50 Chpter 2 | Hemostsis Answers to Questions 1218 12. B Post-trnsf
usion purpur
is  rre form of lloimmune throm ocytopeni chrcterized y severe throm ocyt
openi followin
trnsfusion of lood or lood products. PTP is cused y nti ody-relted pltel
et destruction in
previously immunized ptients. In the mjority of cses, the llonti ody produc
ed is inst
pltelet ntien A 1 (Pl A1 ), lso referred to s HPA-1. 13. C HUS is cused
y E. coli
0157:H7. It is ssocited with inestion of E. colicontminted foods nd is comm
only seen in
children. The clinicl mnifesttions in HUS re fever, dirrhe, throm ocytopen
microniopthic hemolytic nemi, nd renl filure. 14. C Store pool de cienci
es re defects
of pltelet rnules. Most commonly,  decrese in pltelet-dense rnules is pr
esent with
decresed relese of ADP, ATP, clcium, nd serotonin from pltelet-dense rnul
es. 15. B
Lumi-retion mesures pltelet retion nd ATP relese. It is performed
on whole lood
diluted with sline. Pltelet retion is mesured y impednce, wheres ATP
relese is
mesured y ddition of luciferin to  lood smple. There is no ATP relese in
store pool
de ciencies. 16. B TTP is chrcterized y neuroloicl pro lems, fever, throm ocy
microniopthic hemolytic nemi, nd renl filure. 17. A Acquired TTP is n 
utoimmune disese
ssocited with utonti odies produced inst VWF clevin enzyme (ADAMTS-13).
This de ciency
results in n increse in plsm VWF nd consequently incresed pltelet re
tion nd
throm ocytopeni. 18. D Hereditry hemorrhic telniectsi (Osler-We er-Rendu
syndrome) is 
connective tissue disorder ssocited with telniectses (dilted cpillries)
of the mucous
mem rnes nd skin. Lesions my develop on the tonue, lips, plte, fce, hnds
, nsl mucos,
nd throuhout the strointestinl trct. This disorder is n utosoml dominn
t condition tht

usully mnifests in dolescence or erly dulthood. 18. Hereditry hemorrhic

telniectsi is
 disorder of: A. Pltelets B. Clottin proteins C. Fi rinolysis D. Connective t
Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/2 2828_Ch02
06/08/12 11:09 AM Pe 50 19. Which of the followin prevents pltelet re
tion? A.
Trom oxne A 2 B. Trom oxne B 2 C. Prostcyclin D. Antithrom in Hemostsis/Appl
y knowlede of
fundmentl ioloicl chrcteristics/Pltelets/2 20. Which defect chrcterize
s Grys
syndrome? A. Pltelet dhesion defect B. Dense rnule defect C. Alph rnule d
efect D.
Coultion defect Hemostsis/Apply knowlede of fundmentl ioloicl chrcte
disorders/2 21. Te P2Y12 ADP receptor onist ssy my e used to monitor plte
let retion
inhi ition to which of the followin drus? A. Wrfrin B. Heprin C. LMWH D. Cl
(Plvix) Hemostsis/Selected methods/Reents/Specil tests/2 2.2 | Pltelet nd
Disorders 51 Answers to Questions 1921 19. C Prostcyclin is relesed from the
endothelium nd
is n inhi itor of pltelet retion. Throm oxne A 2 promotes pltelet re
Throm oxne B 2 is n oxidized form of throm oxne A 2 nd is excreted in the ur
ine. Antithrom in
is  physioloicl nticoulnt. 20. C Grys syndrome is  pltelet rnule defe
ct ssocited
with  decrese in lph rnules resultin in decresed production of lph r
nule proteins
such s pltelet fctor 4 nd et throm olo ulin. Alph rnule de ciency result
s in the
ppernce of rnulr pltelets when viewed on  Wrihts- stined lood smer.
21. D The
VerifyNow P2Y12 test is used to ssess  ptients response to ntipltelet drus
such s
clopidorel (Plvix) nd prsurel (E ent). These drus re iven orlly for preve
ntion of
throm osis lon with spirin, or s lterntive ntipltelet drus for ptients
who cnnot
tolerte or re not sensitive to spirin. Clopidorel nd prsurel prevent plt
elet retion
y irreversi ly indin to P2Y12, which is  pltelet mem rne receptor for ADP.
The VerifyNow
P2Y12 test is  whole lood test nd uses ADP s n retin ent to mesure
the level of
pltelet retion impired y these medictions. The seline pltelet re
tion is
est lished. The percent (%) chne from seline retion is clculted nd
reported s %
P2Y12 inhi ition. 2828_Ch02_041-074 06/08/12 11:09 AM Pe 51 22. Which of th
e followin
instruments cn e used to evlute pltelet function? A. Pltelet reometer
B. VerifyNow C.
PFA-100 D. All of the  ove Hemostsis/Selected methods/Reents/Specil tests/2
23. Which of the
followin pltelet retin ents demonstrtes  monophsic retion curv
e when used in

optiml concentrtion? A. Trom in B. Collen C. Adenosine diphosphte (ADP) D.

Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/Aretin
ents/1 52
Chpter 2 | Hemostsis Answers to Questions 2223 22. D All of the instruments lis
ted cn e used
to evlute pltelet function. Pltelet function testin is done to either deter
mine the cuse of
leedin in  ptient with norml pltelet count nd norml coultion tests, o
r to ssess the
e ccy of ntipltelet drus. Pltelet reometry is used for the dinosis of i
pltelet disorders. A pltelet reometer uses pltelet-rich plsm to mesure
retion in response to di erent pltelet retin ents y mesurin the l
trnsmission. A Lumi-reometer uses whole lood, nd hs the  ility to mesu
re dense-rnule
secretion (usin  luminescent mrker) in ddition to pltelet retion. The
mesures  ptients response to multiple ntipltelet drus includin spirin, P2
Y12 inhi itors,
nd lycoprotein II /III inhi itors. The PFA-100 (Pltelet Function nnlyzer-1
00) is used s 
pltelet function screen in plce of the leedin time. It uses citrted whole
lood. A drop of
venous lood is put into  test crtride. Vcuum is used to move the lood thro
uh  very thin
lss tu e tht hs een coted with  mem rne continin collen nd either e
pinephrine (EPI)
or ADP. This cotin ctivtes the pltelets in the movin smple, nd promotes
pltelet dhesion
nd retion. The time it tkes for the clot to form inside the lss tu e n
d prevent further
ow is mesured s the closure time (CT). An initil screen is done with collen/
EPI. If the CT
is norml, it is unlikely tht pltelet dysfunction exists. The collen/ADP mem
rne is used to
con rm n  norml collen/EPI test. If oth tests re  norml, it is likely th
t the ptient
hs  pltelet dysfunction, nd further testin for inherited nd cquired leed
in disorders is
indicted. If collen/ADP is norml, then the  norml collen/EPI test is lik
ely due to
spirin sensitivity. 23. B Collen is the only commonly used ent tht demonst
sinle-wve (monophsic) response preceded y  l time. 2828_Ch02_041-074 06/
08/12 11:09 AM
Pe 52 53 2.3 Coultion System Disorders 1. Te APTT is sensitive to  de ciency
of which
clottin fctor? A. Fctor VII B. Fctor X C. PF3 D. Clcium Hemostsis/Evlute
l ortory dt
to reconize helth nd disese sttes/Fctor de ciency/2 2. Which test result wou
ld e norml in
 ptient with dys rinoenemi? A. Trom in time B. APTT C. PT D. Immunoloic rino
en level
Hemostsis/Correlte clinicl nd l ortory dt/ Fctor de ciency/3 3. A ptient
proloned PT is iven intrvenous vitmin K. Te PT corrects to norml fter 24 h
ours. Wht

clinicl condition most likely cused these results? A. Necrotic liver disese B
. Fctor X
de ciency C. Fi rinoen de ciency D. O structive jundice Hemostsis/Correlte clini
cl nd
l ortory dt/ Vitmin K de ciency/3 4. Which fctor de ciency is ssocited with
PT nd APTT? A. X B. VIII C. IX D. XI Hemostsis/Evlute l ortory dt to rec
onize helth nd
disese sttes/Fctor de ciency/2 5. A proloned APTT is corrected with fctor VII
I de cient
plsm ut not with fctor IXde cient plsm. Which fctor is de cient? A. V B. VIII
C. IX D. X
Hemostsis/Evlute l ortory dt to reconize helth nd disese sttes/Fcto
r de ciency/3
Answers to Questions 16 1. B The APTT is sensitive to the de ciency of coultion
fctors in
the intrinsic pthwy (fctors XII, XI, IX, nd VIII) nd the common pthwy (f
ctors X, V, II,
nd I). 2. D The level of plsm rinoen determined immunoloiclly is norml. I
n  ptient
with dys rinoenemi,
rinoen is not polymerized properly, cusin  norml
rinoen-dependent coultion tests. 3. D O structive jundice contri utes to co
disorders y preventin vitmin K  sorption. Vitmin K is ft solu le nd requi
res ile slts
for  sorption. Prenterl dministrtion of vitmin K ypsses the owel; hence
the need for
ile slts. 4. A Fctor X,  common pthwy fctor de ciency, is most likely suspe
cted, ecuse
oth PT nd APTT re proloned. Other cuses my include liver disese, vitmin
K de ciency, nd
nticoulnt drus such s Coumdin nd heprin. 5. C Becuse the proloned APT
T is not
corrected with  fctor IXde cient plsm, fctor IX is suspected to e de cient in t
he test
plsm. 6. C Hemophili A (fctor VIII de ciency) is chrcterized y mild to seve
re leedin
episodes, dependin upon the concentrtion of fctor VIII:C. Hemophili A is inh
erited s 
sex-linked disese. Bleedin time nd prothrom in time re oth norml in hemoph
ili A. 6. Which
of the followin is  chrcteristic of clssic hemophili A? A. Proloned leed
in time B.
Autosoml recessive inheritnce C. Mild to severe leedin episodes D. Proloned
Hemostsis/Correlte clinicl nd l ortory dt/ Hemostsis/Hemophili/2 2828_
06/08/12 11:09 AM Pe 53 7. Refer to the followin results: PT = proloned AP
TT = proloned
Pltelet count = decresed Which disorder my e indicted? A. Fctor VIII de cien
cy B. von
Wille rnds disese C. DIC D. Fctor IX de ciency Hemostsis/Correlte clinicl nd
l ortory
dt/ Coultion disorders/3 8. Which of the followin is  predisposin condit
ion for the
development of DIC? A. Adenocrcinom B. Idiopthic throm ocytopenic purpur (IT
P) C.
Post-trnsfusion purpur (PTP) D. Heprin-induced throm ocytopeni (HIT) Hemost
clinicl nd l ortory dt/DIC/1 9. Fctor XII de ciency is ssocited with: A.

episodes B. Epistxis C. Decresed risk of throm osis D. Incresed risk of throm
Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/Fctor de cie
ncy/2 10. Te
followin results were o tined on  ptient: norml pltelet count nd function
, norml PT, nd
proloned APTT. Which of the followin disorders is most consistent with these r
esults? A.
Hemophili A B. BernrdSoulier syndrome C. von Wille rnds disese D. Glnzmnns
throm stheni Hemostsis/Correlte clinicl nd l ortory dt/ Coultion di
sorders/3 11. Te
followin l ortory results were o tined from  40-yer-old womn: PT = 20 sec
; APTT = 50 sec;
throm in time = 18 sec. Wht is the most pro  le dinosis? A. Fctor VII de cien
cy B. Fctor
VIII de ciency C. Fctor X de ciency D. Hypo rinoenemi Hemostsis/Correlte clinic
l nd
l ortory dt/ Fctor de ciency/3 12. When performin  fctor VIII ctivity ss
y,  ptients
plsm is mixed with: A. Norml ptients plsm B. Fctor VIII de cient plsm C. P
lsm with 
hih concentrtion of fctor VIII D. Norml control plsm Hemostsis/Apply prin
ciples of sic
l ortory procedures/Coultion tests/2 54 Chpter 2 | Hemostsis Answers to Q
uestions 712 7.
C In DIC, there is  di use intrvsculr enertion of throm in nd rin. As  res
coultion fctors nd pltelets re consumed, resultin in decresed pltelet
count nd
incresed PT nd APTT. 8. A Adenocrcinom cn li erte procoulnt (throm opl
stic) su stnces
tht cn ctivte prothrom in intrvsculrly. ITP is  throm ocytopeni cused
y n
utonti ody; PTP is n lloimmune throm ocytopeni cused y trnsfusion of lo
od or lood
products; HIT results from n nti ody to heprin-PF4 complex cusin throm ocyt
openi in 1%5%
of ptients who re on heprin therpy. In some  ected persons, throm osis my l
so occur. 9. D
Fctor XIIde cient ptients commonly hve throm otic episodes. Fctor XII is the co
ctivtor of the intrinsic pthwy of coultion. It lso plys  mjor role in
the rinolytic
system y ctivtin plsminoen to form plsmin. Hemorrhic mnifesttions re
not ssocited
with fctor XII de ciency ecuse throm in enerted y the extrinsic pthwy cn
ctivte fctor
XI to XI, nd fctor VII/TF cn ctivte fctor IX to IX. 10. A Hemophili A
is ssocited
with the de ciency of fctor VIII resultin in leedin nd n  norml APTT. The
pltelet num er
nd function re norml in this disorder. Von Wille rnds disese is  disorder o
f pltelet
dhesion ssocited with decresed VWF nd fctor VIII, cusin n  norml plt
elet function
test nd n  norml APTT test. Both Glnzmnns throm stheni nd BernrdSoulier
cuse de cient pltelet retion, ut do not cuse n  norml APTT. 11. D Fi r
inoen (fctor

I) is  clottin protein of the common pthwy nd is evluted y the throm in

time. In
hypo rinoenemi ( rinoen concentrtion <100 m/dL), the PT, APTT, nd TT re pro
loned. In
fctor VII de ciency, the APTT is norml; in fctor VIII de ciency, the PT is norml
; nd in
fctor X de ciency, the TT is norml. 12. B Coultion fctor ssys re sed up
on the  ility
of the ptients plsm to correct ny speci c fctor-de cient plsm. To mesure for
fctor VIII
ctivity in  ptients plsm, diluted ptient plsm is mixed with  fctor VIIId
e cient
plsm. An APTT test is performed on the mixture. Ech l ortory should clcul
te its own norml
rnes sed on ptient popultion, reents, nd the instrument used. An pprox
imte rne of
50%150% is considered norml. 2828_Ch02_041-074 06/08/12 11:09 AM Pe 54 13.
Te most
suit le product for tretment of fctor VIII de ciency is: A. Fresh frozen plsm
B. Fctor VIII
concentrte C. Prothrom in complex concentrte D. Fctor V Leiden Hemostsis/Cor
relte clinicl
nd l ortory dt/Tretment/2 14. Which of the followin is ssocited with n
pltelet retion test? A. Fctor VIII de ciency B. Fctor VIII inhi itor C. Lu
nticoulnt D. A rinoenemi Hemostsis/Correlte clinicl nd l ortory dt/
de ciency/2 15. Refer to the followin results: PT = norml APTT = proloned Bleed
in time=
incresed Pltelet count = norml Pltelet retion to ristocetin =  norml
Which of the
followin disorders my e indicted? A. Fctor VIII de ciency B. DIC C. von Wille
rnds disese
D. Fctor IX de ciency Hemostsis/Correlte clinicl nd l ortory dt/ Coult
ion disorders/3
16. Which results re ssocited with hemophili A? A. Proloned APTT, norml PT
B. Proloned PT
nd APTT C. Proloned PT, norml APTT D. Norml PT nd APTT Hemostsis/Correlte
clinicl nd
l ortory dt/ Hemophili/2 17. Fi rin monomers re incresed in which of the
conditions? A. Primry rinolysis B. DIC C. Fctor VIII de ciency D. Fi rinoen de ci
Hemostsis/Correlte clinicl nd l ortory dt/2 18. Which of the followin i
s ssocited with
multiple fctor de ciencies? A. An inherited disorder of coultion B. Severe liv
er disese C.
Dys rinoenemi D. Lupus nticoulnt Hemostsis/Correlte clinicl nd l orto
ry dt/ Fctor
de ciency/2 2.3 | Coultion System Disorders 55 Answers to Questions 1319 13. B
Fctor VIII
concentrte (humn or recom innt) is the tretment of choice for ptients with
fctor VIII
de ciency. Fresh frozen plsm contins fctor VIII; however, it is no loner used
s the primry
tretment for fctor VIII de ciency. Prothrom in complex concentrte is used to tr
et ptients
with fctor VIII inhi itor. 14. D Fi rinoen is  plsm protein tht is essenti
l for pltelet

retion nd rin formtion. In  rinoenemi, pltelet retion is  norml

. 15. C VWF
is involved in oth pltelet dhesion nd coultion vi complexin with fctor
VIII. Therefore,
in von Wille rnds disese (de ciency or functionl  normlity of VWF) fctor VIII
is lso
decresed, cusin n  norml APTT s well s  norml pltelet retion to
ristocetin. The
pltelet count nd the PT re not  ected in VWF de ciency. 16. A Hemophili A is s
socited with
fctor VIII de ciency. Fctor VIII is  fctor in the intrinsic coultion pthw
y tht is
evluted y the APTT nd not the PT test. The PT test evlutes the extrinsic 
nd common
pthwys. 17. B Incresed rin monomers result from coultion ctivtion. DIC i
s n cquired
condition ssocited with spontneous ctivtion of coultion nd rinolysis. I
n primry
rinolysis, the rinolytic system is ctivted nd rin monomers re norml. 18. B
Most of the
clottin fctors re mde in the liver. Therefore, severe liver disese results
in multiple
fctor de ciencies. An inherited disorder of coultion is commonly ssocited wi
th  sinle
fctor de ciency. Lupus nticoulnt is directed inst the phospholipid-depende
nt coultion
fctors. Dys rinoenemi results from n  norml
rinoen molecule. 19. D Fctor
de ciency cn led to impired wound helin nd my cuse severe leedin pro lem
s. Fctor XIII
rin st ilizin fctor tht chnes the
rinoen onds in
rin polymers to st
covlent onds. Fctor XIII is not involved in the process of rin formtion nd,
therefore, the
PT nd APTT re oth norml. 19. Norml PT nd APTT results in  ptient with 
poor wound
helin my e ssocited with: A. Fctor VII de ciency B. Fctor VIII de ciency C.
Fctor XII
de ciency D. Fctor XIII de ciency Hemostsis/Correlte clinicl nd l ortory dt
/ Fctor
de ciency/2 2828_Ch02_041-074 06/08/12 11:09 AM Pe 55 20. Fletcher fctor (pr
de ciency my e ssocited with: A. Bleedin B. Trom osis C. Trom ocytopeni D. T
rom ocytosis
Hemostsis/Correlte clinicl nd l ortory dt/ Fctor de ciency/2 21. One of t
complictions ssocited with  severe hemophili A is: A. Hemrthrosis B. Mucou
s mem rne
leedin C. Mild leedin durin surery D. Immune-medited throm ocytopeni Hem
knowlede of fundmentl ioloicl chrcteristics/Hemophili/1 22. Te most com
mon su type of
clssic von Wille rnds disese is: A. Type 1 B. Type 2A C. Type 2B D. Type 3 Hem
knowlede of fundmentl ioloicl chrcteristics/von Wille rnds disese/2 23.
A proloned
APTT nd PT re corrected when mixed with norml plsm. Which fctor is most li
kely de cient? A.
VIII B. V C. XI D. IX Hemostsis/Evlute l ortory dt to reconize helth n
d disese

sttes/Fctor de ciency/3 56 Chpter 2 | Hemostsis Answers to Questions 2023 20. B

fctor (prekllikrein) is  contct fctor. Activted prekllikrein is nmed kl
likrein nd is
involved in ctivtion of fctor XII to XII. Like fctor XII de ciency, Fletcher
de ciency my e ssocited with throm osis. 21. A In severe hemophili A, fctor
VIII ctivity
is less thn 1%, resultin in  severe leedin dithesis such s hemrthrosis (
leedin into the
joints). 22. A VWF is  multimeric plsm lycoprotein tht results in di erent su
types of von
Wille rnds disese with vried severity. The most common su type is su type 1, 
nd 70%80% of
these cses re ssocited with mild leedin. Su type 3 involves the totl  se
nce of the von
Wille rnds molecule nd is ssocited with severe leedin. Su types 2A nd 2B r
esult in
de ciency of intermedite nd/or hih moleculr weiht portions of the von Wille r
nd molecule
nd re ssocited with 10%12% nd 3%6% of cses of von Wille rnds disese, respec
tively. 23.
B Fctor V (common pthwy fctor) de ciency is most likely suspected, ecuse ot
h the PT nd
APTT re proloned, nd oth re corrected when mixed with norml plsm. 2828_C
06/08/12 11:09 AM Pe 56 57 2.4 Inhi itors, Trom otic Disorders, nd Antico
ulnt Drus 1.
Which chrcteristic descri es ntithrom in (AT)? A. It is synthesized in mek
ryocytes B. It is
ctivted y protein C C. It is  cofctor of heprin D. It is  ptholoicl in
hi itor of
coultion Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics
/AT/1 2. Which
l ortory test is  ected y heprin therpy? A. Trom in time B. Fi rinoen ssy
C. Protein C
ssy D. Protein S ssy Hemtoloy/Apply knowlede of fundmentl ioloicl
chrcteristics/Hemostsis/Heprin/2 3. An  norml APTT cused y  ptholoic
l circultin
nticoulnt is: A. Corrected with fctor VIIIde cient plsm B. Corrected with f
IXde cient plsm C. Corrected with norml plsm D. Not corrected with norml pls
Hemostsis/Correlte clinicl nd l ortory dt/ Specil tests/2 4. Te lupus 
 ects which of the followin tests? A. Fctor VIII ssy B. Fctor IX ssy C. VW
F ssy D.
Phospholipid-dependent ssys Hemostsis/Apply knowlede of fundmentl ioloic
chrcteristics/Lupus nticoulnt/2 5. Which sttement  out Coumdin (wrfri
n) is ccurte?
A. It is  vitmin B ntonist B. It is not recommended for prennt nd lctt
in women C. It
needs ntithrom in s  cofctor D. APTT test is used to monitor its dose Hemo
knowlede of fundmentl ioloicl chrcteristics/Wrfrin/2 Answers to Questi
ons 15 1. C
Antithrom in is heprin cofctor nd it is the most importnt nturlly occurrin
inhi itor of lood coultion. It represents  out 75% of ntithrom otic ctivi

ty nd is n 2lo ulin mde y the liver. 2. A Heprin is n ntithrom in dru, nd therefore
increses the
throm in time test lon with the APTT nd PT. Heprin therpy hs no e ect on rin
oen, protein
C, or protein S ssys. APTT is the test of choice for monitorin heprin therp
y. 3. D In the
presence of  ptholoicl circultin nticoulnt,  mixin test usin norml
plsm does not
correct the  norml APTT. These nticoulnts re ptholoicl su stnces nd
re endoenously
produced. They re either directed inst  speci c clottin fctor or inst 
roup of
fctors. A proloned APTT due to  fctor de ciency is corrected when mixed with 
norml plsm.
Fctors VIII nd IX de cient plsms re used for ssyin fctor VIII nd IX cti
respectively. 4. D The lupus nticoulnt interferes with phospholipid-dependen
t coultion
ssys such s the PT nd APTT tests. The lupus nticoulnt does not inhi it c
lottin fctor
ssys, nd does not inhi it in vivo coultion. 5. B Coumdin (wrfrin) cross
es the plcent
nd is present in humn milk; it is not recommended for prennt nd lcttin w
omen. Wrfrin is
 vitmin K ntonist dru tht retrds synthesis of the ctive form of vitmin
fctors (II, VII, IX, nd X). Antithrom in is  heprin (not wrfrin) cofctor.
Interntionl Normlized Rtio (INR) is used to monitor wrfrin dose. 2828_Ch
06/08/12 11:09 AM Pe 57 6. Which sttement rerdin protein C is correct? A
. It is  vitmin
Kindependent zymoen B. It is ctivted y
rinoen C. It ctivtes cofctors V n
d VIII D. Its
ctivity is enhnced y protein S Hemostsis/Apply knowlede of fundmentl iol
chrcteristics/Protein C/1 7. Which of the followin is n pproprite screenin
 test for the
dinosis of lupus nticoulnt? A. Trom in time test B. Diluted Russells viper
venom test
(DRVVT) C. D-dimer test D. FDP test Hemostsis/Correlte clinicl nd l ortory
nticoulnt/2 8. Which of the followin is most commonly ssocited with ctiv
ted protein C
resistnce (APCR)? A. Bleedin B. Trom osis C. Epistxis D. Menorrhi Hemosts
clinicl nd l ortory dt/ APCR/2 9. A 50-yer-old mn hs een on heprin fo
r the pst 7
dys. Which com intion of the tests is expected to e  norml? A. PT nd APTT
only B. APTT, TT
only C. APTT, TT, rinoen ssy D. PT, APTT, TT Hemostsis/Correlte clinicl n
d l ortory
dt/ Heprin therpy/3 10. Which of the followin drus inhi its ADP medited p
retion? A. Heprin B. Wrfrin C. Aspirin D. Prsurel Hemostsis/Correlte
clinicl nd
l ortory dt/ Pltelet retion/2 11. Trom in-throm omodulin complex is ne
cessry for
ctivtion of: A. Protein C B. Antithrom in C. Protein S D. Fctors V nd VIII H

knowlede of fundmentl ioloicl chrcteristics/Trom omodulin/2 58 Chpter 2
| Hemostsis
Answers to Questions 611 6. D Protein S functions s  cofctor of protein C nd
s such
enhnces its ctivity. Activted protein C inctivtes fctors V nd VIII. 7.
B Russells viper
venom (RVV) reent contins fctors X nd V, ctivtin enzymes tht re stron
ly phospholipid
dependent. The reent lso contins RVV, clcium ions, nd phospholipid. In the
presence of
phospholipid utonti odies such s lupus nticoulnt, the reent phospholipi
d is prtilly
neutrlized cusin prolontion of the clottin time. Throm in time evlutes
inoen. FDP nd
D-dimer tests evlute rinoen nd rin derdtion products. 8. B Activted prot
ein C
resistnce is the sinle most common cuse of inherited throm osis. In 90% of in
dividuls, the
cuse is ene muttion of fctor V (fctor V Leiden). A ected individuls re pred
isposed to
throm osis, minly fter e 40. Heterozyous individuls my not mnifest throm
osis unless
other clinicl conditions coexist. 9. D Heprin is  therpeutic nticoulnt w
ith n
ntithrom in ctivity. Heprin lso inhi its fctors XII, XI, X, nd IX. In
receivin heprin therpy, the PT, APTT, nd TT re ll proloned. Quntittive
rinoen ssy,
however, is not  ected y heprin therpy. 10. D Prsurel (E ent) is n ntipltel
et dru tht
reduces pltelet retion y irreversi ly lockin the P2Y12 receptors on the
pltelet surfce
mem rne, there y inhi itin pltelet retion to ADP. Aspirin is nother nt
ipltelet dru
tht inhi its pltelet retion y lockin the ction of the enzyme cyclo-ox
yense. Wrfrin
nd heprin re nticoulnt drus tht ct inst clottin fctors. 11. A Pro
tein C is
ctivted y throm inthrom omodulin complex. Throm omodulin (TM) is  trnsmem r
ne protein tht
ccelertes protein C ctivtion 1,000-fold y formin  complex with throm in.
When throm in
inds to TM, it loses its clottin function, includin ctivtion of fctors V 
nd VIII.
Activted protein C dectivtes fctors V nd VIII. Protein S is  cofctor ne
cessry for the
ctivtion of protein C. 2828_Ch02_041-074 06/08/12 11:09 AM Pe 58 12. Wht
test is used to
monitor heprin therpy? A. INR B. APTT C. TT D. PT Hemostsis/Correlte clinic
l nd l ortory
dt/ Heprin therpy/2 13. Wht test is commonly used to monitor wrfrin ther
py? A. INR B.
APTT C. TT D. Ecrin time Hemostsis/Correlte clinicl nd l ortory dt/ Wr
frin therpy/2
14. Wht clottin fctors (cofctors) re inhi ited y protein S? A. V nd X B.
V nd VIII C.
VIII nd IX D. VIII nd X Hemostsis/Correlte clinicl nd l ortory dt/ Clo
ttin fctors/2
15. Which dru promotes rinolysis? A. Wrfrin B. Heprin C. Urokinse D. Aspiri

Hemostsis/Correlte clinicl nd l ortory dt/ Terpies/2 16. Dinosis of l
nticoulnt is con rmed y which of the followin criteri? A. Decresed APTT B.
Correction of
the APPT y mixin studies C. Neutrliztion of the nti ody y hih concentrti
on of pltelets
D. Con rmtion tht  norml coultion tests re time nd temperture dependent
Hemostsis/Correlte clinicl nd l ortory dt/ LA/3 17. Which of the followi
n  normlities
is consistent with the presence of lupus nticoulnt? A. Decresed APTT/ leedi
n complictions
B. Proloned APTT/throm osis C. Proloned APTT/throm ocytosis D. Trom ocytosis/t
hrom osis
Hemostsis/Correlte clinicl nd l ortory dt/ LA/3 2.4 | Inhi itors, Trom o
tic Disorders,
nd Anticoulnt Drus 59 Answers to Questions 1217 12. B Heprin dose my
e monitored y
the APTT test. Heprin dose is djusted to n APTT of 1.52.5 times the men of th
e l ortory
reference rnes. This level of APTT is equivlent to plsm heprin levels of 0
.30.7 U/mL. The
PT would e proloned in heprin therpy, ut the test is not s sensitive s th
e APTT. Heprin
inhi its throm in, nd therefore, cuses  proloned TT. The TT test, however, i
s not used to
monitor heprin therpy. 13. A Wrfrin is  vitmin K ntonist dru. It inhi
its vitmin
Kdependent fctors (II, VII, IX, nd X) nd other vitmin Kdependent proteins such
s proteins
C nd S. Wrfrin therpy is monitored y the INR. An INR of 2.03.0 is used s th
e tret when
monitorin wrfrin therpy for prophylxis nd tretment of DVT. A hiher dose
of wrfrin
(ivin n INR of 2.5 3.5) is required for ptients with mechnicl hert vlves.
14. B Fctors
V nd VIII re dectivted y protein S nd ctivted protein C. 15. C Urokin
se is 
throm olytic dru commonly used to tret cute rteril throm osis. Urokinse c
n lso e used
for the tretment of venous throm oem olism, myocrdil infrction, nd clotted
Wrfrin nd heprin re nticoulnt drus, wheres spirin prevents pltelet
retion y
inhi itin cyclo-oxyense. 16. C The Interntionl Society of Hemostsis nd Th
rom osis hs
recommended four criteri for the dinosis of lupus nticoulnt: (1)  prolon
tion of one or
more of the phospholipid-dependent clottin tests such s APTT or DRVVT; (2) the
presence of n
inhi itor con rmed y mixin studies (not corrected); (3) evidence tht the inhi i
tor is directed
inst phospholipids y neutrlizin the nti odies with  hih concentrtion o
f pltelets
(pltelet neutrliztion test or DRVVT with pltelet-rich plsm); (4) lck of 
ny other cuses
for throm osis. Lupus inhi itor is not commonly time or temperture dependent. 1
7. B Lupus
nticoulnt interferes with phospholipids in the APTT reent, resultin in pr
olontion of

APTT. However, in vivo, lupus nticoulnt decreses

rinolytic ctivity, cusin
 n incresed
risk of throm osis. Lupus nticoulnt does not result in  leedin tendency u
nless there is 
coexistin throm ocytopeni or other coultion  normlity. 2828_Ch02_041-074
06/08/12 11:09
AM Pe 59 18. Which of the followin is  chrcteristic of low moleculr wei
ht heprin
(LMWH)? A. Generlly requires monitorin B. Speci clly cts on fctor V C. Hs 
hlf-life thn unfrctionted heprin D. Cn e used s  rinolytic ent Hemost
knowlede of fundmentl ioloicl chrcteristics/LMWH/1 19. Which of the foll
owin tests is
most likely to e  norml in ptients tkin spirin? A. Pltelet morpholoy B.
Pltelet count
C. Bleedin time D. Prothrom in time Hemostsis/Correlte clinicl nd l ortor
y dt/ Aspirin
therpy/2 20. Which of the followin is ssocited with ntithrom in de ciency? A.
Trom ocytosis
B. Trom osis C. Trom ocytopeni D. Bleedin Hemostsis/Correlte clinicl nd l
ortory dt/
Inhi itors/2 21. Which of the followin my e ssocited with throm otic events
? A. Decresed
protein C B. Incresed
rinolysis C. A rinoenemi D. ITP Hemostsis/Correlte cli
nicl nd
l ortory dt/ Protein C/2 22. Aspirin resistnce my e ssocited with: A. B
leedin B. Fctor
VIII de ciency C. Trom osis D. Trom ocytosis Hemostsis/Correlte clinicl nd l
ortory dt/
Aspirin resistnce/2 23. A proloned throm in time is indictive of which of the
ntithrom otic therpies? A. Prsurel B. Clopidorel C. Aspirin D. Heprin Hemo
clinicl nd l ortory dt/ Antithrom otic therpy/2 60 Chpter 2 | Hemostsis
Answers to
Questions 1824 18. C Low moleculr weiht heprin (LMWH) is  smll lycosminol
ycn tht is
derived from unfrctionted heprin (UFH). The LMWH hs  low  nity for plsm pr
oteins nd
endothelil cells nd therefore hs  loner hlf-life. The hlf-life of the dru
 does not depend
on the dose. LMWH hs n inhi itory e ect on fctors X nd II. It does not req
uire routine
monitorin except in ptients with renl filure, o ese ptients, peditric pti
ents, nd
prennt ptients. 19. C Aspirin is n ntipltelet dru. It prevents pltelet 
retion y
inhi ition of cyclo-oxyense. Aspirin hs no e ect on the pltelet count, pltele
t morpholoy,
or prothrom in time. 20. B Antithrom in is  physioloicl nticoulnt. It inh
i its fctors
II, X, IX, XI, nd XII. De ciency of ntithrom in is ssocited with throm os
is. Throm otic
events my e primry (in the  sence of  trierin fctor) or my e ssoci
ted with nother
risk fctor such s prenncy or surery. 21. A Protein C is  physioloicl inh
i itor of
coultion. It is ctivted y throm inthrom omodulin complex. Activted protein
C inhi its

cofctors V nd VIII. The de ciency of protein C is ssocited with throm osis.
rinolysis,  rinoenemi, nd ITP re ssocited with leedin. 22. C Up to 22% o
f ptients
tkin spirin ecome resistnt to spirins ntipltelet e ect. Ptients who re s
resistnt hve  hiher risk of throm osis (hert ttcks nd strokes). 23. D He
prin is n
ntithrom in dru cusin proloned TT in ptients who re on heprin therpy. P
clopidorel, nd spirin re ntipltelet drus cusin inhi ition of pltelet 
retion. 24. C
L ortory tests for evlution of throm ophili re justi ed in youn ptients wi
th throm otic
events, in ptients with  positive fmily history fter  sinle throm otic eve
nt, in those with
recurrent spontneous throm osis, nd in prenncies ssocited with throm osis.
24. Screenin
tests for throm ophili should e performed on: A. All prennt women ecuse of
the throm otic
risk B. Ptients with  netive fmily history C. Ptients with throm otic even
ts occurrin t 
youn e D. Ptients who re receivin nticoulnt therpy Hemostsis/Correl
te clinicl nd
l ortory dt/Trom ophili/2 2828_Ch02_041-074 06/08/12 11:09 AM Pe 60 25
. Prothrom in
G20210A is chrcterized y which of the followin cuses nd conditions? A. Sin
le muttion of
prothrom in molecule/ leedin B. Sinle muttion of prothrom in molecule/ throm
osis C.
Decresed levels of prothrom in in plsm/ throm osis D. Incresed levels of pro
throm in in
plsm/ leedin Hemostsis/Correlte clinicl nd l ortory dt/ Prothrom in/
3 26. Fctor V
Leiden promotes throm osis y preventin: A. Dectivtion of fctor V B. Activ
tion of fctor V
C. Activtion of protein C D. Activtion of protein S Hemostsis/Correlte clini
cl nd
l ortory dt/ Fctor V Leiden/3 27. Wht is the pproximte incidence of nti
nti odies in the enerl popultion? A. <1% B. 2% C. 10% D. 20% Hemostsis/Appl
y knowlede of
fundmentl ioloicl chrcteristics/LA/1 28. Which of the followin l ortor
y tests is
helpful in the dinosis of spirin resistnce? A. APTT B. PT C. Pltelet count
nd morpholoy D.
Pltelet retion Hemostsis/Correlte clinicl nd l ortory dt/ Aspirin
resistnce/3 29.
Which of the followin complictions my occur s  result of decresed tissue f
ctor pthwy
inhi itor (TFPI)? A. Incresed hemorrhic episodes B. Incresed throm otic risk
C. Impired
pltelet plu formtion D. Immune throm ocytopeni Hemostsis/Apply knowlede of
ioloicl chrcteristics/ TFPI/2 2.4 | Inhi itors, Trom otic Disorders, nd An
ticoulnt Drus
61 Answers to Questions 2530 25. B Prothrom in G20210A is de ned s  sinle-poin
t muttion of
the prothrom in ene, resultin in incresed concentrtion of plsm prothrom in
nd there y 

risk fctor for throm osis. Prothrom in G20210A is the second most common cuse
of inherited
hypercoul ility ( ehind fctor V Leiden). It hs the hihest incidence in whi
tes from southern
Europe. The throm otic episodes enerlly occur efore e 40. 26. A Fctor V Le
iden is 
sinle-point muttion in the fctor V ene tht inhi its fctor V inctivtion
y protein C.
Activted protein C enhnces dectivtion of fctors V nd VIII. 27. B The inc
idence of
ntiphospholipid nti odies in the enerl popultion is  out 2%. 28. D Current
ly, the pltelet
retion test is considered the old stndrd for evlution of spirin resis
tnce. In spirin
resistnce, pltelet retion is not inhi ited y spirin inestion. Aspirin
resistnce hs no
e ect on pltelet count nd morpholoy. 29. B Tissue fctor pthwy inhi itor (TFP
I) is relesed
from the vsculture nd is the most importnt inhi itor of the extrinsic pthw
y. TFPI inhi its
fctors X nd VII-TF complex. Therefore, the de ciency of TFPI is ssocited wit
h throm osis.
30. D Fctor VIII inhi itors (nti odies) occur in 10%20% of ptients with fctor
VIII de ciency
receivin fctor VIII replcement. 30. Fctor VIII inhi itors occur in _________
___ of ptients
with fctor VIII de ciency? A. 40%50% B. 30%40% C. 25%30% D. 10%20% Hemostsis/Apply
knowlede of fundmentl ioloicl chrcteristics/Inhi itors/1 2828_Ch02_041-0
74 06/08/12
11:09 AM Pe 61 31. Which therpy nd resultin mode of ction re pproprite
for the
tretment of  ptient with  hih titer of fctor VIII inhi itors? A. Fctor VI
II concentrte to
neutrlize the nti odies B. Recom innt fctor VII (rVII) to ctivte fctor
X C. Fctor X
concentrte to ctivte the common pthwy D. Fresh frozen plsm to replce fc
tor VIII
Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/Inhi itors/
2 32. Te Bethesd
ssy is used for which determintion? A. Lupus nticoulnt titer B. Fctor VI
II inhi itor
titer C. Fctor V Leiden titer D. Protein S de ciency Hemostsis/Select methods/Re
tests/2 33. Hyperhomocysteinemi my e  risk fctor for: A. Bleedin B. Trom o
cythemi C.
Trom osis D. Trom ocytopeni Hemostsis/Correlte clinicl nd l ortory dt/H
omocysteine/2 34.
Which dru my e ssocited with deep venous throm osis (DVT)? A. Aspirin B. tP
A C. Orl
contrceptives D. Plvix (clopidorel) Hemostsis/Apply knowlede of fundmentl
chrcteristics/Trom ophili/2 35. Artro n my e used s n nticoulnt dr
u in ptients
with: A. DVT B. Hemorrhe C. TTP D. Trom ocytosis Hemostsis/Apply knowlede of
ioloicl chrcteristics/Terpies/2 36. Heprin-induced throm ocytopeni (HIT)
results from: A.
Anti odies to heprin B. Anti odies to pltelets C. Anti odies to PF4 D. Anti od
ies to
heprin-PF4 complex Hemostsis/Apply knowlede of fundmentl ioloicl chrct

eristics/HIT/2 62
Chpter 2 | Hemostsis Answers to Questions 3136 31. B Recom innt fctor VII (rV
II) is
e ective for the tretment of  hih titer fctor VIII inhi itor. Fctor VII cn
ctivte fctor X to X in the  sence of fctors VIII nd IX. Recom innt fcto
r VII does not
stimulte nmnestic responses in ptients with fctor VIII inhi itor. Fctor VI
II concentrte is
used for  low titer fctor VIII inhi itor. Fctor X concentrte nd FFP re not
the tretments
of choice for fctor VIII inhi itor. 32. B The Bethesd ssy is  quntittive
ssy for fctor
VIII inhi itor. In this ssy, norml plsm is incu ted with di erent dilutions
of the
ptients plsm or  norml control. The inhi itor inctivtes fctor VIII presen
t in norml
plsm followin incu tion for 2 hours t 37C. The residul ctivities in the s
mple re
determined, nd the inhi itor titer is clculted. 33. C Elevted plsm homocys
teine is  risk
fctor for the development of venous throm osis. Homocystinemi my e inherited
or cquired.
Acquired homocystinemi is cused y the dietry de ciencies of vitmins B 6 , B 1
2 , nd folic
cid. 34. C Orl contrceptive drus re cquired risk fctors for throm osis. A
spirin nd Plvix
re ntipltelet drus nd tPA is  rinolytic dru used for the tretment of thr
om osis. 35. A
Artro n is  throm in inhi itor dru nd my e used s n nticoulnt in p
tients with
heprin-induced throm ocytopeni (HIT) to prevent throm osis. Artro n is  sm
ll synthetic
molecule tht inds to free nd clot- ound throm in. Artro n ffects TT, PT,
tests. The APTT test is recommended for monitorin the dose with the tret th
erpeutic rne
of 1.5 to 3.0 times the men of the l ortory reference rne. In ptients with
nticoulnt or fctor deficiencies, the seline APTT is proloned; in these c
onditions, the
Ecrin time cn e used s n lterntive ssy. 36. D Heprin-induced throm ocy
topeni is n
immune process cused y the production of nti odies to heprin-PF4 complex. Th
is immune complex
inds to pltelet Fc receptors, cusin pltelet ctivtion nd formtion of pl
microprticles tht in turn induce hypercoul ility nd throm ocytopeni. 2828
06/08/12 11:09 AM Pe 62 37. Which l ortory test is used to screen for cti
vted protein C
resistnce? A. Mixin studies with norml plsm B. Mixin studies with fctor-d
e cient plsm C.
Modi ed APTT with nd without ctivted protein C D. Modi ed PT with nd without ct
protein C Hemostsis/Select methods/Reents/Specil tests/2 38. Ecrin clottin
time my e used
to monitor: A. Heprin therpy B. Wrfrin therpy C. Fi rinolytic therpy D. Hi
rudin therpy
Hemostsis/Select methods/Reents/Specil tests/2 39. Which of the followin m

y interfere with
the ctivted protein C resistnce (APCR) screenin test? A. Lupus nticoulnt
B. Protein C
de ciency C. Antithrom in de ciency D. Protein S de ciency Hemostsis/Correlte clinic
l nd
l ortory/Specil tests/2 40. Trom ophili my e ssocited with which of the
disorders? A. A rinoenemi B. Hypo rinoenemi C. Fctor VIII inhi itor D. Hyper r
Hemostsis/Apply knowlede of fundmentl ioloicl chrcteristics/Fi rinoen/
2 41. Which of
the followin nticoulnt drus cn e used in ptients with HIT? A. Wrfrin
B. Heprin C.
Aspirin D. Lepirudin Hemostsis/Apply knowlede of fundmentl ioloicl
chrcteristics/Terpies/2 2.4 | Inhi itors, Trom otic Disorders, nd Anticoul
nt Drus 63
Answers to Questions 3741 37. C Activted protein C resistnce cn e evluted
y  two-prt
APTT test. The APTT is mesured on the ptients plsm with nd without the ddit
ion of
ctivted protein C (APC). The result is expressed s the rtio of the APTT with
APC to the APTT
without APC. The norml rtio is 2:5. Ptients with APCR hve  lower rtio thn
the reference
rne. A positive screenin test should e followed y  con rmtory test such s
chin rection (PCR) for fctor V Leiden. 38. D Ecrin clottin time,  snke ve
nom sed
clottin ssy, my e used to monitor hirudin therpy in instnces when the s
eline APTT is
proloned due to lupus nticoulnt or fctor de ciencies. The APTT is insensitiv
e to hirudin
levels  ove 0.6 m/L, nd this insensitivity my result in  dru overdose desp
ite  monitorin
protocol. Heprin therpy is monitored y the APTT; wrfrin therpy is monitore
d y the INR.
Fi rinolytic therpy my e monitored y D-dimer. 39. A The lupus nticoulnt
interferes with
the APCR screenin ssy sed on the APTT rtio with nd without APC ddition.
Persons with the
lupus nticoulnt hve  proloned APTT tht renders the test invlid for APCR
screenin. 40. D
Hyper rinoenemi is  risk fctor for throm ophili. Fi rinoen is n cute phs
e rectnt nd
my e incresed in in mmtion, stress, o esity, smokin, nd medictions such s
contrceptives. Hypo rinoenemi,  rinoenemi, nd fctor VIII inhi itors re s
socited with
leedin. 41. D Lepirudin is  recom innt nloue of hirudin. It is n ltern
nticoulnt dru used in ptients with HIT who cnnot tolerte heprin or LMWH
Wrfrin should not e used to nticoulte persons with HIT ecuse it cuses
 fll in protein
C concentrtion prior to inducin  decrese in coultion fctors derived from
vitmin K. The
lower protein C predisposes HIT ptients to le throm osis. 2828_Ch02_041-074 0
6/08/12 11:09 AM
Pe 63 42. Which of the followin is the preferred method to monitor heprin t
herpy t the

point of cre durin crdic surery? A. APTT B. Activted clottin time test (A
Hemostsis/Correlte clinicl nd l ortory/Specil tests/2 43. Mrs. Smith hs
the followin
l ortory results, nd no leedin history: APTT: proloned APTT results on  1
:1 mixture of the
ptients plsm with norml plsm: Preincu tion: proloned APTT 2-hour incu ti
on: proloned
APTT Tese results re consistent with: A. Fctor VIII de ciency B. Fctor VIII inh
i itor C. Lupus
nticoulnt D. Protein C de ciency Hemostsis/Correlte clinicl nd l ortory
dt/ Specil
tests/3 44. Which test my e used to monitor LMWH therpy? A. APTT B. INR C. An
ti-X heprin
ssy D. Activted clottin time Hemostsis/Correlte clinicl nd l ortory d
therpy/3 64 Chpter 2 | Hemostsis Answers to Questions 4244 42. B The ctivted
clottin time
(ACT) is  point-of-cre coultion test used to monitor hih-dose heprin ther
py durin
crdic surery, crdic nioplsty, hemodilysis, nd other mjor sureries. I
t is the
preferred method to determine if su cient heprin ws dministered to prevent clot
tin durin
surery ecuse it is more rpid thn the APTT test. The test uses  clot ctiv
tor such s
Kolin or Celite to stimulte coultion, nd the time in seconds is linerly r
elted to the
dose of heprin dministered. The ACT test is vil le in di erent formts, nd t
he reference
rne vries dependin on the method used. At low to moderte heprin doses, the
ACT test does
not correlte well with the APTT or the nti- fctor X ssy. 43. C Mixin stud
ies di erentite
fctor de ciencies from fctor inhi itors. Lupus nticoulnt is ssocited with
throm osis, nd
it is directed inst phospholipid-dependent coultion tests such s the APTT
. In ptients
with lupus nticoulnt, the APTT fter mixin ptients plsm with norml plsm
proloned immeditely fter mixin nd followin 2-hours incu tion. Fctor VIII
de ciency nd
fctor VIII inhi itor re ssocited with leedin. Fctor VIII inhi itor is tim
e nd temperture
dependent. The proloned APTT my e corrected immeditely fter mixin, nd ec
omes proloned
followin incu tion. In fctor VIII de ciency, the proloned APTT would e correc
ted fter
mixin the ptients plsm with norml plsm. 44. C The nti-fctor X heprin 
ssy is used to
monitor LMWH therpy when required ecuse the APTT test is insensitive to LMWH.
The ssy cn e
performed y chromoenic end-point detection used on utomted nlyzers. The pr
inciple of the
test is to mesure the inhi ition of X y heprin. The reent is  mixture of
concentrtion of fctor X,  su strte which is speci c for fctor X, nd  xed c
of ntithrom in (AT). Some kits rely on the ntithrom in in ptients plsm. Hep
rin forms 

complex with AT nd fctor X (AT-heprin-X). Excess free fctor X cleves the
su strte nd releses  yellow product. The color intensity of the product is i
proportionl to plsm heprin concentrtion, nd is mesured y  photodetector
t 405 nm. LMWH
therpy does not usully require monitorin; however, exceptions include peditr
ic, o ese, nd
prennt ptients nd those with renl filure. 2828_Ch02_041-074 06/08/12 11:
09 AM Pe 64 65
2.5 Hemostsis Pro lem Solvin 1. Ptient History A 3-yer-old mle ws dmitted
to  hospitl
with scttered petechie nd epistxis. Te ptient hd norml rowth nd hd no
other medicl
pro lems except for chickenpox 3 weeks erlier. His fmily history ws unremrk
le. Answer to
Question 1 1. C These clinicl mnifesttions nd l ortory results re consist
ent with ITP. ITP
is n utoimmune throm ocytopeni. In children, cute ITP throm ocytopeni occur
s followin 
virl infection, s is the cse in this 3-yer-old ptient. Clinicl mnifestti
ons re
ssocited with petechie, purpur, nd mucous mem rne leedins such s epist
xis nd inivl
leedin. A norml l ortory tests include  very low pltelet count nd  prol
oned leedin
time. Other cuses of throm ocytopeni should e ruled out in ptients with ITP.
L ortory
Results Ptient Reference Rne PT: 11 sec 1013 sec APTT: 32 sec 2837 sec Pltele
t count: 18
10 3
L 150450 10
Tese clinicl mnifesttions nd l ortory results re consistent with
which condition? A.
TTP B. DIC C. ITP D. HUS Hemostsis/Evlute l ortory dt to reconize helth
nd disese
sttes/Pltelet disorders/3 2828_Ch02_041-074 06/08/12 11:09 AM Pe 65 2. P
tient History A
12-yer-old white mle hs the followin symptoms: visi le ruisin on rms nd
les, ruisin
fter sports ctivities, nd excessive postopertive hemorrhe followin tonsil
lectomy 3 months
o. His fmily history reveled tht his mother su ers from hevy menstrul leed
in, nd his
mternl rndfther hd recurrent nose leeds nd ruisin. 66 Chpter 2 | Hemos
tsis Answers to
Questions 24 2. B These clinicl mnifesttions nd l ortory results re consis
tent with von
Wille rnds disese. Von Wille rnds disese is n inherited leedin disorder cu
sed y
 norml pltelet dhesion. Pltelet dhesion depends on VWF nd lycoprotein I
. In von
Wille rnds disese, VWF is de cient or dysfunctionl. VWF promotes secondry hemos
tsis y
ctin s  crrier for fctor VIII. De cient or dysfunctionl VWF results in decr
esed fctor
VIII nd therefore  norml secondry hemostsis. The clinicl mnifesttions s
socited with von

Wille rnds disese re esy ruisin, epistxis, nd leedin fter surery. A n
l ortory test results re incresed leedin time nd  norml pltelet re
tion to
ristocetin, which is corrected on ddition of norml plsm continin VWF. Acti
vted prtil
throm oplstin time (APTT) is proloned s  result of the de ciency of fctor VII
I. Fctor VIII
ctivity (VIII:C), VWF ristocetin cofctor ctivity (VWF:Rco), nd VWF:ntienic
(VWF:ntien) re ll  norml. The pltelet count nd prothrom in time re norm
l in von
Wille rnds disese. 3. D Cryoprecipitte contins
rinoen, fctor VIII, nd VWF.
Fresh frozen
plsm hs ll of the clottin fctors; however, it is not the est choice if cr
yoprecipitte is
vil le. 4. C The pltelet count should e checked every other dy in ptients
heprin therpy. Heprin-induced throm ocytopeni (HIT) should e suspected in p
tients who re
not respondin to heprin therpy nd/or re developin throm ocytopeni (50% e
low the seline
vlue) nd throm otic complictions while on heprin therpy. Increse in hepri
n dose should e
voided in ptients with the clinicl symptoms of throm osis while they re rece
ivin heprin.
Fi rinoen ssy nd PT re not the pproprite ssys for monitorin heprin th
erpy, nor re
they used to test for HIT. L ortory Results Reference Ptient Rne Pltelet
Count: 350 10
L 200450 10
PT: 11.0 sec 1012 sec APTT: 70 sec 2837 sec TT: 13 sec 1015 sec Pltelet A
Norml retion with collen, epinephrine, ADP A norml retion with ris
Confirmtory Reference Tests Ptient Rne VWF:Rco 25% 45%140% VIII:C 20% 5
WWF:ntien 10% 45%185% Tese clinicl mnifesttions nd l ortory results re c
onsistent with
which dinosis? A. Fctor VIII de ciency B. von Wille rnds disese C. Glnzmnns
throm stheni D. BernrdSoulier syndrome Hemostsis/Evlute l ortory dt to
helth nd disese sttes/Pltelet disorders/3 3. Te followin results re o ti
ned from 
ptient who developed severe leedin: Proloned PT nd APTT Pltelet count = 10
0 10 9
Fi rinoen = 40 m/dL Which of the followin lood products should e re
commended for
trnsfusion? A. Fctor VIII concentrte B. Pltelets C. Fresh frozen plsm D. C
Hemostsis/Correlte clinicl nd l ortory dt/ Terpies/2 4. A 30-yer-old w
omn develops
sins nd symptoms of throm osis in her left lower le followin 5 dys of hepr
in therpy. Te
ptient hd open-hert surery 3 dys previously nd hs een on heprin ever si
nce. Which of the

followin would e the most helpful in mkin the dinosis? A. Fi rinoen ssy
B. Prothrom in
time C. Pltelet counts D. Incresed heprin dose Hemostsis/Correlte clinicl
nd l ortory
dt/Heprin therpy/3 2828_Ch02_041-074 06/08/12 11:09 AM Pe 66 5. Te foll
owin l ortory
results were o tined on  25-yer-old womn with menorrhi fter delivery of
her second son.
Te ptient hs no previous leedin history. Norml pltelet count; norml leed
in time; norml
PT; proloned APTT Mixin of the ptients plsm with norml plsm corrected the
proloned APTT
on immedite testin. However, mixin followed y 2-hour incu tion t 37C cused
APTT. Wht is the most pro  le cuse of these l ortory results? A. Lupus nti
coulnt B.
Fctor VIII de ciency C. Fctor IX de ciency D. Fctor VIII inhi itor Hemostsis/Cor
clinicl nd l ortory dt/ Specil tests/3 6. A 62-yer-old femle presents w
ith jundice nd
the followin l ortory dt: Peripherl lood smer: mcrocytosis, tret cell
s Pltelet count:
355 10 9
PT: 25 sec (reference rne =1014) APTT: 65 sec (reference rne = 2836) T
elevted (AST:ALT>1) Totl nd direct iliru in: elevted Tese clinicl present
tions nd
l ortory results re consistent with: A. Inherited fctor VII de ciency B. DIC C
. Cirrhosis of
the liver D. von Wille rnds disese Hemostsis/Correlte clinicl nd l ortory
dt/Coultion disorders/3 7. When performin  mixin study, the ptients APTT
is corrected
to 12% of norml. Wht is the most pproprite interprettion of these ndins? A.
Te APTT is
considered corrected B. Te APTT is considered uncorrected C. Te mixin study nee
ds to e repeted
D. A circultin nticoulnt cn e ruled out Hemostsis/Correlte clinicl n
d l ortory
dt/ Mixin studies/3 2.5 | Hemostsis Pro lem Solvin
67 Answers to Question
s 57 5. D Fctor
VIII inhi itor is found in 10%20% of hemophili ptients receivin replcement th
erpy. It my
lso develop in ptients with immunoloic pro lems, women fter child irth, nd
ptients with
lymphoprolifertive nd plsm cell disorders, or it my develop in response to
Fctor VIII inhi itor is n IG immunolo ulin with n inhi itory e ect tht is ti
me nd
temperture dependent. The presence of fctor VIII inhi itor cuses n elevted
APTT in the fce
of  norml prothrom in time. Mixin studies in fctors VIII nd IX de ciencies wi
ll correct the
proloned APTT oth t the immedite mixin ste nd fter incu tion for 2 hou
rs. The APTT
would not e corrected y mixin studies if lupus nticoulnt ws present. In
ddition, lupus
nticoulnt is not ssocited with leedin unless it coexists with throm ocyt
openi. 6. C The
clinicl presenttion nd l ortory results in this ptient re indictive of c

irrhosis of the
liver. Most of the clottin fctors re mde in the liver. A decrese in multipl
e clottin
fctors is ssocited with  proloned PT nd APTT. Mcrocytosis nd tret cell
s re present in
liver disese. The liver chnes the unconjuted iliru in to conjuted iliru
in. Conjuted
iliru in is excreted into the intestines, where the iliru in is then converted
to uro ilinoen
nd excreted into the stool. In cirrhosis of the liver, oth necrosis nd o stru
ction cused y
scrrin produce n increse in unconjuted nd conjuted iliru in, respectiv
ely. In ddition,
the liver enzymes re elevted (the AST:ALT rtio is <1 in necrotic liver dises
es such s
heptitis ut not in cirrhosis). 7. C In mixin studies, correction occurs if 
proloned APTT
result drops to within 10% of the result of norml humn plsm. Only 50% fctor
ctivity is
required for  norml PT or APTT. Clottin results
15% re not considered corrected, nd results
etween 10%15% should e repeted. A circultin nticoulnt typiclly
results in filure
to correct the APTT with norml plsm. 2828_Ch02_041-074 06/08/12 11:09 AM P
e 67 8. A
stndrd lue-top tu e lled ppropritely (with 4.5 mL lood) ws su mitted to th
e l ortory
for preopertive PT nd APTT testin. Te results of oth tests were elevted. Te
ptients PT nd
APTT from the previous dy were within norml limits, nd he is not on heprin t
herpy. Which is
the most pproprite rst step to investite the  norml results? A. Report the
result s
o tined B. Perform  mixin study C. Check the smple for  clot D. Report the
APTT only
Hemostsis/Apply knowlede to identify sources of errors/Specimens/3 9. A plsm
smple su mitted
to the l for PT testin hs een stored for 25 hours t 4C. Te PT result is sho
rtened. Wht is
the most pro  le cuse? A. Fctor VII de ciency B. Activtion of fctor VII due t
o exposure to
cold temperture C. Lupus inhi itor D. Fctor X inhi itor Hemostsis/Apply knowl
ede to identify
sources of errors/Specimen store/3 10. Te APTT results re not elevted in  p
tient receivin
heprin. Which of the followin fctors my e ssocited with the lck of respo
nse to heprin
therpy in this ptient? A. Protein C de ciency B. Antithrom in de ciency C. Protein
S de ciency
D. Fctor VIII de ciency Hemostsis/Correlte clinicl nd l ortory dt/ Inhi i
tors/3 11. A
50-yer-old ptient ws dmitted to the emerency deprtment complinin of pin
in her riht
le. Her le ws red, swollen, nd wrm to the touch. Deep venous throm osis ws
suspected, nd
the ptient ws strted on heprin therpy. Which of the followin is (re) the
proper protocol
to evlute ptients receivin heprin therpy? A. A seline APTT nd pltelet
count; APTT
testin every 6 hours until the tret is reched B. Repet APTT fter 5 dys po

stheprin therpy
to djust the therpeutic dose C. Monitor the pltelet count dily nd every oth
er dy fter
heprin therpy is completed D. Monitor PT dily to djust the therpeutic dose
Hemostsis/Correlte clinicl nd l ortory dt/ Heprin therpy/2 68 Chpter
2 | Hemostsis
Answers to Questions 811 8. C A clot cn form ecuse of indequte mixin of the
smple fter
venipuncture, if the lood lls the evcuted tu e t  slow rte, or with trumt
venipuncture. In vitro, lood clots result in consumption of the clottin fctor
s nd therefore
prolontion of PT, APTT, nd other clot- sed ssys. If the clottin fctors h
ve een
ctivted ut the clot formtion is incomplete, it my result in shortenin of t
he PT nd APTT.
Checkin the smple for  clot is the most reson le step in this cse. 9. B S
mples for
evlution of PT re st le for 24 hours if kept t room temperture. Proloned
exposure to cold
will ctivte fctor VII, resultin in decresed PT results. 10. B Antithrom in
de ciency in
ptients receivin heprin therpy my led to heprin resistnce, nd therefore
, lck of
prolontion of APTT results. Antithrom in is  heprin cofctor nd s such inc
reses heprin
ctivity y 1,000-fold. The de ciency of AT is ssocited with  poor response to
therpy. 11. A The seline pltelet count nd APTT should e performed on ll p
tients prior to
dministrtion of heprin. The response to heprin therpy vries mon di erent p
tients for the
followin resons: Heprin hlf-life is decresed in extended throm osis, nd th
e nticoulnt
ctivities of heprin chne sed upon nonspeci c indin of heprin to plsm pr
Therefore, heprin therpy should e closely monitored. Heprin dose cn e mo
nitored y n
APTT or ctivted clottin time (ACT) test ut not y the PT. In ddition, the p
ltelet count
should e monitored reulrly durin heprin therpy, ecuse  decrese of the
pltelet count to
50% elow the seline vlue is sini cnt nd my e ssocited with HIT. 2828_Ch
06/08/12 11:09 AM Pe 68 12. Ptient History: A 46-yer-old femle ws dmitt
ed to the
emerency deprtment with complints of hedche, dizziness, lethry, nuse, v
omitin, nd
wekness. Te ptient hd  strectomy procedure 4 months erlier to remove den
ocrcinom of the
stomch. She ws plced on mitomycin therpy. Dinostic procedures indicted re
currence of the
crcinom. 2.5 | Hemostsis Pro lem Solvin
69 Answer to Question 12 12. C The
mnifesttions nd l ortory results in this ptient re consistent with TTP. T
he clinicl
mnifesttions of TTP include microniopthic hemolytic nemi (MAHA), throm oc
ytopeni, fever,
renl filure, nd neuroloicl symptoms. The neuroloicl symptoms in this pti
ent re

mnifested y hedche, dizziness, nuse, nd vomitin. Wekness nd lethry 

re sins nd
symptoms of nemi. Low hemolo in nd hemtocrit with norml MCV nd MCHC indic
normocytic/normochromic nemi. The presence of schistocytes on the peripherl
lood with low
pltelet counts nd low hptolo in re consistent with microniopthic hemolyt
ic nemi. The
hih lood ure nitroen nd cretinine levels re chrcteristic of renl filu
re. The pltelet
count, performed on dmission, ws done on  hemtoloy nlyzer nd ws flsely
elevted ecuse
of the presence of microcytes or frmented red cells. The mnul pltelet count
ws much lower.
The coultion tests re norml in TTP. In von Wille rnds disese, the pltelet
count is
norml nd the APTT is usully  norml. ITP is chrcterized y throm ocytopeni
 ut not HA.
Althouh DIC is ssocited with  low pltelet count nd HA, it is chrcterized
y  norml
coultion studies. The cute onset of symptoms my e relted to mitomycin use
d for the
tretment of stric crcinom in this ptient. Admission CBC Results Reference
Ptient Rne
WBC 17.1 10 9
L 4.810.8 10
RBC 2.29 10 12
L 3.805.50 10
8.1 /dL 12.015.2 /dL Hct 23% 37%46% MCV 95.7 fL 79101 fL MCH 35.4 p
 2733 p MCHC
35.0 /dL 3134 /dL RDW 18.5 11.514.5 PLT 48.0 10 9
L 140450 10
MPV 11.2 7.49.4 DIFFERENTIAL COUNTS % Semented 79 30%70% neutrophils Bnd
neutrophils 3
0%10% Lymphocytes 11 20%50% Monocytes 6 2%12% Bsophils 1 0%2% NRBCs (/100 WBCs) 3 0
pltelet 18 10 9
L 140450 10
count: Mrked nisocytosis none Mrked RBC none frmenttion PT, APTT,
nd TT: Norml
ADDITIONAL LABORATORY DATA Reference Urinlysis Ptient Rne pH 5.0 57 Prote
in 30.0 m/dL
015 m/dL RBC 60100/L 05/L Csts 10/hpf Not detect le rnulr/ hyline Cretinine
m/dL 0.71.3 m/dL BUN 39 m/dL 822 m/dL Hptolo in 5.0 m/dL 50150 m/dL Tese
mnifesttions nd l ortory results re consistent with: A. ITP B. von Wille r
nds disese C.
TTP D. DIC Hemostsis/Correlte clinicl nd l ortory dt/ Pltelet disorders
2828_Ch02_041-074 06/08/12 11:09 AM Pe 69 13. Ptient History A 1-yer-old
infnt ws

dmitted to the hospitl with recurrent epistxis for the pst 5 dys. Te pst m
edicl history
reveled esy ruisin nd  severe nose leed t 3 months of e, necessittin
therpy. Te mother hd hd  severe nose leed 8 yers o. Te fther ws reporte
d to leed esily
fter lcertions. Te ptient ws trnsfused with 2 units of pcked red cells up
on dmission. 70
Chpter 2 | Hemostsis Answer to Question 13 13. C These clinicl mnifesttions
nd l ortory
results re consistent with Glnzmnns throm stheni. Epistxis nd esy ruisin
chrcteristics of pltelet disorders. The positive fmily history is indictive
of n inherited
leedin disorder. L ortory tests revel  low hemolo in level due to epistx
is. The norml
pltelet count rules out ny quntittive pltelet disorder. The pltelet count
is typiclly low
in BernrdSoulier syndrome. The leedin time test evlutes in vivo pltelet fun
ction nd
num er. Norml PT nd APTT com ined with  norml fctor VIII ssy rule out co
disorders. The l ortory tests tht con rm n inherited pltelet disorder re pl
retion studies. Pltelet retion is norml to ristocetin nd  norml t
o ADP,
epinephrine, nd throm in. These results re consistent with Glnzmnns throm st
heni. Pltelet
retion is  norml to ristocetin in von Wille rnds disese nd BernrdSoulie
r syndrome.
Admission L ortory Results Reference Ptient Rne H : 4.5 /dL 1315 /dL Pl
telet count:
249 10 9
L 150450 10
PT: 11.2 sec 1113 sec APTT: 34 sec 2837 sec ADDITIONAL LABORATORY TESTS F
ctor VIII ssy
70% 50%150% Pltelet A norml to retion: ADP, epinephrine, nd throm in; no
rml to
ristocetin Tese clinicl mnifesttions nd l ortory results re consistent wi
th which
condition? A. von Wille rnds disese B. BernrdSoulier syndrome C. Glnzmnns thro
m stheni
D. Fctor VIII de ciency Hemostsis/Correlte clinicl nd l ortory dt/ Pltel
et disorders/3
2828_Ch02_041-074 06/08/12 11:09 AM Pe 70 14. Ptient History: A 30-yer-ol
d femle ws
referred to the hospitl for evlution for multiple spontneous  ortions nd c
urrent complint
of pin nd swellin in her riht le. Her fmily history is unremrk le. 2.5 |
Pro lem Solvin
71 Answers to Questions 1415 14. D These clinicl mnifesttion
s nd
l ortory results re consistent with lupus nticoulnt. Pin nd swellin in
her riht le
my e indictive of throm osis. As mny s 48% of women with repeted spontneo
us  ortions hve
lupus nticoulnt or/nd nti ody to phospholipid such s nticrdiolipin nti
odies. The

unremrk le fmily history in this ptient rules out n inherited throm otic di
sorder. A norml
TT rules out rinoen disorders. A proloned PT nd APTT in the  sence of leedi
n history
eliminte the dinosis of fctor de ciency, includin fctor VIII de ciency. The AP
TT performed
on  mixture of ptient plsm nd norml plsm did not correct. This result is
indictive of n
inhi itor. However, ecuse the ptient is not leedin, fctor VIII inhi itor i
s not indicted.
A netive nticrdiolipin nti ody result rules out the possi ility of nticrd
nti odies ein responsi le for the ptients clinicl symptoms. The l ortory t
est tht
con rms the presence of  lupus nticoulnt is  proloned APTT tht is not corr
ected when
mixed with norml plsm nd tht is neutrlized y preincu tion with pltelets
(n excess of
pltelet phospholipid neutrlizes the nti ody, resultin in  norml APTT). 15.
C Liver iopsy
in  ptient with  proloned PT nd  hih INR could e life thretenin. In th
is ptient, the
proloned PT is likely cused y liver disese. Vitmin K is stored in the liver
nd is essentil
for ctivtion of fctors II, VII, IX, nd X. Vitmin K needs ile (secreted y
the liver) for
its  sorption. In liver disese chrcterized y o struction, ile is not secre
ted into the GI
trct, nd therefore, vitmin K is poorly  sor ed. The most loicl course of 
ction is to
recommend the followin: Strt the ptient on vitmin K therpy, repet the PT t
est 4 dys fter
strtin vitmin K dministrtion, nd cncel the iopsy until the ptients PT re
turns to
norml. L ortory Reference Tests Ptient Rne PT: 14.5 sec 1113 sec APTT:
63.0 sec 2837
sec Throm in time: 12.0 sec 1015 sec Mixin Study APTT: Preincu tion nd 57.0 s
ec fter 2-hour
incu tion t 37C Pltelet Neutrliztion Procedure: Ptient plsm + APTT: 35.0
freeze-thwed pltelets Ptient plsm + APTT: 59.0 sec sline Anticrdiolipin
nti odies done y ELISA: Tese clinicl mnifesttions nd l ortory results r
e consistent
with: A. Fctor VIII inhi itor B. Fctor VIII de ciency C. Anticrdiolipin nti od
ies D. Lupus
nticoulnt Hemostsis/Correlte clinicl nd l ortory dt/ Coulopthies/
3 15. A
60-yer-old ptient ws dmitted to  hospitl for  liver iopsy. Te iopsy ws
scheduled for
11:00 .m. Te coultion results performed t the time of dmission reveled 
proloned PT with
n INR of 4.5. Wht is the physicins most pproprite course of ction? A. Proce
ed with iopsy,
ecuse  proloned PT is expected in liver disese B. Postpone the procedure fo
r  couple of
dys C. Cncel the procedure nd strt the ptient on vitmin K therpy D. Put p
tient on vitmin
K nd proceed with the procedure immeditely Hemostsis/Correlte clinicl nd l
 ortory dt/

INR/3 2828_Ch02_041-074 06/08/12 11:09 AM Pe 71 16. A fresh lood smple w

s sent to the
l ortory t 8:00 .m. for  PT test. At 4:00 p.m., the doctor requested n APT
T test to e done
on the sme smple. Wht should the technoloist do? A. Rerun APTT on the 8:00 
.m. smple nd
report the result B. Request  new smple for APTT C. Run APTT in duplicte nd
report the
vere D. Mix the ptient plsm with norml plsm nd run the APTT Hemostsis
methods/Reents/Specimen collection nd hndlin/Specimens/3 17. An APTT test i
s performed on 
ptient nd the result is 50 sec (reference rne 2737 sec). Te instrument s the
result owin
to filure of the delt check. Te ptient hd n APTT of 35 sec the previous dy
. Te technoloist
clls the nursin unit to check whether the ptient is on heprin therpy. Te p
tient is not
receivin heprin. Wht is the next pproprite step? A. Check the fmily histor
y for n
inherited fctor VIII de ciency B. Check to see if the ptient hs received ny ot
nticoulnt medictions C. Perform mixin studies D. Perform  fctor VIII ss
Hemostsis/Select course of ction/3 18. A ptient ws put on heprin therpy po
stopertively for
prevention of throm osis. Te ptient hd the followin l ortory results on dm
ission: Pltelet
count = 350 10 9
L; PT =
12 sec (reference: 1013 sec); APTT = 35 sec (reference: 2837). After 6 dy
s of heprin
therpy, the ptient complined of pin nd swellin in her left le. Her pltel
et count dropped
to 85 10 9
L nd her APTT result ws 36 sec.
Te physicin suspected heprin-induced throm ocytopeni (HIT) nd ordere
d  pltelet
retion test to e performed immeditely. Te heprin-induced pltelet re
tion test result
ws netive. Heprin therpy ws continued. Severl dys lter, the ptient dev
eloped  mssive
clot in her left le tht necessitted mputtion. Which of the followin should
hve een
reconized or initited? A. Te ptient should hve een plced on LMWH B. Te hep
rin dose should
hve een incresed C. Te netive pltelet retion does not rule out HIT D.
Te ptient
should hve een plced on wrfrin therpy Hemostsis/Correlte clinicl nd l
ortory dt/
HIT/3 72 Chpter 2 | Hemostsis Answers to Questions 1618 16. B Accordin to Clin
icl L ortory
Stndrds Institute (CLSI) uidelines, smples for APTT should e centrifued n
d tested within 2
hours fter collection. However, the smple is st le for 4 hours if stored t 4
evlutes the clottin fctors in the intrinsic nd common coultion pthwys,
includin fctor
VIII (intrinsic) nd fctor V (common). Fctors VIII nd V re cofctors necess
ry for rin

formtion. However, they re oth l ile. Store eyond 4 hours cuses flsely
elevted APTT
results. The technoloist should request  new smple for the APTT. 17. B Trdit
nticoulnt drus such s heprin nd wrfrin re well known. There re new 
drus vil le for the tretment nd prevention of throm osis. Some of these ne
w drus hve
ntithrom in e ects nd therefore increse PT, APTT, nd TT results. Exmples of t
hese drus re
hirudin, which inhi its throm in; nd dnproid, which inhi its fctor X. 18.
C Heprin therpy
should e stopped immeditely when clinicl symptoms indicte HIT. The lood sm
ple should e
tested t lest 4 hours fter heprin therpy is discontinued. Erly smplin fo
r HIT testin my
ive  flse-netive result due to the neutrliztion of nti ody y heprin. L
MWH should not e
used in ptients who develop HIT, ecuse LMWH drus cn lso cuse HIT. Wrfri
n therpy cn e
strted in ptients who respond to heprin therpy s soon s the APTT is incre
sed to 1.5 times
the seline APTT. Heprin therpy must overlp wrfrin therpy until the INR r
eches  st le
therpeutic rne (2.03.0). Wrfrin therpy could not e used in this ptient e
cuse she did
not respond to heprin therpy. The rst step in the tretment of HIT is discontin
ution of
heprin, includin intrvenous ctheter ushes, heprin- coted indwellin cthete
unfrctionted heprin, nd LMWH. 2828_Ch02_041-074 06/08/12 11:09 AM Pe 72
19. A
50-yer-old femle ws dmitted to  hospitl for hip replcement surery. Te pr
eopertive tests
were performed nd the results showed n H of 13.5 /dL; Hct = 42%; PT = 12 se
c; APTT = 36 sec.
Te ptient ws leedin durin surery nd the postopertive test results revel
ed n H = 5.0
/dL; Hct = 16%; PT = 8 sec; nd APTT = 25 sec. Wht steps should e tken efor
e relesin these
results? A. No follow-up steps re needed; report the results s o tined B. Rep
ort H nd Hct
results, djust the nticoulnt volume, nd redrw  new smple for PT nd APT
T C. Cll the
nurse nd sk if the ptient is receivin heprin D. Becuse the ptient is seve
rely nemic,
multiply the PT nd APTT results y two nd report the results Hemostsis/Select
course of
ction/3 20. Ptient nd Fmily History A 45-yer-old womn visited her doctor c
omplinin of
esy ruisin nd menorrhi occurrin for the pst few weeks. Te ptient hd n
o history of
excessive leedin durin child irth severl yers erlier nor durin  tonsille
ctomy in
childhood. Her fmily history ws unremrk le. 2.5 | Hemostsis Pro lem Solvin
73 Answers to
Questions 1920 19. B The nticoulnt-to- lood rtio should e djusted for PT 
nd APTT tests
in ptients with  severe nemi. The stndrd nticoulnt volume (0.5 mL) is
not su cient for

the lre quntity of plsm in these ptients, cusin unreli le PT nd APTT r
esults. The low
H nd Hct in this ptient were due to severe leedin durin surery. To et 
ccurte PT nd
APTT results, the mount of nticoulnt is djusted ccordin to the followin
(0.00185)(V)(100H) = C, where V = lood volume in mL; H = ptients Hct; nd C = vo
lume of
nticoulnt in mL. A new smple should e drwn to rerun the PT nd APTT. Ther
e re other
cuses for decresed PT nd APTT, such s incresed
rinoen nd incresed fctor
VIII; however,
the prenlyticl vri les  ectin unreli le results should e ruled out rst. He
prin therpy
would increse PT nd APTT. 20. B The lck of  positive fmily history in this
ptient indictes
the presence of n cquired coulopthy. Becuse oth PT nd APTT tests re  n
orml, the
clottin fctor involved is most pro  ly in the common pthwy. The lck of cor
rection y mixin
studies suests the presence of n inhi itor. Fctor V nti odies re the most
common nti odies
mon the clottin fctors of the common pthwy (I, II, V, nd X). Fctor V nt
i odies re
reported to e ssocited with surery, some nti iotics such s streptomycin, p
tients who re
exposed to lood products, or the ovine form of rin lue. Ptients with nti odie
s to fctor
V my require lon-term therpy with immunosuppressive drus. Acute leedin epi
sodes my e
treted y pltelet trnsfusions. The PT test is norml in ptients with fctor
VIII de ciency
nd fctor VIII inhi itor. Lupus nticoulnt is not present with leedin unle
ss ssocited
with coexistin throm ocytopeni. L ortory Reference Tests Ptient Rne
PT 45 sec 1113
sec APTT 125 sec 2837 sec Throm in Time 14.0 sec 1015 sec Mixin studies (ptient
plsm +
norml plsm): PT = 40 sec; APTT = 90 sec Pltelet count nd morpholoy = norm
l Liver function
tests = norml Tese clinicl mnifesttions nd l ortory results re consisten
t with: A. Fctor
VIII inhi itor B. Fctor V inhi itor C. Fctor VIII de ciency D. Lupus nticoul
Hemostsis/Correlte clinicl nd l ortory dt/ Inhi itors/3 BI BL I OGRAPHY
1. Bick RL.
Disorders of Trom osis nd Hemostsis. 3rd edition, 2002. Lippincott Willims n
d Wilkins,
Phildelphi. 2. Colemn RW, Hirsh J, Mrder VJ, et l. Hemostsis nd Trom osi
s, Bsic
Principles nd Clinicl Prctice. 5th edition, 2006. Lippincott Willims nd Wil
Phildelphi. 3. Greer JP, Foester J, Roders GM, et l. Wintro es Clinicl Hemt
oloy. 12th
edition, Vol. 2, 2009. Lippincott Willims nd Wilkins, Phildelphi. 4. Kushn
sky K, Lichtmn
MA, Beutler E, et l. Willims Hemtoloy. 8th edition, 2010. McGrw-Hill, New Y
ork. 5. Nthn
DG, Orkin SH, Gins ur D, et l. Hemtoloy of Infncy nd Childhood. 7th editio
n, Vol. 2, 2008.

W.B.Sunders, Phildelphi. 6. Rodk BF, Fritsm GA, nd Doi K. Hemtoloy, Cli
nicl nd
Appliction. 3rd edition, 2007. W.B. Sunders, Phildelphi. 2828_Ch02_041-074
06/08/12 11:09
AM Pe 73 2828_Ch02_041-074 06/08/12 11:09 AM Pe 74 75 3.1 Bsic Principl
es of Immunoloy
3.2 Immunoloic Procedures 3.3 Infectious Diseses 3.4 Autoimmune Diseses 3.5 H
3.6 Immunolo ulins, Complement, nd Cellulr Testin 3.7 Tumor Testin nd Trn
splnttion 3.8
Immunoloy Pro lem Solvin CHAPTER 3 Immunoloy 2828_Ch03_075-120 06/08/12 11:
10 AM Pe 75
2828_Ch03_075-120 06/08/12 11:10 AM Pe 76 77 3.1 Bsic Principles of Immuno
loy 1. From the
followin, identify  speci c component of the dptive immune system tht is form
ed in response
to ntienic stimultion: A. Lysozyme B. Complement C. Commensl ornisms D. Im
munolo ulin
Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Immune syst
em/1 2. Which two
orns re considered the primry lymphoid orns in which immunocompetent cells
oriinte nd
mture? A. Tyroid nd Peyers ptches B. Tymus nd one mrrow C. Spleen nd mucos
lymphoid tissue (MALT) D. Lymph nodes nd thorcic duct Immunoloy/Apply knowled
e of fundmentl
ioloicl chrcteristics/Immune system/Orns/1 3. Wht type of B cells re fo
rmed fter
ntien stimultion? A. Plsm cells nd memory B cells B. Mture B cells C. Ant
ien-dependent B
cells D. Receptor-ctivted B cells Immunoloy/Apply knowlede of fundmentl i
chrcteristics/Immune system/Cells/1 4. T cells trvel from the one mrrow to
the thymus for
mturtion. Wht is the correct order of the mturtion sequence for T cells in
the thymus? A.
Bone mrrow to the cortex; fter thymic eduction, relesed ck to peripherl c
ircultion B.
Mturtion nd selection occur in the cortex; mirtion to the medull; relese
of mture T cells
to secondry lymphoid orns C. Store in either the cortex or medull; relese
of T cells into
the peripherl circultion D. Activtion nd selection occur in the medull; mt
ure T cells re
stored in the cortex until ctivted y ntien Immunoloy/Apply knowlede of fu
ioloicl chrcteristics/Immune system/Cells/1 Answers to Questions 14 1. D Imm
unolo ulin is
 speci c prt of the dptive immune system nd is formed only in response to  s
peci c
ntienic stimultion. Complement, lysozyme, nd commensl ornisms ll ct non
speci clly s 
prt of the dptive immune system. These three components do not require ny ty
pe of speci c
ntienic stimultion. 2. B The one mrrow nd thymus re considered primry ly
mphoid orns
ecuse immunocompetent cells either oriinte or mture in them. Some immunocom
petent cells
mture or reside in the one mrrow (the source of ll hemtopoietic cells) unti
l trnsported to

the thymus, spleen, or Peyers ptches, where they process ntien or mnufcture
nti ody. T
lymphocytes, fter oriintin in the one mrrow, trvel to the thymus to mtur
e nd
di erentite. 3. A Mture B cells exhi it surfce immunolo ulin tht my cross li
nk  forein
ntien, thus formin the ctivted B cell nd ledin to cppin nd internliz
tion of ntien.
The ctivted B cell ives rise to plsm cells tht produce nd secrete immuno
lo ulins nd
memory cells tht reside in lymphoid orns. 4. B Immture T cells trvel from t
he one mrrow to
the thymus to mture into functionl T cells. Once in the thymus, T cells under
o  selection nd
mturtion sequence tht eins in the cortex nd moves to the medull of the th
ymus. Thymic
fctors such s thymosin nd thymopoietin nd cells within the thymus such s m
crophes nd
dendritic cells ssist in this sequence. After completion of the mturtion cycl
e, T cells re
relesed to secondry lymphoid orns to wit ntien reconition nd ctivtio
2828_Ch03_075-120 06/08/12 11:10 AM Pe 77 5. Which cluster of di erentition
(CD) mrker
ppers durin the rst ste of T-cell development nd remins present s n iden
tifyin mrker
for T cells? A. CD1 B. CD2 C. CD3 D. CD4 or CD8 Immunoloy/Apply principles of
sic l ortory
procedures/T cells/Mrkers/1 6. Which mrkers re found on mture, peripherl he
lper T cells? A.
CD1, CD2, CD4 B. CD2, CD3, CD8 C. CD1, CD3, CD4 D. CD2, CD3, CD4 Immunoloy/Appl
y knowlede of
fundmentl ioloicl chrcteristics/T cells/Mrkers/1 7. Which T cell express
es the CD8 mrker
nd cts speci clly to kill tumors or virlly infected cells? A. Helper T B. T su
ppressor C. T
cytotoxic D. T inducer/suppressor Immunoloy/Apply knowlede of fundmentl iol
chrcteristics/T cells/Cytokines/1 8. How re cytotoxic T cells (T C cells) nd
nturl killer
(NK) cells similr? A. Require nti ody to e present B. E ective inst virlly
infected cells
C. Reconize ntien in ssocition with HLA clss II mrkers D. Do not ind to
infected cells
Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Lymphocytes
/Functions/1 9.
Wht is the nme of the process y which phocytic cells re ttrcted to  su
stnce such s 
cteril peptide? A. Dipedesis B. Dernultion C. Chemotxis D. Photxis Im
knowlede of fundmentl ioloicl chrcteristics/Immune system/Cells/1 10. Al
l of the
followin re immunoloic functions of complement except: A. Induction of n nt
ivirl stte B.
Opsoniztion C. Chemotxis D. Anphyltoxin formtion Immunoloy/Apply knowlede
of fundmentl
ioloicl chrcteristics/Complement/Functions/1 78 Chpter 3 | Immunoloy Answ
ers to Questions
511 5. B The CD2 mrker ppers durin the rst ste of T-cell development nd cn
e used to

di erentite T cells from other lymphocytes. This T-lymphocyte receptor inds shee
p red lood
cells (RBCs). This peculir chrcteristic ws the sis for the clssic E roset
te test once used
to enumerte T cells in peripherl lood. CD2 is not speci c for T cells, however,
nd is lso
found on lre rnulr lymphocytes (LGL or nturl killer [NK] cells). 6. D Mt
ure, peripherl
helper T cells hve the CD2 (E rosette), CD3 (mture T cell), nd CD4 (helper) m
rkers. 7. C T
cytotoxic cells reconize ntien in ssocition with mjor histocompti ility c
omplex (MHC)
clss I complexes nd ct inst tret cells tht express forein ntiens. Th
ese include virl
ntiens nd the humn leukocyte ntiens (HLA) tht re the tret of rft rej
ection. 8. B Both
T C nd NK cells re e ective inst virlly infected cells, nd neither requires
nti ody to e
present to ind to infected cells. NK cells do not exhi it MHC clss restriction
, wheres
ctivtion of T C cells requires the presence of MHC clss I molecules in ssoci
tion with the
virl ntien. 9. C Chemotxis is the process y which phocytic cells re ttr
cted towrd n
re where they detect  distur nce in the norml functions of ody tissues. Pr
oducts from
cteri nd viruses, complement components, coultion proteins, nd cytokines
from other
immune cells my ll ct s chemotctic fctors. 10. A Complement components re
serum proteins
tht function in opsoniztion, chemotxis, nd nphyltoxin formtion ut do no
t induce n
ntivirl stte in tret cells. This function is performed y interferons. 11.
D C3 is found in
oth the clssic nd lterntive (lternte) pthwys of the complement system.
In the clssic
pthwy, C3 forms  complex on the cell with C4 2 tht enzymticlly cleves C
5. In the
lterntive pthwy, C3 inds to n ctivtor on the cell surfce. It forms  c
omplex with
fctor B clled C3 B which, like C4 23 , cn split C5. 11. Which complement co
mponent is found
in oth the clssic nd lterntive pthwys? A. C1 B. C4 C. Fctor D D. C3 Immu
knowlede of fundmentl ioloicl chrcteristics/Complement/Components/1 2828
06/08/12 11:10 AM Pe 78 12. Which immunolo ulin(s) help(s) initite the cl
ssic complement
pthwy? A. IA nd ID B. IM only C. IG nd IM D. IG only Immunoloy/Apply
knowlede of
fundmentl ioloicl chrcteristics/Complement/Activtion/1 13. How is comple
ment ctivity
destroyed in vitro? A. Hetin serum t 56C for 30 min B. Keepin serum t room t
emperture of
22C for 1 hour C. Hetin serum t 37C for 45 min D. Freezin serum t 0C for 24 ho
Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Complement/
Activtion/1 14.
Wht is the purpose of C3, C4, nd C5, the split products of the complement c
scde? A. To

ind with speci c mem rne receptors of lymphocytes nd cuse relese of cytotoxic
su stnces B.
To cuse incresed vsculr perme ility, contrction of smooth muscle, nd rele
se of histmine
from sophils C. To ind with mem rne receptors of mcrophes to fcilitte p
hocytosis nd
the removl of de ris nd forein su stnces D. To reulte nd derde mem rne
cofctor protein
fter ctivtion y C3 convertse Immunoloy/Apply knowlede of fundmentl iol
chrcteristics/Complement/Anphyltoxins/1 15. Which reion of the immunolo ul
in molecule cn
ind ntien? A. F B. Fc C. C L D. C H Immunoloy/Apply knowlede of fundment
l ioloicl
chrcteristics/Immunolo ulins/ Structures/1 16. Which reion determines whethe
r n
immunolo ulin molecule cn x complement? A. V H B. C H C. V L D. C L Immunoloy/
Apply knowlede
of fundmentl ioloicl chrcteristics/Immunolo ulins/Structures/1 3.1 | Bs
ic Principles of
Immunoloy 79 Answers to Questions 1217 12. C Both IG nd IM re the immunol
o ulins tht
help to initite the ctivtion of the clssic complement pthwy. IM is  more
complement ctivtor, however. 13. A Complement ctivity in serum in vitro is de
stroyed y
hetin the serum t 56C for 30 min. In test procedures where complement my inte
rfere with the
test system, it my e necessry to destroy complement ctivity in the test smp
le y het
inctivtion. 14. B C3, C4, nd C5 re split products of the complement csc
de tht
prticipte in vrious ioloicl functions such s vsodiltion nd smooth musc
le contrction.
These smll peptides ct s nphyltoxins, e.., e ector molecules tht prticip
te in the
in mmtory response to ssist in the destruction nd clernce of forein ntien
s. 15. A The
F (frment ntien indin) is the reion of the immunolo ulin molecule tht
cn ind
ntien. Two F frments re formed from hydrolysis of the immunolo ulin mole
cule y ppin.
Ech consists of  liht chin nd the V H nd C H1 reions of the hevy chin.
The vri le
reions of the liht nd hevy chins interct, formin  speci c ntien-com inin
 site. 16. B
The composition nd structure of the constnt reion of the hevy chin determin
e whether tht
immunolo ulin will x complement. The Fc frment (frment crystlliz le) is fo
rmed y prtil
immunolo ulin diestion with ppin nd includes the C H2 nd C H3 domins of
oth hevy chins.
The complement component C1q molecule will ind to the C H2 reion of n IG or
IM molecule. 17.
C Both IM nd secretory IA hve  J chin joinin individul molecules toethe
r; the J chin in
IM joins ve molecules nd the J chin in sIA joins two molecules. 17. Which imm
unolo ulin
clss(es) hs (hve)  J chin? A. IM B. IE nd ID C. IM nd sIA D. IG3 n
d IA

Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Immunolo u

2828_Ch03_075-120 06/08/12 11:10 AM Pe 79 18. Which immunolo ulin ppers r
st in the
primry immune response? A. IG B. IM C. IA D. IE Immunoloy/Apply knowlede
of fundmentl
ioloicl chrcteristics/Immunolo ulins/Functions/1 19. Which immunolo ulin
ppers in
hihest titer in the secondry response? A. IG B. IM C. IA D. IE Immunoloy/
Apply knowlede
of fundmentl ioloicl chrcteristics/Immunolo ulin/Function/1 20. Which im
munolo ulin cn
cross the plcent? A. IG B. IM C. IA D. IE Immunoloy/Apply knowlede of fu
ioloicl chrcteristics/Immunolo ulins/Functions/1 21. Which immunolo ulin
cross links mst
cells to relese histmine? A. IG B. IM C. IA D. IE Immunoloy/Apply knowled
e of fundmentl
ioloicl chrcteristics/Immunolo ulins/Functions/1 22. All of the followin
re functions of
immunolo ulins except: A. Neutrlizin toxic su stnces B. Fcilittin phocy
tosis throuh
opsoniztion C. Interctin with T C cells to lyse viruses D. Com inin with com
plement to
destroy cellulr ntiens Immunoloy/Apply knowlede of fundmentl ioloicl
chrcteristics/Immunolo ulins/Functions/1 23. Which of the followin cell surf
ce molecules is
clssi ed s n MHC clss II ntien? A. HLA-A B. HLA-B C. HLA-C D. HLA-DR Immunol
knowlede of fundmentl ioloicl chrcteristics/MHC/HLA ntiens/1 80 Chpte
r 3 | Immunoloy
Answers to Questions 1823 18. B The rst nti ody to pper in the primry immune r
esponse to n
ntien is IM. The titer of ntivirl IM (e.., IM nti ody to cytomeloviru
s [nti-CMV]) is
more speci c for cute or ctive virl infection thn IG nd my e mesured to h
di erentite ctive from prior infection. 19. A A hih titer of IG chrcterizes
the secondry
immune response. Consequently, IG nti odies comprise  out 80% of the totl im
munolo ulin
concentrtion in norml serum. 20. A IG is the only immunolo ulin clss tht c
n cross the
plcent. All su clsses of IG cn cross the plcent, ut IG2 crosses more sl
owly. This
process requires reconition of the Fc reion of the IG y plcentl cells. The
se cells tke up
the IG from the mternl lood nd secrete it into the fetl lood, providin h
umorl immunity
to the neonte for the rst few months fter delivery. 21. D IE is the immunolo
ulin tht cross
links with sophils nd mst cells. IE cuses the relese of such immune respo
nse modi ers s
histmine nd medites n lleric immune response. 22. C Cytotoxic T cells lyse
virlly infected
cells directly, without requirement for speci c nti ody. The T C cell is ctivte
d y virl
ntien tht is ssocited with MHC clss I molecules on the surfce of the infe
cted cell. The
ctivted T C cell secretes severl toxins, such s tumor necrosis fctor, which

destroy the
infected cell nd virions. 23. D The MHC reion is locted on the short rm of c
hromosome 6 nd
codes for ntiens expressed on the surfce of leukocytes nd tissues. The MHC r
eion enes
control immune reconition; their products include the ntiens tht determine t
rejection. HLA-DR ntiens re expressed on B cells. HLA-DR2, DR3, DR4, nd DR5
ntiens show
linke with  wide rne of utoimmune diseses. 2828_Ch03_075-120 06/08/12 1
1:10 AM Pe 80
24. Which MHC clss of molecule is necessry for ntien reconition y CD4-posi
tive T cells? A.
Clss I B. Clss II C. Clss III D. No MHC molecule is necessry for ntien rec
Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/MHC/Functio
ns/1 25. Which of
the followin re products of HLA clss III enes? A. T-cell immune receptors B.
HLA-D ntiens
on immune cells C. Complement proteins C2, C4, nd Fctor B D. Immunolo ulin V
L reions
Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/MHC/Functio
ns/1 26. Wht
molecule on the surfce of most T cells reconizes ntien? A. IT,  four-chin
molecule tht
includes the tu hevy chin B. MHC protein,  two-chin molecule encoded y the
HLA reion C.
CD3, consistin of six di erent chins D. TcR, consistin of two chins, lph nd
Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Functions/1
27. Te T-cell
ntien receptor is similr to immunolo ulin molecules in tht it: A. Remins
ound to the cell
surfce nd is never secreted B. Contins V nd C reions on ech of its chins
C. Binds
complement D. Cn cross the plcent nd provide protection to  fetus Immunolo
y/Apply knowlede
of fundmentl ioloicl chrcteristics/TcR/Functions/2 28. Toll-like receptor
s re found on
which cells? A. T cells B. Dendritic cells C. B cells D. Lre rnulr lymphocy
Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Innte immu
ne system/
Toll-like receptors/1 3.1 | Bsic Principles of Immunoloy 81 Answers to Quest
ions 2428 24. B
Helper T lymphocytes (CD4-positive T cells) reconize ntiens only in the conte
xt of  clss II
molecule. Becuse clss II ntiens re expressed on mcrophes, monocytes, nd
B cells, the
helper T-cell response is medited y interction with processed ntien on the
surfce of these
cells. 25. C Complement components C2 nd C4 of the clssic pthwy nd Fctor B
of the
lterntive pthwy re clss III molecules. HLA-A, HLA-B, nd HLA-C ntiens r
e clssi ed s
clss I ntiens, nd HLA-D, HLA-DR, HLA-DQ, nd HLA-DP ntiens s clss II nt
iens. 26. D T
cells hve  mem rne ound receptor (T-cell receptor or TcR) tht is ntien sp
eci c. This twochin molecule consists of  sinle -chin, similr to n immunolo ulin liht ch

in, nd 
sinle -chin, similr to n immunolo ulin hevy chin. Some T cells my express
 - receptor
instea of the - molecule. There is no heavy chain. MHC and CD3 molecules are pres
en on T
cells, bu hey are no he molecules ha give anigen speci ciy o he cell. 27
. B The anigen
binding regions of boh he - nd -chins of the T-cell receptor re encoded y V
enes tht
undero rerrnement similr to tht o served in immunolo ulin enes. The -chi
n ene consists
of V nd J sements, similr to n immunolo ulin liht chin. The -chin consist
s of V, D, nd
J sements, similr to n immunolo ulin hevy chin. The - nd -chins ech hve
C-reion ene encodin the constnt reion of the molecule. While nswer A is tr
ue for T-cell
receptors, it is not true for immunolo ulins tht cn e cell ound or secreted
. Answers C nd D
re true for certin immunolo ulin hevy-chin isotypes ut re not true for th
e T-cell
receptor. 28. B Toll-like receptors (TLR) re the primry ntien reconition pr
otein of the
innte immune system. They re found on ntien-presentin cells such s dendrit
ic cells nd
mcrophes. Eleven TLRs hve een descri ed. TLRs reconize certin structurl
motifs common to
infectin ornisms. TLR 4, for exmple, reconizes cteril lipopolyscchride
(LPS). The nme
comes from their similrity to the Toll protein in Drosophil. 2828_Ch03_075-120
06/08/12 11:10
AM Pe 81 29. Mcrophes produce which of the followin proteins durin nti
en processin? A.
IL-1 nd IL-6 B. -Interferon C. IL-4, IL-5, nd IL-10 D. Complement components C1
nd C3
Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Innte immu
ne system/Toll
cytokines/2 30. A superntien, such s toxic shock syndrome toxin-1 (TSST-1),
ypsses the
norml ntien processin ste y indin to nd cross linkin: A. A portion of
immunolo ulin molecule nd complement component C1 B. Toll-like receptors nd 
n MHC clss 1
molecule C. A portion of n immunolo ulin nd  portion of  T-cell receptor D.
A portion of 
T-cell receptor nd n MHC clss II molecule Immunoloy/Apply knowlede of fund
mentl ioloicl
chrcteristics/Antien processin/ Superntiens/2 31. T reultor cells, respo
nsi le for
controllin utoimmune nti ody production, express which of the followin pheno
types? A. CD3,
CD4, CD8 B. CD3, CD8, CD25 C. CD3, CD4, CD25 D. CD8, CD25, CD56 Immunoloy/Apply
knowlede of
fundmentl ioloicl chrcteristics/T cells/Mrkers/1 82 Chpter 3 | Immunolo
y Answers to
Questions 2931 29. A Interleukin-1 (IL-1) nd IL-6 re proin mmtory mcrophe-pr
cytokines. In ddition to their in mmtory properties, they ctivte T-helper cel
ls durin
ntien presenttion. -Interferon, IL-4, 5, nd 10 re ll produced y T cells. C

components re produced y  vriety of cells ut re not prt of the mcrophe
presenttion process. 30. D A superntien inds to the V portion of the T-cell
receptor nd n
MHC clss II molecule. This indin cn ctivte T cells without the involvement
of n
ntien-presentin cell. In some individuls,  sinle V protein tht reconizes
TSST-1 is
expressed on up to 10%20% of T cells. The simultneous ctivtion of this mount
of T cells
cuses  hevy cytokine relese, resultin in the vsculr collpse nd ptholo
y of toxic shock
syndrome. 31. C T reultor cells re elieved to e the primry immune suppress
or cells nd
express CD3, CD4, nd CD25. CD25 is the interleukin 2 receptor. CD25 my e expr
essed y
ctivted T cells, ut is constitutively expressed y the T-reultor cells. CD2
5 expression on
T-reultor cells occurs in the thymus nd is reulted y the FOXP3 protein. 28
06/08/12 11:10 AM Pe 82 83 3.2 Immunoloic Procedures 1. Te interction etw
een n individul
ntien nd nti ody molecule depends upon severl types of onds such s ionic
onds, hydroen
onds, hydropho ic onds, nd vn der Wls forces. How is the strenth of this
chrcterized? A. Avidity B. A nity C. Rectivity D. Vlency Immunoloy/Apply prin
ciples of sic
l ortory procedures/1 2. A l ortory is evlutin n enzyme-linked immunosor
ent ssy
(ELISA) for detectin n nti ody to cyclic citrullinted peptide (CCP), which i
s  mrker for
rheumtoid rthritis. Te l ortory includes serum from helthy volunteers nd p
tients with
other connective tissue diseses in the evlution. Tese specimens determine whi
ch fctor of the
ssy? A. Sensitivity B. Precision C. Bis D. Speci city Immunoloy/Apply principl
es of sic
l ortory procedures/RA/2 3. Te detection of precipittion rections depends on
the presence of
optiml proportions of ntien nd nti ody. A ptients smple contins  lre 
mount of
nti ody, ut the rection in  test system continin ntien is netive. Wht
hs hppened? A.
Performnce error B. Low speci city C. A shift in the zone of equivlence D. Prozo
ne phenomenon
Immunoloy/Apply principles of sic l ortory procedures/3 4. Which prt of th
e rdil
immunodi usion (RID) test system contins the ntiser? A. Center well B. Outer we
lls C. Gel D.
Antiser my e dded to ny well Immunoloy/Apply principles of sic l ortor
procedures/RID/Principles/1 Answers to Questions 14 1. B Affinity refers to the s
trenth of 
sinle nti ody ntien interction. Avidity is the strenth of interctions etw
een mny
different nti odies in  serum inst  prticulr ntien (i.e., the sum of m
ny ffinities).
2. D Specificity is defined s  netive result in the  sence of the disese.

nonrheumtoid rthritis specimens would e expected to test netive if the ssy
hs hih
specificity. Precision is the  ility of the ssy to repetedly yield the sme
results on 
sinle specimen. Both is nd sensitivity clcultions would include specimens
from rheumtoid
rthritis specimens. Althouh those specimens would e included in the evlutio
n, they re not
listed in the question. 3. D Althouh performnce error nd low specificity shou
ld e considered,
if  test system fils to yield the expected rection, excessive nti ody preven
precipittion rection is usully the cuse. Prozone occurs when nti ody molecu
les sturte the
ntien sites, preventin cross linkin of the ntiennti ody complexes y other
nti ody
molecules. Becuse the ntien nd nti ody do not rect t equivlence,  visi
le product is not
formed, ledin to  flse-netive result. 4. C In n RID test system, for exm
ple, one
mesurin hemopexin concentrtion, the el would contin the ntihemopexin. A st
ndrdized volume
of serum continin the ntien is dded to ech well. Antien di uses from the we
ll into the el
nd forms  precipitin rin y rection with nti ody. At equivlence, the re
of the rin is
proportionl to ntien concentrtion. 2828_Ch03_075-120 06/08/12 11:10 AM P
e 83 5. Wht is
the interprettion when n Ouchterlony plte shows crossed lines etween wells 1
nd 2 (ntien
is plced in the center well nd ntiser in wells 1 nd 2)? A. No rection etw
een wells 1 nd 2
B. Prtil identity etween wells 1 nd 2 C. Nonidentity etween wells 1 nd 2 D
. Identity
etween wells 1 nd 2 Immunoloy/Apply principles of sic l ortory procedures
techniques/Interprettion/2 6. Why is  chemiluminescent immunossy (CIA) or en
zyme immunossy
(EIA) the method of choice for detection of certin nlytes, such s hormones,
normlly found in
low concentrtions? A. Becuse of low cross rectivity B. Becuse of hih speci ci
ty C. Becuse
of hih sensitivity D. Becuse test systems my e desined s oth competitive
noncompetitive ssys Immunoloy/Apply principles of sic l ortory procedures
7. Wht comprises the indictor system in n indirect ELISA for detectin nti o
dy? A.
Enzyme-conjuted nti ody + chromoenic su strte B. Enzyme conjuted ntien
+ chromoenic
su strte C. Enzyme + ntien D. Su strte + ntien Immunoloy/Apply principles
of sic
l ortory procedures/ELISA/1 8. Wht outcome results from improper wshin of 
tu e or well
fter ddin the enzymenti ody conjute in n ELISA system? A. Result will e f
decresed B. Result will e flsely incresed C. Result will e un ected D. Resul
t is impossi le
to determine Immunoloy/Apply knowlede to identify sources of error/ELISA/3 9.

Wht would hppen

if the color rection phse is proloned in one tu e or well of n ELISA test? A
. Result will e
flsely decresed B. Result will e flsely incresed C. Result will e un ected
D. Impossi le
to determine Immunoloy/Apply knowlede to identify sources of error/ELISA/3 84
Chpter 3 |
Immunoloy Answers to Questions 510 5. C Crossed lines indicte nonidentity etwe
en wells 1 nd
2. The nti ody from well 1 reconizes  different ntienic determinnt thn th
e nti ody from
well 2. 6. C The sensitivity of EIA methods producin visi le color chne, nd u
orescent nd
chemiluminescent products pproches nnorm levels of nti ody. These methods
re esily
utomted. 7. A The ELISA test mesures nti ody usin immo ilized reent nti
en. The ntien
is xed to the wlls of  tu e or ottom of  microtiter well. Serum is dded (nd
incu ted) nd
the nti ody inds, if present. After wshin, the ntiennti ody complexes re
detected y
ddin n enzyme l eled nti-immunolo ulin. The un ound enzyme l el is remove
d y wshin, nd
the ound enzyme l el is detected y ddin chromoenic su strte. The enzyme c
tlyzes the
conversion of su strte to colored product. 8. B If un ound enzyme-conjuted n
ti-immunolo ulin
is not wshed wy, it will ctlyze conversion of su strte to colored product,
flsely elevted result. 9. B If the color rection is not stopped within the ti
me limits
speci ed y the procedure, the enzyme will continue to ct on the su strte, produ
cin  flsely
elevted test result. 10. D Usully when  test smple reds t  vlue  ove th
e hihest
stndrd in n ELISA test, it is diluted nd mesured in. In those instnces
where no
dditionl clinicl vlue cn e o tined y dilution, the result my e reporte
d s reter thn
the hihest stndrd (citin the upper report le limit of the ssy). 10. Te 
sor nce of 
smple mesured y ELISA is reter thn the hihest stndrd. Wht corrective 
ction should e
tken? A. Extrpolte n estimted vlue from the hihest redin B. Repet the
test usin 
stndrd of hiher concentrtion C. Repet the ssy usin one hlf the volume o
f the smple D.
Dilute the test smple Immunoloy/Evlute l ortory dt to tke corrective c
tion ccordin to
predetermined criteri/ELISA/3 2828_Ch03_075-120 06/08/12 11:10 AM Pe 84 11
. A ptient ws
suspected of hvin  lymphoprolifertive disorder. After severl l ortory tes
ts were
completed, the ptient ws found to hve n IM paraproein. In wha sequence sho
uld he
laboraory ess leading o his diagnosis have been performed? A. Serum proein
(SPE) followed by immuno xaion elecrophoresis (IFE) B. Immunoglobulin levels fol
lowed by SPE C.
Toal lymphocye coun followed by immunoglobulin levels D. Immunoglobulin level

s followed by
urine proein elecrophoresis Immunology/Evaluae laboraory daa o reach concl
usions/IFE/3 12.
An IFE performed on a serum sample showed a narrow dar band in he lanes conai
ning ani- an
anti-. How shou this resut be interprete? A. Abnormay ecrease IG concent
ration B.
Abnorma test resut emonstratin monocona IG C. Norma test resut D. Imposs
ibe to
etermine without ensitometric quantitation Immunooy/Evauate aboratory ata
to make
ienti cations/IFE/2 13. Which type of nepheometry is use to measure immune comp
ex formation
amost immeiatey after reaent has been ae? A. Rate B. Enpoint C. Continuo
us D. One
imensiona Immunooy/Appy principes of basic aboratory proceures/Nepheome
try/1 14. An
immuno uorescence microscopy assay (IFA) was performe, an a sini cant antiboy ti
ter was
reporte. Positive an neative contros performe as expecte. However, the ci
nica evauation
of the patient was not consistent with a positive nin. What is the most ikey
expanation of
this situation? A. Te cinica conition of the patient chane since the sampe
was teste B. Te
pattern of uorescence was misinterprete C. Te contro resuts were misinterprete
 D. Te wron
ce ine was use for the test Immunooy/Appy principes of basic aboratory
3.2 | Immunooic Proceures 85 Answers to Questions 1114 11. A Serum protein e
shou be performe initiay to etect the presence of an abnorma immunoobu
in that
emonstrates restricte eectrophoretic mobiity. A patient proucin ony monoc
ona iht
chains may not show any abnorma serum nin because the iht chains may be excr
ete in the
urine. A positive nin for either serum or urine shou be foowe by IFE on th
e positive
specimen. This is require to con rm the presence of monocona immunoobuin an
to ientify
the heavy an iht chain type. 12. B A narrow ark ban forme in both the ane
anti- an anti- inicates the presence of a monocona IG immunoobuin. A iffu
se ark
ban wou inicate a poycona increase in IG that often accompanies chronic
isorers such as systemic upus erythematosus (SLE). 13. A Rate nepheometry is
use to measure
formation of sma immune compexes as they are forme uner conitions of antib
oy excess. The
rate of increase in photoetector output is measure within secons or minutes a
n increases with
increasin antien concentration. Antien concentration is etermine by compari
n the rate for
the sampe to that for stanars usin an aorithm that compensates for nonine
arity. In
enpoint nepheometry, reactions are rea after equivaence. Immune compexes ar
e of maxima size
but may have a tenency to sette out of soution, thereby ecreasin the amount

of scatter. 14.
B In an IFA, for exampe, an antinucear antiboy (ANA) test, the fuorescence p
attern must be
correate correcty with the specificity of the antiboies. Both pathooica a
nonpathooica antiboies can occur, an antiboies may be etecte at a sinif
icant titer in a
patient whose isease is inactive. Faiure to correcty ientify subceuar str
uctures may
resut in misinterpretation of the antiboy specificity, or a fase positive cau
se by
nonspecific fuorescence. 2828_Ch03_075-120 06/08/12 11:10 AM Pae 85 15. Wha
t corrective
action shou be taken when an ineterminate pattern occurs in an inirect IFA?
A. Repeat the
test usin a arer voume of sampe B. Ca the physician C. Have another meic
a aboratory
scientist rea the sie D. Diute the sampe an retest Immunooy/Evauate ab
oratory ata to
take corrective action accorin to preetermine criteria/IFA/3 16. Which state
ment best
escribes passive autination reactions use for seroianosis? A. Such aut
ination reactions
are more rapi because they are a sine-step process B. Reactions require the a
ition of a
secon antiboy C. Passive autination reactions require biphasic incubation D
. Carrier
partices for antien such as atex partices are use Immunooy/Appy princip
es of basic
aboratory proceures/Autination/1 17. What has happene in a titer, if tube
Nos. 57 show a
stroner reaction than tube Nos.14? A. Prozone reaction B. Postzone reaction C. E
reaction D. Poor technique Immunooy/Evauate ata to etermine possibe incons
resuts/Serooica titration/3 18. What is the titer in tube No. 8 if tube No.
1 is uniute
an iutions are oube? A. 64 B. 128 C. 256 D. 512 Immunooy/Cacuate/Sero
titration/2 19. Te irections for a sie autination test instruct that after
mixin the
patients serum an atex partices, the sie must be rotate for 2 minutes. What
wou happen
if the sie were rotate for 10 minutes? A. Possibe fase-positive resut B. P
fase-neative resut C. No e ect D. Depens on the amount of antiboy present in
the sampe
Immunooy/Appy principes of basic aboratory proceures/Autination/3 86 Ch
apter 3 |
Immunooy Answers to Questions 1520 15. D An unexpecte pattern may inicate the
presence of
more than one antiboy. Diutin the sampe may hep to ceary show the antibo
y speci cities,
if they are foun in i erent titers. If the pattern is sti atypica, a new samp
e shou be
coecte an the test repeate. 16. D Most autination tests use in serooy
empoy passive
or inirect autination where carrier partices are coate with the antien. T
he carrier
moecue is of su cient size so that the reaction of the antien with antiboy res

uts in
formation of a compex that is more easiy visibe. 17. A In tubes Nos.14, insu cie
nt antien is
present to ive a visibe reaction because excess antiboy has saturate a ava
iabe antien
sites. After iution of antiboy, tubes Nos.14 have the equivaent concentration
s of antien
an antiboy to aow formation of visibe compexes. 18. B The antiboy titer i
s reciproca of
the hihest iution of serum ivin a positive reaction. For oubin iutions
, each tube has
one haf the amount of serum as the previous tube. Because the rst tube was uni
ute (neat),
the iution in tube No. 8 is (1/2) 7 an the titer equas 2 7 or 128. 19. A Fai
ure to foow
irections, as in this case where the reaction was aowe to procee beyon the
time, may resut in a fase-positive reain. Dryin on the sie may ea to a
erroneous positive reain. 20. C In compement xation, hemoysis inicates a ne
ative test
resut. The absence of hemoysis inicates that compement was xe in an antienan
reaction an, therefore, that the speci c compement binin antiboy was present
in the
patients serum. Consequenty, it was not avaiabe to react in the inicator syst
em. 20. Which
outcome inicates a neative resut in a compement xation test? A. Hemautinat
ion B. Absence
of hemautination C. Hemoysis D. Absence of hemoysis Immunooy/Appy princi
pes of basic
aboratory proceures/Compement xation/1 2828_Ch03_075-120 06/08/12 11:10 AM
Pae 86 21.
What e ect oes seectin the wron ate have on the resuts when ces are counte
 by ow
cytometry? A. No e ect B. Faiure to count the esire ce popuation C. Fasey
resuts D. Impossibe to etermine Immunooy/Appy principes of basic aborato
proceures/Fow cytometry/3 22. Which statement best escribes immunophenotypin
? A. Lineae
etermination by etectin antiens on the surface of the ate ces usin uores
cent antiboies
B. Ienti cation of ce maturity usin antiboies to etect antiens within the n
uceus C.
Ienti cation an sortin of ces by front an sie-scatter of iht from a aser
D. Anaysis of
ces coecte by ow cytometry usin traitiona autination reactions Immuno
principes of basic aboratory proceures/Fow cytometry/1 23. A ow cytometry sca
tterram of a
bone marrow sampe shows a ense popuation of ces ocate in-between norma 
ymphoi an
norma myeoi ces. What is the most ikey expanation? A. Te sampe was impr
opery coecte
B. An abnorma ce popuation is present C. Te aser optics are out of ainmen
t D. Te ces are
most ikey not eukocytes Immunooy/Appy principes of basic aboratory proce
cytometry/3 3.2 | Immunooic Proceures 87 Answers to Questions 2123 21. B Gat

in is the step

performe to seect the proper ces to be counte. Faiure to propery perform
this proceure
wi resut in probems in isoatin an countin the esire ces. It is impos
sibe to
etermine if the na resut wou be fasey eevate or fasey owere by prob
ems with
atin. 22. A Immunophenotypin refers to cassi cation of ces (ineae an ma
assinment) usin a pane of uorescent-abee antiboies irecte aainst speci c
antiens on the ces. Antiboies are referre to by their CD (custer of i erent
iation) number.
Monocona antiboies havin a common CD number o not necessariy bin to the s
ame epitope but
reconize the same antien on the ce surface. Reactivity of the seecte ces
with a pane of
antiboies i erentiates ymphoi from myeoi ces an ienti es the stae of ce
23. B Lymphoi ces an myeoi ces ispay in preictabe reions of the sca
tterpot because
of their characteristic size an ensity. Lymphoi ces cause ess forwar an
sie scatter from
the aser than o myeoi ces. A ense zone of ces in between those reions
is cause by the
presence of a are number of abnorma ces, usuay basts. The ineae of the
ces can be
etermine by immunophenotypin with a pane of uorescent-abee antiboies. 282
06/08/12 11:10 AM Pae 87 88 3.3 Infectious Diseases 1. Which serum antiboy r
esponse usuay
characterizes the primary (eary) stae of syphiis? A. Antiboies aainst syphi
is are
unetectabe B. Detecte 13 weeks after appearance of the primary chancre C. Dete
cte in 50% of
cases before the primary chancre isappears D. Detecte within 2 weeks after inf
Immunooy/Correate aboratory ata with physiooica processes/Syphiis/Testi
n/1 2. What
substance is etecte by the rapi pasma reain (RPR) an Venerea Disease Rese
arch Laboratory
(VDRL) tests for syphiis? A. Carioipin B. Anticarioipin antiboy C. Anti-T.
antiboy D. Treponema paium Immunooy/Appy knowee of funamenta biooi
characteristics/Syphiis/Testin/1 3. What type of antien is use in the RPR ca
r test? A. Live
treponema oranisms B. Kie suspension of treponema oranisms C. Carioipin
D. Tanne sheep
ces Immunooy/Appy principes of basic aboratory proceures/Syphiis/Testin
/1 4. Which of
the foowin is the most sensitive test to etect conenita syphiis? A. VDRL
Microhemautinin test for T. paium (MHA-TP) D. Poymerase chain reaction (P
Immunooy/Appy principes of basic aboratory proceures/Syphiis/Testin/1 An
swers to
Questions 15 1. B Durin the primary stae of syphiis, about 90% of patients ev
eop antiboies
between 1 an 3 weeks after the appearance of the primary chancre. 2. B Reain

is the name for

a nontreponema antiboy that appears in the serum of syphiis-infecte persons
an is etecte
by the RPR an VDRL assays. Reain reacts with carioipin, a ipi-rich extract
of beef heart
an other anima tissues. 3. C Carioipin is extracte from anima tissues, suc
h as beef hearts,
an attache to carbon partices. In the presence of reain, the partices wi
autinate. 4. D
The PCR wi ampify a very sma amount of DNA from T. paiuman aow for e
tection of the
oranism in the infant. Antiboy tests such as VDRL an RPR may etect materna
antiboy ony,
not inicatin if the infant has been infecte. 5. B The FTA-ABS test is more sp
eci c for T.
paium than nontreponema tests such as the VDRL an RPR an wou be east i
key to etect a
biooica fase-positive resut. The FTA-ABS test uses heat-inactivate serum t
hat has been
absorbe with the Reiter strain of T. paiumto remove nonspeci c antiboies. Non
tests have a biooica fase-positive rate of 1%10%, epenin upon the patient
teste. Fase-positive nins are cause commony by infectious mononuceosis (IM
), SLE, vira
hepatitis, an human immunoe ciency virus (HIV) infection. 5. A biooica fasepositive
reaction is east ikey with which test for syphiis? A. VDRL B. Fuorescent T.
antiboy absorption test (FTA-ABS) C. RPR D. A are equay ikey to etect a
resut Immunooy/Appy principes of basic aboratory proceures/Syphiis/Testi
2828_Ch03_075-120 06/08/12 11:10 AM Pae 88 6. A 12-year o ir has symptom
s of fatiue an
a ocaize ymphaenopathy. Laboratory tests revea a periphera boo ymphocy
tosis, a positive
RPR, an a positive spot test for IM. What test shou be performe next? A. HIV
test by ELISA B.
VDRL C. EpsteinBarr virus (EBV) speci c antien test D. Treponema paium partice
autination (TP-PA) test Immunooy/Correate aboratory ata with physiooic
processes/Syphiis/Testin/3 7. Which test is most ikey to be positive in the
tertiary stae of
syphiis? A. FTA-ABS B. RPR C. VDRL D. Reain screen test (RST) Immunooy/Corre
ate aboratory
ata with physiooica processes/Syphiis/Testin/3 8. What is the most ikey
interpretation of
the foowin syphiis serooica resuts? RPR: reactive; VDRL: reactive; MHA-T
P: nonreactive A.
Neurosyphiis B. Seconary syphiis C. Syphiis that has been successfuy treat
e D. Biooica
fase positive Immunooy/Correate aboratory ata with physiooica
processes/Syphiis/Testin/2 9. Which specimen is the sampe of choice to evaua
te atent or
tertiary syphiis? A. Serum sampe B. Chancre ui C. CSF D. Joint ui Immunooy/C
aboratory ata with physiooica processes/Syphiis/Testin/1 10. Interpret th
e foowin
quantitative RPR test resuts. RPR titer: weaky reactive 1:8; reactive 1:81:64 A

. Excess
antiboy, prozone e ect B. Excess antien, postzone e ect C. Equivaence of antien
an antiboy
D. Impossibe to interpret; testin error Immunooy/Correate aboratory ata w
ith physiooica
processes/Syphiis/Testin/2 3.3 | Infectious Diseases 89 Answers to Questions
610 6. D The
patients symptoms are nonspeci c an cou be attribute to many potentia causes.
However, the
patients ae, ymphocytosis, an serooica resuts point to infectious mononuc
eosis (IM). The
rapi spot test for antiboies seen in IM is hihy speci c. The EBV-speci c antien
test is more
sensitive but is unnecessary when the spot test is positive. HIV infection is un
common at this
ae an is often associate with eneraize ymphaenopathy an a norma or re
uce tota
ymphocyte count. IM antiboies are commony impicate as a cause of biooica
nontreponema tests for syphiis. Therefore, a treponema test for syphiis shou
 be performe
to ocument this phenomenon in this case. 7. A The FTA-ABS or one of the trepone
ma tests is more
ikey to be positive than a nontreponema test in the tertiary stae of syphii
s. In some cases,
systemic esions have subsie by the tertiary stae an the nontreponema tests
seroneative. Athouh the FTA-ABS is the most sensitive test for tertiary syphi
is, it wi be
positive in both treate an untreate cases. 8. D A positive reaction with nont
reponema antien
an a neative reaction with a treponema antien is most ikey cause by a bio
fase-positive nontreponema test. 9. C Latent syphiis usuay beins after the
secon year of
untreate infection. In some cases, the serooica tests become neative. Howev
er, if
neurosyphiis is present, cerebrospina ui serooy wi be positive an the CSF
wi ispay
increase protein an peocytosis characteristic of centra nervous system infec
tion. 10. A This
patient may be in the seconary stae of syphiis an is proucin are amounts
of antiboy to
T. paium su cient to cause antiboy excess in the test. The test became stron
y reactive ony
after the antiboy was iute. 2828_Ch03_075-120 06/08/12 11:10 AM Pae 89 1
1. Tests to
ientify infection with HIV fa into which three enera cassi cation types of t
ests? A. Tissue
cuture, antien, an antiboy tests B. Tests for antiens, antiboies, an nuc
eic aci C. DNA
probe, DNA ampi cation, an Western bot tests D. ELISA, Western bot, an Southe
rn bot tests
Immunooy/Appy principes of basic aboratory proceures/HIV/Testin/1 12. Whi
ch tests are
consiere screenin tests for HIV? A. ELISA, 4th eneration, an rapi antiboy
tests B.
Immuno uorescence, Western bot, raioimmuno-precipitation assay C. Cuture, anti
en capture
assay, DNA ampi cation D. Reverse transcriptase an messener RNA (mRNA) assay Im

principes of basic aboratory proceures/HIV/Testin/1 13. Which tests are cons
con rmatory tests for HIV? A. ELISA an rapi antiboy tests B. Western bot test,
i erentiation assays, an poymerase chain reaction C. Cuture, antien capture a
poymerase chain reaction D. Reverse transcriptase an mRNA assay Immunooy/App
y principes of
basic aboratory proceures/HIV/Testin/1 14. Which is most ikey a positive We
stern bot resut
for infection with HIV? A. Ban at p24 B. Ban at p60 C. Bans at p24 an p31 D
. Bans at p24
an p120 Immunooy/Evauate aboratory ata to reconize heath an isease st
bot/2 15. A woman who has ha ve prenancies subsequenty tests positive for HIV
by Western
bot. What is the most ikey reason for this resut? A. Possibe cross-reaction
with herpes or
EBV antiboies B. Interference from meication C. Cross-reaction with HLA antie
ns in the antien
preparation D. Possibe technica error Immunooy/Evauate aboratory ata to r
econize heath
an isease states/HIV/Western bot/3 90 Chapter 3 | Immunooy Answers to Quest
ions 1116 11. B
Two common methos for etectin antiboies to HIV are the ELISA an Western bo
t tests. Two
common methos for etectin HIV antiens are ELISA an immuno uorescence. Two com
mon methos for
etectin HIV enes are the Southern bot test an DNA ampi cation usin the poy
merase chain
reaction to etect vira nuceic aci in infecte ymphocytes. 12. A ELISA, rapi
 antiboy tests,
as we as the 4th eneration automate antien/antiboy combination assays are
screenin tests
for HIV. The 4th eneration assays etect both antien an antiboy. 13. B Weste
rn bot, an PCR
tests are eneray use as con rmatory tests for HIV. An HIV-1,2 i erentiation ass
ay is
recommene as the con rmin proceure foowin a reactive 4th eneration HIV ass
ay. PCR,
however, is more often use for eary etection of HIV infection, for ocumentin
 infant HIV
infection, an for foowin antivira therapy. 14. D To be consiere positive
by Western bot
testin, bans must be foun for at east two of the foowin three HIV protein
s: p41, p24, an
p120 or 160. The p24 ban enotes antiboy to a a protein. The p160 is the p
recursor protein
from which p120 an p41 are mae; these are env proteins. 15. C Mutiparous wo
men often have
HLA antiboies. The Western bot antiens are erive from HIV rown in human ce
 ines havin
HLA antiens. A cross reaction with HLA antien(s) in the Western bot cou hav
e occurre. 16. B
These resuts are not inicative of an HIV infection an may be ue to a testin
error in the
rst ELISA assay. Known fase-positive ELISA reactions occur in autoimmune isease
s, syphiis,
acohoism, an ymphoproiferative iseases. A sampe is consiere positive fo

r HIV if it is
repeatey positive by ELISA or other screenin metho an positive by a con rmato
ry metho. 16.
Interpret the foowin resuts for HIV infection. ELISA: positive; repeat ELISA
: neative;
Western bot: no bans A. Positive for HIV B. Neative for HIV C. Ineterminate
D. Further
testin neee Immunooy/Evauate aboratory ata to reconize heath an isea
states/HIV/Testin/2 2828_Ch03_075-120 06/08/12 11:10 AM Pae 90 17. Interpre
t the foowin
resuts for HIV infection. HIV 1,2 ELISA: positive; HIV-1 Western bot: ineterm
inate; HIV-1 p24
antien: neative A. Positive for antiboies to human immunoe ciency virus, HIV-1
B. Positive
for antiboies to human immunoe ciency virus, HIV-2 C. Cross reaction; biooica
resut D. Aitiona testin require Immunooy/Evauate aboratory ata to rec
onize heath an
isease states/HIV/Testin/3 18. What is the most ikey expanation when antibo
y tests for HIV
are neative but a poymerase chain reaction test performe 1 week ater is posi
tive? A. Probaby
not HIV infection B. Patient is in the winow phase before antiboy prouction C.
Tests were
performe incorrecty D. Cinica sins may be misinterprete Immunooy/Correa
te aboratory
ata with physiooica processes/HIV/Testin/3 19. What criteria constitute the
cassi cation
system for HIV infection? A. CD4-positive T-ce count an cinica symptoms B.
symptoms, conition, uration, an number of positive bans on Western bot C. P
resence or
absence of ymphaenopathy D. Positive bans on Western bot an CD8-positive Tce count
Immunooy/Appy knowee of funamenta biooica characteristics/HIV/2 20. W
hat is the main
i cuty associate with the eveopment of an HIV vaccine? A. Te virus has been 
i cut to
cuture; antien extraction an concentration are extremey aborious B. Human t
rias cannot be
performe C. Di erent strains of the virus are eneticay iverse D. Anti-iiotyp
e antiboies
cannot be eveope Immunooy/Appy principes of basic immunooy/ HIV/Vaccine
s/2 21. Which
CD4:CD8 ratio is most ikey in a patient with acquire immunoe ciency synrome (
AIDS)? A. 2:1
B. 3:1 C. 2:3 D. 1:2 Immunooy/Correate aboratory ata with physiooica
processes/HIV/Testin/2 3.3 | Infectious Diseases 91 Answers to Questions 1721
17. D The
ineterminate Western bot an neative p24 antien assay inicate that HIV-1 in
fection is
unikey, However, aitiona testin is require to etermine if the patient ha
s antiboies to
HIV-2 or if this cou be a fase-positive ELISA assay. 18. B In eary seroconve
rsion, patients
may not be makin enouh antiboies to be etecte by antiboy tests. The perio
infection with HIV an the appearance of etectabe antiboies is cae the win
ow phase.

Athouh this perio has been reuce to a few weeks by sensitive enzyme immunoa
ssays, patients
at hih risk or ispayin cinica conitions associate with HIV isease shou
 be teste aain
after waitin severa more weeks. 19. A The cassification system for HIV infect
ion is base upon
a combination of CD4-positive T-ce count (heper T ces) an various cateori
es of cinica
symptoms. Cassification is important in eterminin treatment options an the p
roression of the
isease. 20. C Vaccine eveopment has been i cut primariy because of the enet
ic iversity
amon i erent strains of the virus, an new strains are constanty emerin. HIV1 can be
ivie into two main subtypes esinate M (for main) an O (for outier). The
M roup is
further ivie into 9 subroups, esinate AJ (there is no E subroup), base u
pon i erences
in the nuceotie sequence of the a ene. Two remainin subtypes are esine
N (non M an non
O) an P (a subtype reate to SIVor). A vaccine has yet to be eveope that i
s e ective for
a of the subroups of HIV-1. 21. D An inverte CD4:CD8 ratio (ess than 1.0) i
s a common nin
in an AIDS patient. The Centers for Disease Contro an Prevention requires a CD
(heper T) ce count of ess than 200/L or 14% in the absence of an AIDS-de ning i
llness (e.g.,
Pneumocystis carinii pneumonia) in the case surveillance de nition of AIDS. 2828_C
06/08/12 11:10 AM Page 91 22. What is the advantage of 4th-generation rapid HI
V tests over
earlier rapid HIV tests? A. Tey use recombinant antigens B. Tey detect multiple
strains of HIV C.
Tey detect p24 antigen D. Tey are quantitative Immunology/Apply principles of ba
sic laboratory
procedures/HIV/Testing/2 23. Which method is used to test for HIV infection in i
nfants who are
born to HIV-positive mothers? A. ELISA B. Western blot test C. Polymerase chain
reaction D. Viral
culture Immunology/Apply principles of special procedures/ HIV/1 24. What is the
most likely
cause when a Western blot or ELISA is positive for all controls and samples? A.
pipetting B. Improper washing C. Improper addition of sample D. Improper reading
Immunology/Evaluate laboratory data to recognize problems/HIV/Testing/3 25. What
constitutes a
diagnosis of viral hepatitis? A. Abnormal test results for liver enzymes B. Clin
ical signs and
symptoms C. Positive results for hepatitis markers D. All of these options Immun
laboratory data to recognize health and disease states/Hepatitis/Testing/2 26. W
hich of the
following statements regarding infection with hepatitis D virus is true? A. Occu
rs in patients
with HIV infection B. Does not progress to chronic hepatitis C. Occurs in patien
ts with hepatitis
B D. Is not spread through blood or sexual contact Immunology/Apply knowledge of
biological characteristics/Hepatitis/1 27. All of the following hepatitis viruse

s are spread
through blood or blood products except: A. Hepatitis A B. Hepatitis B C. Hepatit
is C D. Hepatitis
D Immunology/Apply knowledge of fundamental biological characteristics/Hepatitis
/1 92 Chapter 3 |
Immunology Answers to Questions 2227 22. C Both 3rd-generation and 4th-generation
rapid tests
for HIV use recombinant and synthetic HIV antigens conjugated to a solid phase.
The multivalent
nature of these tests allows for detection of less common subgroups of HIV-1 and
detection of both HIV-1 and HIV-2. However, the 4th-generation assays also use s
antibodies to p24 antigen to detect its presence. Because p24 antigen appears be
fore antibodies
to HIV, 4th-generation tests can detect infection 47 days earlier than tests base
d on antibody
detection alone. 23. C ELISA and Western blot primarily re ect the presence of mat
ernal antibody.
The PCR uses small amounts of blood and does not rely on the antibody response.
PCR ampli es
small amounts of viral nucleic acid and can detect less than 200 copies of viral
RNA per
milliliter of plasma. These qualities make PCR ideal for the testing of infants.
Nucleic acid
methods for HIV RNA include the Roche Amplicor reverse- transcriptase assay, the
branched DNA
(bDNA) signal ampli cation method, and the nucleic acid sequence-based ampli cation
method. 24. B Improper washing may not remove unbound enzyme conjugated anti-hum
an globulin, and
every sample may appear positive. 25. D To diagnose a case of hepatitis, the phy
sician must
consider clinical signs as well as laboratory tests that measure liver enzymes a
nd hepatitis
markers. 26. C Hepatitis D virus is an RNA virus that requires the surface antig
en or envelope of
the hepatitis B virus for entry into the hepatocyte. Consequently, hepatitis D v
irus can infect
only patients who are coinfected with hepatitis B. 27. A Hepatitis A is spread t
hrough the
fecaloral route and is the cause of infectious hepatitis. Hepatitis A virus has a
incubation period (27 weeks) than hepatitis B virus (16 months). Epidemics of hepa
titis A virus
can occur, especially when food and water become contaminated with raw sewage. H
epatitis E virus
is also spread via the oralfecal route and, like hepatitis A virus, has a short i
period. 2828_Ch03_075-120 06/08/12 11:10 AM Page 92 28. Which hepatitis B mar
ker is the best
indicator of early acute infection? A. HBsAg B. HBeAg C. Anti-HBc D. Anti-HBs
Immunology/Correlate laboratory data with physiological processes/Hepatitis/Test
ing/2 29. Which
is the rst antibody detected in serum after infection with hepatitis B virus (HBV
)? A. Anti-HBs
B. Anti-HBc IgM C. Anti-HBe D. All are detectable at the same time Immunology/Co
laboratory data with physiological processes/Hepatitis/Testing/2 30. Which antib
ody persists in

low-level carriers of hepatitis B virus? A. IgM anti-HBc B. IgG anti-HBc C. IgM

anti-HBe D. IgG
anti-HBs Immunology/Correlate laboratory data with physiological processes/Hepat
31. What is the most likely explanation when a patient has clinical signs of vir
al hepatitis but
tests negative for hepatitis A IgM, hepatitis B surface antigen, and hepatitis C
Ab? A. Tests
were performed improperly B. Te patient does not have hepatitis C. Te patient ma
y be in the core
window D. Clinical evaluation was performed improperly Immunology/Correlate labor
atory data with
physiological processes/Hepatitis/Testing/3 32. Which hepatitis B markers should
be performed on
blood products? A. HBsAg and anti-HBc B. Anti-HBs and anti-HBc C. HBeAg and HBcA
g D. Anti-HBs and
HBeAg Immunology/Apply principles of laboratory operations/ Hepatitis/Testing/1
33. Which
hepatitis antibody confers immunity against reinfection with hepatitis B virus?
A. Anti-HBc IgM
B. Anti-HBc IgG C. Anti-HBe D. Anti-HBs Immunology/Correlate laboratory data wit
h physiological
processes/Hepatitis/Testing/1 3.3 | Infectious Diseases 93 Answers to Question
s 2833 28. A
Hepatitis B surface antigen (HBsAg) is the first marker to appear in hepatitis B
virus infection.
It is usually detected within 4 weeks of exposure (prior to the rise in transami
nases) and
persists for about 3 months after serum enzyme levels return to normal. 29. B An
tibody to the
hepatitis B core antigen (anti-HBc) is the rst detectable hepatitis B antibody. I
t persists in
the serum for 12 years postinfection and is found in the serum of asymptomatic ca
rriers of HBV.
Because levels of total anti-HBc are high after recovery, IgM anti-HBc is a more
useful marker
for acute infection. Both anti-HBc and anti-HBs can persist for life, but only a
nti-HBs is
considered protective. 30. B IgG antibodies to the hepatitis B core antigen (ant
i-HBc) can be
detected in carriers who are HBsAg and anti-HBs negative. These persons are pres
umed infective
even though the level of HBsAg is too low to detect. No specific B core IgG test
is available,
however. This patient would be positive in the anti-B core total antibody assay
and negative in
the anti-HB core IgM test. 31. C The patient may be in the core window, the period
of hepatitis
B infection when both the surface antigen and surface antibody are undetectable.
The IgM
anti-hepatitis B core and the anti-hepatitis B core total antibody assays would
be the only
detectable markers in the serum of a patient in the core window phase of hepatit
is B infection.
32. A Blood products are tested for HBsAg, an early indicator of infection, and
anti-HBc, a
marker that may persist for life. Following recovery from HBV infection, some pa
demonstrate negative serology for HBsAg and anti-HBs but are positive for anti-H
Bc. Such patients

are considered infective. 33. D Anti-HBs appears later in infection than anti-HB
c and is used as
a marker for immunity following infection or vaccination rather than for diagnos
is of current
infection. 2828_Ch03_075-120 06/08/12 11:10 AM Page 93 34. Which test, other
than serological
markers, is most consistently elevated in viral hepatitis? A. Antinuclear antibo
dies B. Alanine
aminotransferase (ALT) C. Absolute lymphocyte count D. Lactate dehydrogenase Imm
laboratory data with physiological processes/Hepatitis/Testing/1 35. If only ant
i-HBs is
positive, which of the following can be ruled out? A. Hepatitis B virus vaccinat
ion B. Distant
past infection with hepatitis B virus C. Hepatitis B immune globulin (HBIG) inje
ction D. Chronic
hepatitis B virus infection Immunology/Correlate laboratory data with physiologi
processes/Hepatitis/Testing/2 36. Interpret the following results for EBV infect
ion: IgG and IgM
antibodies to viral capsid antigen (VCA) are positive. A. Infection in the past
B. Infection with
a mutual enhancer virus such as HIV C. Current infection D. Impossible to interp
ret; need more
information Immunology/Correlate laboratory data with physiological processes/EB
V/Testing/3 37.
Which statement concerning non-Forssman heterophile antibody is true? A. It is n
ot absorbed by
guinea pig antigen B. It is absorbed by guinea pig antigen C. It does not agglut
inate horse RBCs
D. It does not agglutinate sheep RBCs Immunology/Apply principles of basic labor
procedures/IM/Testing/1 38. Given a heterophile antibody titer of 224, which of
the following
results indicate IM? A. B. C. D. Immunology/Evaluate laboratory data to recogniz
e health and
disease states/IM/Testing/2 94 Chapter 3 | Immunology Answers to Questions 3439 3
4. B ALT is a
liver enzyme and may be increased in hepatic disease. Highest levels occur in ac
ute viral
hepatitis, reaching 2050 times the upper limit of normal. 35. D Persons with chro
nic HBV
infection show a positive test result for anti-HBc (IgG or total) and HBsAg but
not anti-HBs.
Patients with active chronic hepatitis have not become immune to the virus. 36.
C Antibodies to
both IgG and IgM VCA are found in a current infection with EBV. The IgG antibody
may persist for
life, but the IgM anti-VCA disappears within 4 months after the infection resolv
es. 37. A
Non-Forssman antibody is not absorbed by guinea pig antigen. This is one of the
principles of the
Davidsohn di erential test for antibodies to IM. These antibodies are non-Forssman
; they are
absorbed by sheep, horse, or beef RBCs but not by guinea pig kidney. Therefore,
a heterophile
titer remaining higher after absorption with guinea pig kidney than with beef RB
Cs indicates IM.
38. A Antibodies to infectious mononucleosis (non- Forssman antibodies) are not
neutralized or

absorbed by guinea pig antigen (but are absorbed by beef cell antigen). A positi
ve test is
indicated by at least a four-tube reduction in the heterophile titer after absor
ption with beef
cells and no more than a three-tube reduction in titer after absorption with gui
nea pig kidney.
39. C In serum sickness, antibodies are neutralized by both guinea pig kidney an
d beef cell
antigens, and at least a three-tube (eightfold) reduction in titer should occur
after absorption
with both. Absorption with Absorption with Beef Guinea Pig Kidney Cells Two-t
ube titer
reduction Five-tube titer reduction No titer reduction No titer reduction Five-t
ube titer
reduction Five-tube titer reduction Five-tube titer reduction No titer reduction
Absorption with
Absorption with Beef Guinea Pig Kidney Cells Two-tube titer reduction Five-tub
e titer reduction
No titer reduction No titer reduction Five-tube titer reduction Five-tube titer
Five-tube titer reduction No titer reduction 39. Given a heterophile antibody ti
ter of 224, which
of the following results indicate serum sickness? A. B. C. D. Immunology/Evaluat
e laboratory data
to recognize health and disease states/Serum sickness/Testing/2 2828_Ch03_075-12
0 06/08/12
11:10 AM Page 94 40. Given a heterophile antibody titer of 224, which of the fo
llowing results
indicate an error in testing? A. B. C. D. Immunology/Evaluate laboratory data to
possible inconsistent results/IM/Testing/2 41. Blood products are tested for whi
ch virus before
being transfused to newborns? A. EBV B. Human T-lymphotropic virus II (HTLV-II)
Cytomegalovirus (CMV) D. Hepatitis D virus Immunology/Apply principles of labora
operations/Virus testing/1 42. What is the endpoint for the antistreptolysin O (
ASO) latex
agglutination assay? A. Highest serum dilution that shows no agglutination B. Hi
ghest serum
dilution that shows agglutination C. Lowest serum dilution that shows agglutinat
ion D. Lowest
serum dilution that shows no agglutination Immunology/Apply principles of basic
procedures/ASO/Interpretation/1 43. Interpret the following ASO results: Tube No
s. 14 (Todd unit
125): no hemolysis; Tube No. 5 (Todd unit 166): hemolysis A. Positive Todd unit
125 B. Positive
Todd unit 166 C. No antistreptolysin O present D. Impossible to interpret Immuno
laboratory data to make identi cations/ASO/Interpretation/2 44. Which control show
s the correct
result for a valid ASO test? A. SLO control, no hemolysis B. Red cell control, n
o hemolysis C.
Positive control, hemolysis in all tubes D. Hemolysis in both SLO and red cell c
Immunology/Apply principles of basic laboratory procedures/ASO/Controls/1 3.3 |
Diseases 95 Answers to Questions 4044 40. B An individual with a 56 or higher t
iter in the

presumptive test (signi cant heterophile antibodies) has either Forssman antibodie
s, non-Forssman
antibodies, or both. A testing error has occurred if no reduction in the titer o
f antibody
against sheep RBCs is observed after absorption because absorption should remove
one or both
types of sheep RBC agglutinins. 41. C CMV can be life threatening if transmitted
to a newborn
through a blood product. HTLV-II is a rare virus, which like HIV, is a T-cell tr
opic RNA
retrovirus. The virus has been associated with hairy cell leukemia, but this is
not a consistent
nding. 42. B The latex test for ASO includes latex particles coated with streptol
ysin O. Serial
dilutions are prepared and the highest dilution showing agglutination is the end
point. 43. A An
ASO titer is expressed in Todd units as the last tube that neutralizes (no visib
le hemolysis) the
streptolysin O (SLO). Most laboratories consider an ASO titer signi cant if it is
166 Todd units
or higher. However, people with a recent history of streptococcal infection may
demonstrate an
ASO titer of 166 or higher; demonstration of a rise in titer from acute to conva
lescent serum is
required to con rm a current streptococcal infection. ASO is commonly measured usi
ng a rapid
latex agglutination assay. These tests show agglutination when the ASO concentra
tion is 200 IU/mL
or higher. 44. B The red cell control contains no SLO and should show no hemolys
is. The SLO
control contains no serum and should show complete hemolysis. An ASO titer canno
t be determined
unless both the RBC and SLO controls demonstrate the expected results. Absorptio
n with
Absorption with Beef Guinea Pig Kidney Cells Two-tube titer reduction Five-tub
e titer reduction
No titer reduction No titer reduction Five-tube titer reduction Five-tube titer
Five-tube titer reduction No titer reduction 2828_Ch03_075-120 06/08/12 11:10
AM Page 95 45. A
streptozyme test was performed, but the result was negative, even though the pat
ient showed
clinical signs of a streptococcal throat infection. What should be done next? A.
Either ASO or
anti-deoxyribonuclease B (anti-DNase B) testing B. Another streptozyme test usin
g diluted serum
C. Antihyaluronidase testing D. Wait for 35 days and repeat the streptozyme test
Immunology/Evaluate laboratory data to recognize health and disease states/ASO/T
esting/3 46.
Rapid assays for in uenza that utilize specimens obtained from nasopharyngeal swab
s detect: A.
IgM anti-in uenza B. IgA anti-in uenza C. IgA-in uenza Ag immune complexes D. In uenza a
Immunology/Apply principles of basic laboratory procedures/Virus testing/2 47. H
ow can
interfering cold agglutinins be removed from a test sample? A. Centrifuge the se
rum and remove
the top layer B. Incubate the clot at 1C4C for several hours, then remove serum C.
the serum at 56C in a water bath for 30 minutes D. Use an anticoagulated sample I

principles of special procedures/ Cold agglutinins/Testing/2 48. All tubes (dilu
tions) except the
negative control are positive for cold agglutinins. Tis indicates: A. Contaminat
ed red cells B. A
rare antibody against red cell antigens C. Te sample was stored at 4C prior to se
parating serum
and cells D. Further serial dilution is necessary Immunology/Select course of ac
agglutinins/ Testing/3 49. All positive cold agglutinin tubes remain positive af
ter 37C
incubation except the positive control. What is the most likely explanation for
this situation?
A. High titer cold agglutinins B. Contamination of the test system C. Antibody o
ther than cold
agglutinins D. Faulty water bath Immunology/Evaluate laboratory data to determin
e possible
inconsistent results/Cold agglutinins/Testing/3 96 Chapter 3 | Immunology Answer
s to Questions
4550 45. A A streptozyme test is used for screening and contains several of the a
associated with streptococcal products. Because some patients produce an antibod
y response to a
limited number of streptococcal products, no single test is su ciently sensitive t
o rule out
infection. Clinical sensitivity is increased by performing additional tests when
initial results
are negative. The streptozyme test generally shows more false positives and fals
e negatives than
ASO and anti-DNase. A positive test for antihyaluronidase occurs in a smaller nu
mber of patients
with recent streptococcal infections than ASO and anti-DNase. 46. D The rapid in u
enza assays are
antigen detection methods. They are designed to detect early infection, before a
ntibody is
produced. 47. B Cold agglutinins will attach to autologous red cells if incubate
d at 1C4C. The
absorbed serum will be free of cold agglutinins. 48. D Cold agglutinins may be m
easured in
patients who have cold agglutinin disease, a cold autoimmune hemolytic anemia. I
n such cases,
titers can be as high as 10 6 . If all tubes (dilutions) for cold agglutinins ar
e positive,
except the negative control, then a high titer of cold agglutinins is present in
the sample.
Further serial dilutions should be performed. 49. C Cold agglutinins do not rema
in reactive above
30C, and agglutination must disperse following incubation at 37C. The most likely
when agglutination remains after 37C incubation is that a warm alloantibody or au
toantibody is
present. 50. C A fourfold (2 tube) or greater increase in antibody titer is usua
lly indicative of
an acute infection. Although answers A and B show a fourfold rise in titer, answ
er C shows a
16-fold rise in titer and is the most de nitive. In most serological tests, a sing
le high titer
is insu cient evidence of acute infection unless speci c IgM antibodies are measured
because age,
individual variation, immunologic status, and history of previous exposure (or v

accination) cause
a wide variation in normal serum antibody titers. 50. Which increase in antibody
titer (dilution)
best indicates an acute infection? A. From 1:2 to 1:8 B. From 1:4 to 1:16 C. Fro
m 1:16 to 1:256
D. From 1:64 to 1:128 Immunology/Correlate laboratory data with physiological pr
titers/1 2828_Ch03_075-120 06/08/12 11:10 AM Page 96 51. Which of the followi
ng positive
antibody tests may be an indication of recent vaccination or early primary infec
tion for rubella
in a patient with no clinical symptoms? A. Only IgG antibodies positive B. Only
IgM antibodies
positive C. Both IgG and IgM antibodies positive D. Fourfold rise in titer for I
gG antibodies
Immunology/Apply principles of basic laboratory procedures/Rubella/Testing/2 52.
Why is
laboratory diagnosis di cult in cases of Lyme disease? A. Clinical response may no
t be apparent
upon initial infection; IgM antibody may not be detected until 36 weeks after the
infection B.
Laboratory tests may be designed to detect whole Borrelia burgdorferi, not agella
r antigen found
early in infection C. Most laboratory tests are technically demanding and lack s
peci city D.
Antibodies formed initially to B. burgdorferi may cross react in antigen tests f
or autoimmune
diseases Immunology/Correlate clinical signs with laboratory procedures/Lyme dis
53. Serological tests for which disease may give a false- positive result if the
patient has Lyme
disease? A. AIDS B. Syphilis C. Cold agglutinins D. Hepatitis C Immunology/Evalu
ate laboratory
data to determine possible inconsistent results/Lyme disease/Testing/3 54. In mo
nitoring an
HIV-infected patient, which parameter may be expected to be the most sensitive i
ndicator of the
e ectiveness of antiretroviral treatment? A. HIV antibody titer B. CD4:CD8 ratio C
. HIV viral
load D. Absolute total T-cell count Immunology/Correlate clinical and laboratory
data/ HIV/2 55.
A renal transplant recipient is found to have a rising creatinine level and redu
ced urine output.
Te physician orders a Urine PCR assay. When you call to nd out what organism the ph
wants to identify, you are told: A. Hepatitis C virus B. Legionella pneumophila
virus Immunology/Apply knowledge of fundamental biological characteristics/Trans
plant/Virus/2 3.3
| Infectious Diseases 97 Answers to Questions 5156 51. B If only IgM antibodies
are positive,
this result indicates a recent vaccination or an early primary infection. 52. A
Lyme disease is
caused by B. burgdorferi, a spirochete, and typical clinical symptoms such as ra
sh or erythema
chronicum migrans may be lacking in some infected individuals. Additionally, IgM
antibody is not
detectable by laboratory tests until 36 weeks after a tick bite, and IgG antibody
later. 53. B Lyme disease is caused by a spirochete and may give positive result

s with some
speci c treponemal antibody tests for syphilis. 54. C The HIV viral load will rise
or fall in
response to treatment more quickly than any of the other listed parameters. The
absolute CD4
count is also an indicator of treatment e ectiveness and is used in resource-poor
areas that
might not have facilities for molecular testing available. Note that the absolut
e CD4 count is
not one of the choices, however. 55. D BK virus is a polyoma virus that can caus
e renal and
urinary tract infections. The virus is an opportunistic pathogen and has become
a well-recognized
cause of poor renal function in kidney transplant recipients. Antibody testing i
s not practical
or useful for this infection. The principal diagnostic assays are urinary cytolo
gy, and speci c
BK virus PCR testing in urine and serum. Although Legionella pneumophila can be
diagnosed through
a urinary antigen assay, that organism is not a primary cause of renal insu ciency
in transplant
patients. 56. A Neonatal HIV diagnosis is performed by screening for the presenc
e of the virus.
The current antibody tests are either IgG-speci c or an IgG/IgM combination assay.
Thus an infant
whose mother is HIV positive will also be positive in the HIV antibody assay. Al
though the CD4
count may be a useful assay to determine disease activity, there are many causes
of reduced CD4
numbers and this assay should not be used to diagnose HIV infection. 56. A newbo
rn is to be
tested for a vertically transmitted HIV infection. Which of the following tests
is most useful?
A. HIV PCR B. CD4 count C. Rapid HIV antibody test D. HIV IgM antibody test Immu
test/Neonatal HIV/2 2828_Ch03_075-120 06/08/12 11:10 AM Page 97 57. Which of
the following
methods used for HIV identi cation is considered a signal ampli cation technique? A.
chain DNA analysis B. DNA PCR C. Reverse transcriptase PCR D. Nucleic acid seque
nce based assay
(NASBA) Immunology/Apply knowledge of special procedures/ Molecular/HIV/1 58. Wh
ich of the
following fungal organisms is best diagnosed by an antibody detection test as op
posed to an
antibody detection assay? A. Histoplasma B. Cryptococcus C. Candida D. Aspergill
Immunology/Apply knowledge of special procedures/ Fungal testing/2 59. Your cyto
logy laboratory
refers a Papanicolaou smear specimen to you for an assay designed to detect the
presence of a
virus associated with cervical cancer. You perform: A. An ELISA assay for anti-H
SV-2 antibodies
B. A molecular assay for HSV-2 C. An ELISA assay for HPV antibodies D. A molecul
ar assay for HPV
Immunology/Select course of action/Virus testing/ Methods/3 60. An immunosuppres
sed patient has
an unexplained anemia. Te physician suspects a parvovirus B19 infection. A parvo
virus IgM test is
negative. Te next course of action is to tell the physician: A. Te patient does

not have
parvovirus B. A convalescent specimen is recommended in 4 weeks to determine if
a fourfold rise
in titer has occurred C. A parvovirus PCR is recommended D. Tat a recent transfu
sion for the
patients anemia may have resulted in a false-negative assay and the patient shoul
d be retested
in 4 weeks Immunology/Select course of action/Virus testing/ Parvovirus/3 98 Cha
pter 3 |
Immunology Answers to Questions 5760 57. A Branched chain DNA is a signal ampli cat
technique, i.e., if you start with one copy of the gene you nish with one copy. T
he detection
reagent is ampli ed, increasing the sensitivity of the assay. 58. B The Cryptococc
us antibody
response is not a reliable indicator of a current infection; thus, an antigen as
say is normally
used to monitor the disease. The antigen assay may be used for serum or spinal ui
d and will
decline in response to treatment much faster than a traditional antibody test. A
urinary antigen
test is avail - able for histoplasmosis, and a serum galactomannan assay is avai
lable for
Aspergillus. Those two assays preform better than antibody detection. No antige
n test is
available for Candida, thus antibody is the best serologic procedure for this or
ganism. 59. D
Cervical cell atypia and cervical cancer are associated with speci c high-risk ser
otypes of human
papilloma virus (HPV) infections. Although HPV antibody assays are available, th
ey are not
serotype speci c, nor do they relate to disease activity. Thus molecular probe ass
ays are the
tests of choice to detect high-risk HPV infection. Although HSV-2 is associated
with genital
herpesvirus, that virus has not been shown to cause cervical cancer. 60. C A neg
ative IgM assay
rarely rules out an infection. While a convalescent specimen may be useful in ma
ny cases, in an
immunosuppressed patient the convalescent specimen may remain negative in the pr
esence of an
infection. Thus a parvovirus PCR test is the preferred choice in this case. A fa
result could conceivably be caused by multiple whole blood or plasma transfusion
s, but retesting
for antibody a month later would not be bene cial to the patient. 2828_Ch03_075-12
0 06/08/12
11:10 AM Page 98 99 3.4 Autoimmune Diseases 1. What is a general de nition for au
toimmunity? A.
Increase of tolerance to self-antigens B. Loss of tolerance to self-antigens C.
Increase in
clonal deletion of mutant cells D. Manifestation of immunosuppression Immunology
/Apply knowledge
of fundamental biological characteristics/Autoimmunity/De nitions/1 2. An antinucl
ear antibody
test is performed on a specimen from a 55-year-old woman who has unexplained joi
nt pain. Te IFA
result is a titer of 40 and a homogeneous pattern. Te appropriate follow-up for
this patient is:
A. Anti-DNA assay B. Extractable nuclear antigen (ENA) testing C. Retest ANA in

36 months D.
CH50 complement assay Immunology/Correlate laboratory data with physiological pr
ocesses/IF/2 3.
Which disease is likely to show a rim (peripheral) pattern in an immuno uorescence
microscopy test for ANA? A. Mixed connective tissue disease (MCTD) B. Rheumatoid
arthritis C.
Systemic lupus erythematosus D. Scleroderma Immunology/Correlate laboratory data
physiological processes/IF/2 4. A patients specimen is strongly positive in an AN
A ELISA. Which
of the following would not be an appropriate follow up to this result? A. Immuno u
orescence test
on HEp-2 cells B. Speci c ENA ELISA tests C. Speci c anti-DNA ELISA D. Rheumatoid fa
ctor assay
Immunology/Select tests/ANA Con rmation/2 5. What type of antibodies is represente
d by the solid
or homogeneous pattern in the immuno uorescence test for antinuclear antibodies? A
. Antihistone
antibodies B. Anticentromere antibodies C. Anti-ENA (anti-Sm and anti-RNP) antib
odies D. Anti-RNA
antibodies Immunology/Correlate laboratory data with physiological processes/IF/
1 Answers to
Questions 16 1. B Autoimmunity is a loss of tolerance to self-antigens and the su
formation of autoantibodies. 2. C Approximately 25% of women in this age range m
ay have low
titer-positive ANA assays with no demonstrable connective tissue disease. A pati
ent with
anti-DNApositive SLE would be expected to have a much higher titer (> 160) in an
IFA assay. A
similar titer would be expected for an ENA positive specimen, although the patte
rn would be
speckled. Complement testing would not be indicated with this low titer in a 55year-old female.
3. C The rim or peripheral pattern seen in indirect immunofluorescence technique
s is most
commonly found in cases of active SLE. The responsible autoantibody is highly co
rrelated to
antidouble-stranded DNA (anti-dsDNA). 4. D The ANA ELISA is a screening assay. A
positive result
may be followed up by more speci c antibody ELISA tests or an ANA immuno uorescence
test to
determine pattern and titer. The ANA ELISA does not screen for rheumatoid factor
. 5. A
Antihistone antibodies (and also anti-DNA antibodies) cause the solid or homogen
eous pattern,
which is commonly found in patients with SLE, RA, mixed connective tissue diseas
e, and Sjgrens
syndrome. Antibodies to the centromere of chromosomes is a marker for the CREST
Raynauds phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) f
orm of systemic
sclerosis. 6. C High titer anti-Sm is indicative of SLE. Anti-Sm is one of two a
ntibodies against
saline extractable nuclear antigens, the other being anti-RNP. These antibodies
cause a speckled
pattern of immuno uorescence. 6. What disease is indicated by a high titer of anti
(anti-Smith) antibody? A. Mixed connective tissue disease (MCTD) B. RA C. SLE D.

Immunology/Correlate laboratory data with physiological processes/IF/2 2828_Ch03
06/08/12 11:10 AM Page 99 7. Which disease is least likely when a nucleolar pa
ttern occurs in
an immuno uorescence test for antinuclear antibodies? A. MCTD B. Sjgrens syndrome C.
Scleroderma Immunology/Correlate laboratory data with physiological processes/IF
/2 8. What
antibodies are represented by the nucleolar pattern in the immuno uorescence test
for antinuclear
antibodies? A. Antihistone antibodies B. Anti-dsDNA antibodies C. Anti-ENA (anti
-Sm and anti-RNP)
antibodies D. Anti-RNA antibodies Immunology/Correlate laboratory data with phys
processes/IF/1 9. Which test would best distinguish between SLE and MCTD? A. Mul
tiplex or ELISA
test for anti-SM and anti-RNP B. Immuno uorescence testing using Crithidia as subs
trate C. Slide
agglutination testing D. Laboratory tests cannot distinguish between these disor
Immunology/Evaluate laboratory data to recognize and report the need for additio
nal testing/
Autoimmune/Testing/3 10. An ANA test on HEp-2 cells shows nucleolar staining in
interphase cells
and dense chromatin staining in mitotic cells. Te most likely cause of this stai
ning pattern is:
A. Anti brillarin antibody B. Antiribosomal p antibody C. A serum with nucleolar a
nd homogeneous
patterns D. Technical artifact Immunology/Correlate laboratory data with physiol
processes/IF/1 11. Which immuno uorescence pattern indicates the need for ENA test
ing by
Ouchterlony immunodi usion, Multiplex, or ELISA assays? A. Homogeneous or solid B.
Peripheral or
rim C. Speckled D. Nucleolar Immunology/Evaluate laboratory data to recognize an
d report the need
for additional testing/ Autoimmune/Testing/3 100 Chapter 3 | Immunology Answers
to Questions 712
7. A All of the diseases except MCTD may cause a nucleolar pattern of immuno uores
Nucleolar uorescence is caused by anti-RNA antibodies and is seen in about 50% of
patients with
scleroderma. 8. D Anti-RNA antibodies are represented by the nucleolar pattern.
This pattern may
be seen in most systemic autoimmune diseases and is especially common in patient
s with
scleroderma. Anti-RNA and anti-Sm are not usually found in patients with mixed c
onnective tissue
disease. This is a syndrome involving aspects of SLE, RA, scleroderma, and polym
yositis. The
immuno uorescence pattern most often seen in MCTD is the speckled pattern caused b
y anti-RNP. 9.
A The Ouchterlony (double) immunodi usion assay may be used to identify and di erent
iate anti-Sm
from anti-RNP. Multiplex and ELISA assays, using puri ed or recombinant antigens,
are also
available for this testing. Anti-Sm with or without anti-RNP is found in approxi
mately one third
of SLE patients. Anti-RNP in the absence of anti-Sm is found in over 95% of MCTD

patients. 10. A
Anti brillarin antibody has this appearance. Ribosomal p antibody has nucleolar st
aining and a
background homogeneous and cytoplasmic stain. A combination nucleolar/homogeneou
s specimen will
also show homogeneous staining in the interphase cells. This pattern is not seen
in typical
technical artifacts. 11. C A speckled pattern is often due to the presence of an
tibodies against
the extractable nuclear antigens, such as Sm, RNP, SSA, and SSB. Homogenous and
rim patterns
suggest antibodies to double-stranded DNA. The homogeneous pattern may also be s
een with
antibodies to deoxyribonuclear protein, which is not an ENA. Nucleolar patterns
often indicate
antibodies to RNA or brillarin. 12. B Rheumatoid factors react with the Fc portio
n of the IgG
molecule and are usually IgM. This is the basis of rapid agglutination tests for
RA. Particles of
latex or cells are coated with IgG. Addition of serum containing rheumatoid fact
or results in
visible agglutination. 12. Which of the following is used in rapid slide tests f
or detection of
rheumatoid factors? A. Whole IgM molecules B. Fc portion of the IgG molecule C.
Fab portion of
the IgG molecule D. Fc portion of the IgM molecule Immunology/Apply knowledge of
biological characteristics/RA/Testing/1 2828_Ch03_075-120 06/08/12 11:10 AM P
age 100 13. Which
of the following methods is least likely to give a de nitive result for the diagno
sis of RA? A.
Nephelometric measurement of anti-IgG B. Agglutination testing for rheumatoid fa
ctor C. Anti CCP
D. Immuno uorescence testing for antinuclear antibodies Immunology/Select routine
procedures/ Autoimmune/RA/Testing/1 14. Which disease might be indicated by anti
bodies to smooth
muscle? A. Atrophic gastritis B. Autoimmune hepatitis C. Myasthenia gravis D. Sjg
rens syndrome
Immunology/Apply knowledge of fundamental biological characteristics/Autoimmune/
Testing/1 15.
Antibodies to thyroid peroxidase can be detected by using agglutination assays.
Which of the
following diseases may show positive results with this type of assay? A. Graves d
isease and
Hashimotos thyroiditis B. Myasthenia gravis C. Granulomatous thyroid disease D. A
disease Immunology/Select routine laboratory procedures/ Autoimmune/Testing/1 16
. What is the
main use of laboratory tests to detect antibodies to islet cells and insulin in
cases of
insulin-dependent diabetes mellitus (IDDM)? A. To regulate levels of injected in
sulin B. To
diagnose IDDM C. To rule out the presence of other autoimmune diseases D. To scr
een susceptible
individuals prior to destruction of cells Immunoloy/Select routine l ortory p
Autoimmune/IDDM/Testin/1 17. A ptient presents with clinicl symptoms of celi
c disese. Tests
for nti-tissue trnslutminse nd ntilidin nti odies re netive. Which

of the followin
tests should e ordered? A. IG level B. HLA DQ typin C. HLA DR typin D. IM l
Immunoloy/Select routine l ortory procedures/ Autoimmune/Celic disese/Testi
n/2 3.4 |
Autoimmune Diseses 101 Answers to Questions 1317 13. D Ptients with RA often
homoeneous pttern of uorescence in tests for ntinucler nti odies. However, t
his pttern is
seen in  wide rne of systemic utoimmune diseses nd in mny norml persons
t  titer elow
10. The rst two methods listed my e used to identify nti-IG, which is require
d to est lish
 dinosis of RA Anti CCP is  speci c ssy for rheumtoid rthritis. 14. B Anti
odies to
smooth muscle re found in the serum of up to 70% of ptients with ctive chroni
c heptitis nd
up to 50% of ptients with primry iliry cirrhosis. 15. A Anti odies to thyroi
d peroxidse my
e detected in oth Grves disese (hyperthyroidism) nd Hshimotos thyroiditis
(hypothyroidism). If  positive result is found to thyroid peroxidse, thyroxine
levels cn e
mesured to distinuish etween the two diseses. 16. D Fstin hyperlycemi is
the primry
ndin used to dinose IDDM. For individuls with n inherited suscepti ility to
the development
of IDDM, l ortory tests for the detection of nti odies to islet cells nd ins
ulin my help to
initite erly tretment efore complete destruction of cells. 17. B While nti
odies to tissue
trnslutminse nd lidin re often found in celic disese, their com ined s
ensitivity is
less thn 100%. Celic disese is lmost exclusively ssocited with the presenc
e of HLA DQ2
nd/or HLA DQ8. These HLA enes re not dinostic of celic disese, ut provid
e  testin
lterntive in nti ody-netive individuls who meet the clinicl dinostic cr
iteri for celic
disese. 2828_Ch03_075-120 06/08/12 11:10 AM Pe 101 18. A specimen ppers
to hve 
perinucler stinin pttern in n ntineutrophil cytoplsmic nti ody (ANCA) im
muno uorescent
ssy usin ethnol- xed neutrophils, suestin the possi ility of  pANCA. On w
hich of the
followin su strtes would this specimen disply cytoplsmic specklin? A. Form
lin- xed
neutrophils B. Un xed neutrophils C. HEp-2 cells D. R it kidney tissue Immunolo
routine l ortory procedures/ Autoimmune/ANCA/Testin/2 102 Chpter 3 | Immunol
oy Answer to
Question 18 18. A Anti odies to neutrophil cytoplsmic ntien demonstrtin  p
pttern of uorescence indicte  dinosis of vsculitis. However, typicl ANCAs
nd ANAs lso
demonstrte  perinucler stinin pttern on ethnol- xed neutrophils. To di erenti
te these
from pANCA, specimens pperin s  pANCA on ethnol- xed cells re tested on for
mlin- xed
neutrophils. The myeloperoxidse continin rnules tht colesce round the nu
cler mem rne

durin ethnol xtion will remin in the cytoplsm durin formlin xtion. Thus, p
ANCA will
hve  cytoplsmic (cANCA) pttern on  formlin- xed slide, ut ANAs will retin
pttern nd the uorescence will e diminished. 2828_Ch03_075-120 06/08/12 11:10
AM Pe 102
103 3.5 Hypersensitivity 1. Which of the followin is  description of  type I
rection? A. Rweed ntien cross links with IE on the surfce of mst cells,
cusin relese
of preformed meditors nd resultin in symptoms of n lleric rection B. Anti
-Fy  from 
prennt womn crosses the plcent nd ttches to the Fy  ntien-positive re
d cells of the
fetus, destroyin the red cells C. Immune complex deposition occurs on the lome
rulr sement
mem rne of the kidney, ledin to renl filure D. Exposure to poison ivy cuse
s sensitized T
cells to relese lymphokines tht cuse  loclized in mmtory rection Immunolo
knowlede of fundmentl ioloicl chrcteristics/Hypersensitivity/2 2. Why is
skin testin the
most widely used method to test for  type I hypersensitivity rection? A. It c
uses less trum
nd is more cost e ective thn other methods B. It hs reter sensitivity thn in
mesurements C. It is more likely to e positive for IE-speci c llerens thn ot
her methods D.
It my e used to predict the development of further lleren sensitivity Immuno
principles of sic l ortory procedures/Hypersensitivity/Testin/1 3. Which in
vitro test
mesures IE levels inst  speci c lleren? A. Histmine relese ssy B. Rdi
oimmunosor ent
test (RIST) C. Fluorescent llerosor ent test (FAST) D. Precipitin rdioimmunos
or ent test
(PRIST) Immunoloy/Apply principles of sic l ortory procedures/Hypersensitiv
ity/IE testin/1
4. A ptient who is lood roup O is ccidentlly trnsfused with roup A lood
nd develops 
rection durin the trnsfusion. Wht nti ody is involved in this type II rect
ion? A. IM B.
IE C. IG nd IE D. IG Immunoloy/Apply principles of sic l ortory
procedures/Hypersensitivity/Testin/1 Answers to Questions 14 1. A Type I immedi
hypersensitivity (nphylctic) responses re chrcterized y IE molecules in
din to mst
cells vi the Fc receptor. Cross linkin of surfce IE cused y indin of ll
erens cuses the
mst cell to dernulte, relesin histmine nd other chemicl meditors of l
lery. Answer B
descri es  type II rection; C descri es  type III rection; nd D descri es 
type IV
rection. 2. B Skin testin is considered much more sensitive thn in vitro test
s tht mesure
either totl or ntien-speci c IE. 3. C The FAST is  uorescent ssy tht mesur
es speci c
IE; the RIST nd PRIST tests re rdioimmunossys tht mesure totl IE. The
FAST procedure
hs replced the RAST, or rdiollerosor ent ssy. The histmine relese ssy

mesures the
mount of histmine. Alleren-speci c IE ssys re vil le sed upon solid-ph
se enzyme
immunossy. The lleren is covlently ound to  cellulose solid phse nd re
cts with speci c
IE in the serum. After wshin, enzyme (-lctosidse)-l eled monoclonl ntiIE is dded.
The un ound nti ody conjute is wshed wy nd uoroenic su strte
(4-methylum elliferyl--D-lctose) is dded. Fluorescence is directly proportion
l to speci c
IE. 4. A IG nd IM re the nti odies involved in  type II cytotoxic rectio
n. Nturlly
occurrin nti-A in the form of IM is present in the lood of  roup O individ
ul nd would
cuse n immedite trnsfusion rection. Cell destruction occurs when nti odies
ind to cells
cusin destruction vi complement ctivtion, there y trierin intrvsculr
2828_Ch03_075-120 06/08/12 11:10 AM Pe 103 5. Which test would mesure the
cotin of red
cells y nti ody s occurs in hemolytic trnsfusion rections? A. Indirect nti
lo ulin test
(IAT) B. Direct ntilo ulin test (DAT) C. ELISA D. Hemlutintion Immunoloy/
Apply principles
of sic l ortory procedures/Hemolytic rection/1 6. Which test detects nti o
dies tht hve
ttched to tissues, resultin in  type-II cytotoxic rection? A. Mirtion inh
i ition fctor
ssy (MIF) B. Direct immuno uorescence (IF) C. Immuno xtion electrophoresis (IFE)
Hemlutintion Immunoloy/Apply principles of sic l ortory procedures/Hemo
lytic rections/1
7. Which of the followin conditions will most likely result in  flse-netive
DAT test? A.
Insu cient wshin of RBCs B. Use of hevy chinspeci c polyclonl nti-humn I C. U
se of
excessive centriful force D. Use of  smple o tined y ner puncture Immunolo
knowlede to identify sources of error/Hemolytic rections/3 8. Which of the fol
lowin tests is
used to detect circultin immune complexes in the serum of some ptients with s
utoimmune diseses such s rheumtoid rthritis? A. Direct immuno uorescence B. E
immunossy C. Assy of cryolo ulins D. Indirect ntilo ulin test Immunoloy/A
pply knowlede of
fundmentl ioloicl chrcteristics/Hypersensitivity/1 9. All of the followin
 tests my e
 norml in  type III immune complex rection except: A. C1q- indin ssy y E
LISA B. Rji cell
ssy C. CH 50 level D. Mitoen response Immunoloy/Apply principles of specil
l ortory
procedures/Hypersensitivity/Testin/1 10. Wht immune elements re involved in 
positive skin
test for tu erculosis? A. IE nti odies B. T cells nd mcrophes C. NK cells
nd IG nti ody
D. B cells nd IM nti ody Immunoloy/Apply knowlede of fundmentl ioloicl
chrcteristics/Hypersensitivity/1 104 Chpter 3 | Immunoloy Answers to Questio
ns 510 5. B The
DAT test mesures nti ody tht hs lredy coted RBCs in vivo. Direct ntilo

ulin nd direct

immuno uorescence tests use nti-immunolo ulin to detect nti ody-sensitized cell
s. 6. B The
direct IF test detects the presence of nti ody tht my cuse  type II cytotox
ic rection. For
exmple, renl iopsies from ptients with Goodpstures syndrome exhi it  smooth
pttern of
uorescence lon the sement mem rne fter rection with uorescein isothiocynt
e (FITC)
conjuted nti-immunolo ulin. The rection detects nti odies inst the se
ment mem rne of
the lomeruli. 7. A Insu cient wshin cn cuse incomplete removl of excess or u
n ound
immunolo ulins nd other proteins, which my neutrlize the ntilo ulin reen
t. 8. C Most
utoimmune diseses involve the formtion of ntiennti ody complexes tht depos
it in the
tissues, cusin locl in mmtion nd necrosis induced y complement ctivtion,
WBC in ltrtion, nd lysosoml dme. Some ptients mke monoclonl or polyclonl
nti odies
with rheumtoid fctor ctivity tht ind to serum immunolo ulins, formin r
etes tht re
insolu le t 4C. These circultin immune complexes re detected y llowin  l
ood smple to
clot t 37C, trnsferrin the serum to  sedimenttion rte tu e, nd then incu 
tin the serum
t 4C for 3 dys. 9. D Mitoen stimultion is used to mesure T-cell, B-cell, nd
responsiveness, which is importnt in ptients displyin nery nd other sins
immunode ciency. The C1q ssy nd the Rji cell ssys detect circultin immune
complexes tht
re present durin  type III rection. The CH 50 level is usully decresed owi
n to complement
ctivtion y the immune complexes. Rji cells re derived from  mlinnt B-ce
ll line tht
demonstrtes C3 receptors ut no surfce mem rne immunolo ulin. Immune complex
es tht hve xed
complement will ind to Rji cells nd cn e identi ed usin rdiol eled or enzy
me l eled
nti-immunolo ulin. More recently,  C3 indin ELISA ssy hs replced the R
ji cell
procedure. 10. B T cells nd mcrophes re the immune elements primrily respo
nsi le for the
clinicl mnifesttions of  positive tu erculosis test. Rections usully tke
72 hours to rech
pek development nd re chrcteristic of loclized type IV cell-medited hyper
sensitivity. The
skin rection is chrcterized y  lesion continin  mononucler cell in ltrte
2828_Ch03_075-120 06/08/12 11:10 AM Pe 104 11. A ptient receives  trnsfu
sion of pcked
red cells nd fresh frozen plsm nd develops n nphylctic, nonhemolytic re
ction. She
reports receivin  trnsfusion 20 yers erlier. She hd no rection to the pre
trnsfusion, ut she did feel poorly  few weeks lter. Which of the followin tr
su stnces most likely elicited the rection? A. IA B. Group A ntien C. Rho (

D) ntien D. An
ntien elonin to the Du y system Immunoloy/Apply knowlede of fundmentl io
chrcteristics/Immune de ciency/Hypersensitivity/3 12. A ptient de cient in the C3
component would e expected to mount  norml: A. Type I nd IV hypersensitivity
response B. Type
II nd IV hypersensitivity response C. Type I nd III hypersensitivity response
D. Type II nd
III hypersensitivity response Immunoloy/Apply knowlede of fundmentl ioloic
chrcteristics/Immune de ciency/ Hypersensitivity/2 3.5 | Hypersensitivity 105
Answers to
Questions 1112 11. A The fct tht this is  nonhemolytic rection suests tht
 nonred cell
ntien my e involved. Selective IA deficiency occurs in pproximtely 1 in 7
00 individuls
nd is often symptomtic. Individuls deficient in IA my mke n nti ody 
inst the hevy
chin if they re exposed to IA vi  trnsfusion. This nti ody my led to 
serum sickness
rection if the IA is still present fter nti ody formtion. This could expli
n the poor
feelin the ptient hd fter the initil trnsfusion. A su sequent trnsfusion m
y led to n
Arthus rection if IG nti-IA is present or n nphylctic rection if IE n
ti-IA is
present. 12. A Complement is involved in types II nd III hypersensitivity; thus
n individul
deficient in C3 will e deficient in those responses. The complement deficiency
should hve no
effect on IE (type I) or cell-medited (type IV) hypersensitivities. 2828_Ch03_
075-120 06/08/12
11:10 AM Pe 105 106 3.6 Immunolo ulins, Complement, nd Cellulr Testin 1.
Which of the
followin symptoms in  youn child my indicte n immunode ciency syndrome? A. A
rections B. Severe rshes nd myli C. Recurrent cteril, funl, nd virl
infections D.
Weiht loss, rpid hert et, rethlessness Immunoloy/Apply knowlede of fund
mentl ioloicl
chrcteristics/T cell/Testin/1 2. Wht screenin test should e performed rst i
n  youn
ptient suspected of hvin n immune dysfunction disorder? A. Complete lood co
unt (CBC) nd
white cell di erentil B. Chemotxis ssy C. Complement levels D. Bone mrrow io
Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Select test
s/3 3. Which test
should e performed when  ptient hs  rection to trnsfused plsm products?
Immunolo ulin levels B. T-cell count C. Hemolo in levels D. Red cell enzymes
Immunoloy/Evlute l ortory nd clinicl dt to specify dditionl tests/Sel
ect tests/3 4.
Wht is the M component in monoclonl mmopthies? A. IM produced in excess B. H
evy chin
produced in excess C. Mlinnt prolifertion of B cells D. Monoclonl nti ody
or cell line
Immunoloy/Apply knowlede of fundmentl ioloicl chrcteristics/Immunolo u

Answers to Questions 14 1. C An immunode ciency syndrome should e considered in 

youn child
who hs  history of recurrent cteril, funl, nd virl infections mnifeste
d fter the
disppernce of mternl IG. Immunode ciency disorders my involve de ciencies in
nd/or function of lymphocytes nd phocytic cells or  de ciency in production o
f  complement
fctor. Choice of l ortory tests is sed upon the ptients clinicl presentti
on, e, nd
history. 2. A The rst screenin tests performed in the initil evlution of  yo
un ptient who
is suspected of hvin n immune dysfunction re the CBC nd di erentil. White l
ood cells tht
re decresed in num er or  norml in ppernce my indicte further testin.
3. A A rection
to plsm products my e found in n IA-deficient person who hs formed nti-I
A nti odies.
Immunolo ulin levels would id in this determintion. Selective IA deficiency
is the most
common immunodeficiency disese nd is chrcterized y serum IA levels elow 5
m/dL. IA is
usully  sent from secretions, ut the B-cell count is usully norml. 4. D The
M component
refers to ny monoclonl protein or cell line produced in  monoclonl mmopth
y such s
multiple myelom. 2828_Ch03_075-120 06/08/12 11:10 AM Pe 106 5. A child sus
pected of hvin
n inherited humorl immunode ciency disese is iven diphtheri/ tetnus vccine.
Two weeks
fter the immuniztion, his level of nti ody to the speci c ntiens is mesured.
Which result
is expected for this ptient if he/she indeed hs  humorl de ciency? A. Increse
d levels of
speci c nti ody B. No chne in the level of speci c nti ody C. An increse in IG
-speci c
nti ody ut not IM-speci c nti ody D. Incresed levels of nonspeci c nti ody
Immunoloy/Evlute l ortory dt/ Immunolo ulins/Testin/2 6. Which disese
my e expected
to show n IM spike on n electrophoretic pttern? A. Hypommlo ulinemi B.
kidney disese C. Wldenstrms mcrolo ulinemi D. WiskottAldrich syndrome Immunolo
l ortory dt to mke identi ctions/Immunolo ulins/Testin/2 7. In testin for
syndrome, wht type of l ortory nlysis would e most helpful in determinin
the num er of
mture T cells? A. Complete lood count B. Nitro lue tetrzolium (NBT) test C. T
-cell enzyme
ssys D. Flow cytometry Immunoloy/Evlute l ortory dt to mke identi ction
cells/Testin/2 8. Interpret the followin description of n immuno xtion electro
phoresis ssy
of urine. Dense wide nds in oth the and anes. No bans present in the heavychain anes.
A. Norma B. Liht chain isease C. Increase poycona Fab framents D. Mutip
e myeoma
Immunooy/Evauate aboratory ata to make ienti cations/Immunoobuins/Testin
/2 9. Free
monocona iht chains are often present in the serum of mutipe myeoma patie

nts, an may be

usefu for isease monitorin. Which of the foowin assays wou be recommene
 to etect the
presence of serum-free iht chains? A. Serum protein eectrophoresis B. Urine i
mmuno xation C.
Nepheometry D. ELISA Immunooy/Evauate aboratory an cinica ata to specif
y aitiona
tests/Testin/2 3.6 | Immunoobuins, Compement, an Ceuar Testin
107 An
swers to
Questions 59 5. B In an immunoeficient patient, the expecte eves of specific
antiboy to the
antiens in the vaccine wou be ecrease or not present. This response provie
s evience of
eficient antiboy prouction. 6. C Waenstrms macroobuinemia is a mainancy
pasmacytoi ymphocytes invovin both the bone marrow an ymph noes. The ma
inant ces
secrete monocona IM an are in transition from B ces to pasma ces. In co
ntrast to
mutipe myeoma, osteoytic bone esions are not foun. 7. D DiGeores synrome
is cause by a
eveopmenta faiure or hypopasia of the thymus, an resuts in a e ciency of T
an ce-meiate immune function. The T-ce count is ow, but the eve of imm
unoobuins is
usuay norma. Fow cytometry is most hepfu in eterminin numbers an subpop
uations of T
ces. 8. C Heavy wie bans seen with both anti- and ani- antisera inicate exce
iht-chain excretion. Liht-chain isease wou show a heavy restricte ban fo
r one of the
iht-chain reactions, but not both. The nin of excess an chains indicaes a p
gammopahy wih increased immunoglobulin urnover and excreion of he ligh cha
ins as Fab
fragmens. 9. C Serum-free ligh chains are a sensiive indicaor of a monoclona
l gammopahy.
They are ofen no presen in sufficien quaniy o show a band on a proein el
gel. Deecing ligh chains in he urine is no an indicaor of wha he serum l
evels may be.
Serum immunoglobulin heavy and ligh chains are mos commonly measured by rae o
r endpoin
nephelomery. ELISA assays are mos ofen used o measure specific anibody leve
ls, no o
quaniae immunoglobulin heavy- or ligh-chain isoypes. 2828_Ch03_075-120 06/
08/12 11:10 AM
Page 107 10. Wha is measured in he CH 50 assay? A. RBC quaniy needed o aggl
uinae 50% of
anibody B. Complemen needed o lyse 50% of RBCs C. Complemen needed o lyse 5
0% of anibodysensiized RBCs D. Anibody and complemen needed o sensiize 50% of RBCs Immun
principles of basic laboraory procedures/Complemen/Tesing/1 11. Wha ype of
disorders would
show a decrease in C3, C4, and CH 50 ? A. Auoimmune disorders such as SLE and R
A B.
Immunode ciency disorders such as common variable immunode ciency C. Tumors D. Bace
rial, viral,
fungal, or parasiic infecions Immunology/Evaluae laboraory daa o mae

ideni caions/Complemen/Tesing/2 12. All of he following ess measure phagocy

e funcion
excep: A. Leuocye adhesion molecule analysis B. Di Hydro rhodamine reducion
assay C. NBT es
D. IL-2 (inerleuin-2) assay Immunology/Apply principles of basic laboraory
procedures/Phagocyes/Tesing/1 108 Chaper 3 | Immunology Answers o Quesions
1012 10. C The
CH 50 is he amoun of complemen needed o lyse 50% of sandardized hemolysin-s
ensiized sheep
RBCs. I is expressed as he reciprocal of he serum diluion resuling in 50% h
emolysis. Low
levels are associaed wih de ciency of some complemen componens and acive sys
emic auoimmune
diseases in which complemen is being consumed. 11. A The paern of decreased C
3, C4, and CH 50
indicaes classic pahway acivaion. This resuls in consumpion of complemen
and is associaed
wih SLE, serum sicness, subacue bacerial endocardiis, and oher immune comp
lex diseases. The
in ammaory response seen in malignancy and acue infecions gives rise o an incr
ease in
complemen componens. Immunode ciency caused by an inheried de ciency in complemen
only abou 1% of immunode ciency diseases. Such disorders reduce he CH 50 bu inv
olve a de cien
serum level of only one complemen facor. 12. D The Di-hydro rhodamine reducio
n assay and NBT
ess are used o diagnose chronic granulomaous disease, an inheried disorder
in which
phagocyic cells fail o ill microorganisms owing o a defec in peroxide produ
(respiraory burs). Leuocye adhesion de ciency is associaed wih a defec in 
he producion
of inegrin molecules on he surface of WBCs and heir granules. IL-2 is a cyo
ine produced by
acivaed T h and B cells. I causes B-cell proliferaion and increased produci
on of anibody,
inerferon, and oher cyoines. IL-2 can be measured by EIA and is used o dee
c ransplan
rejecion, which is associaed wih an increase in he serum and urine levels. 2
06/08/12 11:10 AM Page 108 109 3.7 Tumor Tesing and Transplanaion 1. A pai
en had surgery
for colorecal cancer, afer which he received chemoherapy for 6 monhs. Te es
carcinoembryonic anigen (CEA) was normal a his ime. One year laer, he bimo
nhly CEA was
elevaed (above 10 ng/mL). An examinaion and biopsy revealed he recurrence of
a small umor.
Wha was he value of he resuls provided by he CEA es in his clinical siu
aion? A.
Diagnosic informaion B. Informaion for furher reamen C. Informaion on h
e immunologic
response of he paien D. No useful clinical informaion in his case Immunolog
principles of basic laboraory procedures/Tumors/Tesing/1 2. A carbohydrae an
igen 125 assay
(CA-125) was performed on a woman wih ovarian cancer. Afer reamen, he leve
ls fell
signi canly. An examinaion performed laer revealed he recurrence of he umor,

bu he CA 125

levels remained low. How can his nding be explained? A. Tes error B. CA-125 was
he wrong
laboraory es; -fetoprotein (AFP) is  etter test to monitor ovrin cncer C.
CA-125 my not
e sensitive enouh when used lone to monitor tumor development D. CA-125 is no
t speci c enouh
to detect only one type of tumor Immunoloy/Apply principles of sic l ortory
procedures/Tumors/Testin/3 3. Wht is the correct procedure upon receipt of  t
est request for
humn chorionic ondotropin (hCG) on the serum from  60-yer-old mn? A. Retur
n the request;
hCG is not performed on men B. Perform  qulittive hCG test to see if hCG is p
resent C. Perform
the test; hCG my e incresed in testiculr tumors D. Perform the test ut use
di erent
stndrds nd controls Immunoloy/Correlte l ortory dt with physioloicl
processes/Tumors/HCG/3 Answers to Questions 13 1. B CEA is  lycoprotein tht is
elevted in
 out 60% of ptients with colorectl cncer nd one third or more ptients with
stric, nd pncretic cncers. CEA my e positive in smokers, ptients with c
irrhosis, Crohns
disese, nd other nonmlinnt conditions. Becuse sensitivity for mlinnt di
sese is low, CEA
is not recommended for use s  dinostic test. However, n elevted CEA fter
tretment is
evidence of tumor recurrence nd the need for second-look surery. 2. C CA-125 i
s  tumor
ssocited cr ohydrte ntien tht is elevted in 70%80% of ptients with ovri
n cncer nd
 out 20% of ptients with pncretic cncer. While n increse in CA-125 my in
dicte recurrent
or proressive disese, filure to do so does not necessrily indicte the  sen
ce of tumor
rowth. 3. C hCG is normlly tested for in prenncy; it is incresed in pproxi
mtely 60% of
ptients with testiculr tumors nd  lower percente of those with ovrin, GI
, rest, nd
pulmonry tumors. Mlinnt cells secretin hCG my produce only the -su unit; th
qulittive nd quntittive tests tht detect only intct hormone my not e p
2828_Ch03_075-120 06/08/12 11:10 AM Pe 109 4. Would n hCG test usin  mon
oclonl nti ody
inst the -su unit of hCG likely e  ected y n incresed level of follicle-sti
hormone (FSH)? A. Yes, the -su unit of FSH is identicl to tht of hCG B. No, the
test would e
speci c for the -su unit of hCG C. Yes,  cross rection would occur ecuse of str
similrities D. No, the structure of FSH nd hCG re not t ll similr Immunolo
l ortory dt to check for sources of error/hCG/Testin/3 5. Which of the foll
owin su stnces,
sometimes used s  tumor mrker, is incresed two- or threefold in  norml pre
nncy? A.
Alkline phosphtse (ALP) B. Clcitonin C. Adrenocortocotropic hormone (ACTH) D
. Neuron-speci c
enolse Immunoloy/Tumor mrkers/Testin/1 6. Wht is n dvnte of performin

 prosttespeci c ntien (PSA) test for prostte cncer? A. PSA is st le in serum nd not
 ected y 
diitl-rectl exmintion B. PSA is incresed only in prosttic mlinncy C. A
norml serum
level rules out mlinnt prosttic disese D. Te percente of free PSA is elev
ted in persons
with mlinnt disese Immunoloy/Correlte l ortory dt with physioloicl
processes/Tumors/PSA/1 7. Which method is the most sensitive for quntittion of
AFP? A. Dou le
immunodi usion B. Electrophoresis C. Enzyme immunossy D. Prticle lutintion
Immunoloy/Select pproprite method/AFP/1 110 Chpter 3 | Immunoloy Answers to
Questions 47 4.
B Luteinizin hormone, FSH, nd hCG shre  common -su unit ut hve di erent su un
its. A test
for hCG usin  monoclonl nti ody would e speci c for hCG provided tht the nt
i ody ws
directed inst n ntienic determinnt on the cr oxy terminl end of the su
unit. 5. A
Isoenzymes of ALP re sometimes used s tumor mrkers ut hve  low speci city e
cuse they re
lso incresed in nonmlinnt diseses. These include the plcentl-like (hetst le) ALP
isoenzymes, which re found (infrequently) in some mlinncies such s cncer o
f the lun; onederived ALP, which is  mrker for metsttic one cncer; nd the fst-mirtin
isoenzyme, which is  mrker for metsttic liver cncer. ACTH is secreted s n
ectopic hormone
in some ptients with cncer of the lun. Clcitonin is  hormone produced y th
e medull of the
thyroid nd is incresed in the serum of ptients with medullry thyroid crcino
Neuron-speci c enolse is n enzyme tht is used s  tumor mrker primrily for n
euro lstom.
6. A PSA is  lycoprotein with protese ctivity tht is speci c for the prostte
lnd. Hih
levels my e cused y prostte mlinncy, enin prosttic hypertrophy, or pr
osttitis, ut
PSA is not incresed y physicl exmintion of the prostte. PSA hs  sensitiv
ity of 80% nd 
speci city of  out 75% for prostte cncer. The sensitivity is su ciently hih to w
rrnt its
use s  screenin test, ut sensitivity for ste A cncer is elow 60%. Most o
f the serum PSA
is ound to protese inhi itors such s 1 -ntitrypsin nd 1 -ntichymotrypsin.
Ptients with
orderline PSA levels (410 n/mL) nd  low percente of free PSA re more likel
y to hve
cncer of the prostte thn ptients with  norml percente of free PSA. 7. C
AFP is 
lycoprotein tht is produced in  out 80% 90% of ptients with heptom nd in 
percente of ptients with other tumors, includin retino lstom, rest, uter
ine, nd
pncretic cncer. The upper reference limit for serum is only 10 n/mL, which r
sensitive method of ssy such s EIA. The hih nlyticl sensitivity of immuno
ssys permits
detection of reduced AFP levels in mternl serum ssocited with Down syndrome,

s well s
elevted levels ssocited with spin i d. 2828_Ch03_075-120 06/08/12 11:10 AM
Pe 110 8.
How is HLA typin used in the investition of enetic diseses? A. For predicti
on of the
severity of the disese B. For enetic linke studies C. For direct dinosis o
f disese D. Is
not useful in this sitution Immunoloy/Correlte clinicl nd l ortory dt/H
LA typin/1 9.
Select the est donor for  mn, lood type AB, in need of  kidney trnsplnt.
A. His rother,
type AB, HLA mtched for clss II ntiens B. His mother, type B, HLA mtched fo
r clss I
ntiens C. His cousin, type O, HLA mtched for mjor clss II ntiens D. Cdv
er donor, type O,
HLA mtched for some clss I nd II ntiens Immunoloy/Correlte dt with othe
r l ortory dt
to ssess test results/Trnsplnttion/Testin/3 10. Interpret the followin mic
results: A9 nd B12 cells dmed; A1 nd Aw19 cells intct. A. Positive for A1
nd Aw19;
netive for A9 nd B12 B. Netive for A1 nd Aw19; positive for A9 nd B12 C.
Error in test
system; retest D. Impossi le to determine Immunoloy/Evlute l ortory dt to
identi ctions/Trnsplnttion/Testin/2 11. Which method, clssiclly used for HL
A-D typin, is
often used to determine the compti ility etween  livin orn donor nd recip
ient? A. Flow
cytometry B. Mixed lymphocyte culture (MLC) C. Primed lymphocyte test (PLT) D. R
frment lenth polymorphism (RFLP) Immunoloy/Apply principles of specil proce
Trnsplnttion/HLA typin/1 12. SITUATION: Cells type netive for ll HLA nti
ens in 
complement-dependent cytotoxicity ssy. Wht is the most likely cuse? A. Too m
uch suprvitl
dye ws dded B. R it complement is inctivted C. All leukocytes re ded D.
Antiser is too
concentrted Immunoloy/Evlute l ortory dt to check for sources of error/H
LA typin/3 3.7 |
Tumor Testin nd Trnsplnttion 111 Answers to Questions 812 8. B HLA typin
is useful in
predictin some enetic diseses nd for enetic counselin ecuse certin HLA
types show stron
linke to some diseses. HLA typin is not speci clly used to dinose  disese
or ssess its
severity. In linke studies,  disese ene cn e predicted ecuse it is loc
ted next to the
locus of  norml ene with which it seretes. For exmple, the reltive risk
of developin
nkylosin spondylitis is 87% in persons who re positive for HLA-B27. Anlysis
of fmily
pedirees for the linke mrker nd disese cn e used to determine the pro 
ility tht 
fmily mem er will inherit the disese ene. 9. A A twin or si lin donor of the
sme lood type
nd HLA mtched for clss II ntiens is the est donor in this sitution. Clss
II ntiens
(HLA-D, HLA-DR, DQ, nd DP) determine the  ility of the trnsplnt recipient to

reconize the
rft. The HLA enes re locted close toether on chromosome 6, nd crossover
etween HLA enes
is rre. Si lins with closely mtched clss II ntiens most likely inherited t
he sme clss I
enes. The pro  ility of si lins inheritin the sme HLA hplotypes from oth
prents is 1:4.
10. B The microcytotoxicity test is sed upon the rection of speci c ntiser n
d HLA ntiens
on test cells. Cells dmed y the indin of nti ody nd complement re detec
ted with 
suprvitl dye such s eosin. 11. B Flow cytometry cn e used in trnsplnttio
n to type
seroloiclly de ned HLA ntiens. The one-wy mixed lymphocyte rection is used t
o identify
HLA-D ntiens on the donors lymphocytes nd is used for cross mtchin livin do
nors with
trnsplnt recipients. The ssy is time consumin nd would not e used s prt
of  workup for
 cdver donor trnsplnt. HLA-D incompti ility is ssocited with the reconi
tion phse of
llorft rejection. The primed lymphocyte test is used to identify HLA-DP nti
ens. 12. B
Inctive r it complement my not ecome xed to nti odies tht hve ound test
therefore, no lysis of cells will occur. When the suprvitl dye is dded, ll c
ells will pper
netive (exclude the dye) for ll HLAs. 2828_Ch03_075-120 06/08/12 11:11 AM
Pe 111 13. Wht
method my e used for tissue typin insted of seroloicl HLA typin? A. PCR B
. Southern
lottin C. RFLP D. All of these options Immunoloy/Apply principles of specil
Trnsplnttion/HLA typin/1 112 Chpter 3 | Immunoloy Answer to Question 13 13
. D PCR, Southern
lottin, nd testin for RFLPs my ll e used to identify HLA enes. Mny l o
rtories use PCR
technoloy for the routine determintion of HLA type. 2828_Ch03_075-120 06/08/1
2 11:11 AM Pe
112 113 3.8 Immunoloy Pro lem Solvin 1. Which of the followin seril dilution
s contins n
incorrect fctor? A. 1:4, 1:8, 1:16 B. 1:1, 1:2, 1:4 C. 1:5, 1:15, 1:45 D. 1:2,
1:6, 1:12
Immunoloy/Apply knowlede to reconize sources of error/Seroloicl dilutions/3
2. A ptient ws
tested for syphilis y the RPR method nd ws rective. An FTA-ABS test ws perf
ormed nd the
result ws netive. Su sequent testin showed the ptient to hve  hih titer
nticrdiolipin nti odies (ACAs) y the ELISA method. Which routine l ortory
test is most
likely to e  norml for this ptient? A. Activted prtil throm oplstin time
Antismooth muscle nti odies C. Asprtte minotrnsferse (AST) D. C3 ssy y
immunonephelometry Immunoloy/Apply knowlede to reconize sources of error/Anti
crdiolipin/3 3.
In mmtion involves  vriety of iochemicl nd cellulr meditors. Which of the
followin my
e incresed within 72 hours fter n initil infection? A. Neutrophils, mcroph
es, nti ody,

complement, 1 -ntitrypsin B. Mcrophes, T cells, nti ody, hptolo in,

en C.
Neutrophils, mcrophes, complement, rinoen, C-rective protein D. Mcrophes
, T cells, B
cells, ceruloplsmin, complement Immunoloy/Apply principles of sic immunoloi
responses/In mmtion/2 Answers to Questions 13 1. D All the dilutions re multipli
ed y the
sme fctor in  proression except the lst one: 1:2 to 1:6 is 3, wheres 1:6 t
o 1:12 is 2.
Threefold dilutions of  1:2 dilution would result in  1:6 followed y  1:18.
2. A
Approximtely 50%70% of ptients with ACA lso hve the lupus nticoulnt (LAC)
in their
serum. The LAC is n immunolo ulin tht interferes with in vitro coultion te
sts: prothrom in
time (PT), APTT, nd dilute Russells viper venom (DRVV) time. These tests require
for the ctivtion of fctor X. A out 30% of ptients with nti odies to crdiol
ipin or
phospholipids hve  ioloicl flse- positive RPR result. Antismooth muscle is
most commonly
ssocited with chronic ctive heptitis, nd incresed AST with necrotic liver
Althouh ACA nd LAC my e ssocited with SLE, the mjority of ptients with t
hese nti odies
do not hve lupus nd would hve  norml C3 level. 3. C The correct list, in wh
ich ll meditors
re involved in n in mmtory response within 72 hours fter initil infection, i
s neutrophils,
mcrophes, complement,
rinoen, nd C-rective protein. Phocytic cells, cut
e phse
rectnts, nd rinolytic fctors enter the site of in mmtion. Anti ody nd lymph
ocytes do not
enter until lter. 2828_Ch03_075-120 06/08/12 11:11 AM Pe 113 4. An 18-mont
h-old oy hs
recurrent sinopulmonry infections nd septicemi. Brutons X-linked immunode ciency
syndrome is
suspected. Which test result would e mrkedly decresed? A. Serum IG, IA, nd
IM B. Totl
T-cell count C. Both B- nd T-cell counts D. Lymphocyte prolifertion with phyto
stimultion Immunoloy/Correlte l ortory dt with physioloicl
processes/Immunode ciency/Testin/2 5. A ptient received 5 units of fresh frozen
plsm (FFP)
nd developed  severe nphylctic rection. He hs  history of respirtory n
strointestinl infections. Post-trnsfusion studies showed ll 5 units to e A
BO-compti le.
Wht immunoloic test would help to determine the cuse of this trnsfusion rec
tion? A.
Complement levels, prticulrly C3 nd C4 B. Flow cytometry for T-cell counts C.
Mesurement of
immunolo ulins D. NBT test for phocytic function Immunoloy/Determine l ort
ory tests/
Immunode ciency/Testin/3 6. An IFE reveled excessive mounts of polyclonl IM 
nd low
concentrtions of IG nd IA. Wht is the most likely explntion of these ndin
s nd the est
course of ction? A. Proper mounts of ntiser were not dded; repet oth test

s B. Test
specimen ws not dded properly; repet oth procedures C. Ptient hs common v
ri le
immunode ciency; perform B-cell count D. Ptient hs immunode ciency with hyper-M; p
immunolo ulin levels Immunoloy/Correlte l ortory dt with physioloicl
processes/Immunode ciency/Testin/3 7. SITUATION: A 54-yer-old mn ws dmitted t
o the hospitl
fter hvin  seizure. Mny l ortory tests were performed, includin n RPR,
ut none of the
results were positive. Te physicin suspects  cse of lte (tertiry) syphilis.
Which test
should e performed next? A. Repet RPR, then perform VDRL B. Treponeml test su
ch s MHA-TP on
serum C. VDRL on CSF D. No l ortory test is positive for lte (tertiry) syphi
Immunoloy/Correlte l ortory dt with physioloicl processes/Syphilis/Testi
n/3 114 Chpter
3 | Immunoloy Answers to Questions 47 4. A A ptient with Brutons X-linked mm
lo ulinemi
presents with clinicl symptoms relted to recurrent infections, demonstrted in
the l ortory
y decresed or  sent immunolo ulins. Peripherl lood B cells re  sent or m
rkedly reduced,
ut T cells re norml in num er nd function. Becuse phytohemlutinin is  T
-cell mitoen,
the lymphocyte prolifertion test usin PHA would e norml for this ptient. 5.
C The ptient
hd n nphylctic rection to  plsm product. This, com ined with the histor
y of respirtory
nd strointestinl infections, suests  selective IA de ciency. Mesurement o
immunolo ulins would e helpful in this cse. A low serum IA nd norml IG su
stntite the
dinosis of selective IA de ciency. Such ptients frequently produce nti-IA, w
hich is often
responsi le for  severe trnsfusion rection when ABO-compti le plsm is dmi
nistered. 6. D
Low plsm concentrtions of IG nd IA nd n  undnce of IM is consistent w
ith hyper-IM
syndrome. Most cses re X-linked nd result from  muttion of the ene TNFSF5
tht encodes 
receptor needed for switchin immunolo ulin production. Ptients with common v
ri le
immunode ciency hve low serum IG, IA, nd IM. 7. B Serum nti ody tests such 
re often netive in cses of lte syphilis. However, treponeml tests remin p
ositive in over
95% of cses. The VDRL test on CSF is the most speci c test for dinosis of neuro
ecuse treponeml tests remin positive fter tretment. It should e used s t
he con rmtory
test when the serum treponeml test is positive. However, the CSF VDRL is limite
d in sensitivity
nd would not e positive if the serum MHA-TP or FTA-ABS ws netive. 2828_Ch03
06/08/12 11:11 AM Pe 114 8. A ptient cme to his physicin complinin of 
rsh, severe
hedches, sti neck, nd sleep pro lems. L ortory tests of sini cnce were n el

sedimenttion rte (ESR) nd slihtly incresed liver enzymes. Further questioni
n of the ptient
reveled tht he hd returned from  huntin trip in upstte New York 4 weeks 
o. His physicin
ordered  seroloicl test for Lyme disese, nd the ssy ws netive. Wht is
the most likely
explntion of these results? A. Te nti ody response is not su cient to e detect
ed t this
ste B. Te clinicl symptoms nd l ortory results re not chrcteristic of L
yme disese C. Te
ptient likely hs n erly infection with heptitis B virus D. L ortory error
hs cused 
flse-netive result Immunoloy/Correlte l ortory dt with physioloicl pr
testin/Testin/3 9. A 19-yer-old irl cme to her physicin complinin of  s
ore throt nd
ftiue. Upon physicl exmintion, lymphdenopthy ws noted. Rective lymphocy
tes were noted on
the differentil, ut  rpid test for IM nti odies ws netive. Liver enzymes
were only
slihtly elevted. Wht test(s) should e ordered next? A. Heptitis testin B.
EBV seroloicl
pnel C. HIV con rmtory testin D. Bone mrrow iopsy Immunoloy/Correlte l or
tory dt with
physioloicl processes/Testin/3 10. A ptient received 2 units of RBCs followi
n surery. Two
weeks fter the surery, the ptient ws seen y his physicin nd exhi ited mil
d jundice nd
slihtly elevted liver enzymes. Heptitis testin, however, ws netive. Wht
should e done
next? A. Nothin until more severe or de nitive clinicl sins develop B. Repet h
testin immeditely C. Repet heptitis testin in  few weeks D. Check lood 
nk donor records
nd contct donor(s) of trnsfused units Immunoloy/Correlte l ortory dt wi
th physioloicl
processes/Heptitis/Testin/3 3.8 | Immunoloy Pro lem Solvin
115 Answers to
Questions 811 8.
A The nti ody response to B. urdorferi my not develop until severl weeks f
ter initil
infection. The nti ody test should e followed y  test such s PCR to detect
the DNA of the
ornism. Rerdless of the test outcome, if the physicin suspects Lyme disese
, tretment
should ein immeditely. 9. B An EBV seroloicl pnel would ive  more ccur
te ssessment
thn  rpid slide IM test. The time of ppernce of the vrious nti odies to
the virl
ntiens di ers ccordin to the clinicl course of the infection. 10. C The level
of HBsA my
not hve reched detect le levels, nd nti odies to HBc nd HCV would not hve
yet developed.
Witin 1 or 2 weeks nd repetin the tests my revel evidence of heptitis vi
rus infection.
11. D She my donte if she is symptom free. The response to heptitis B vccine
would include 
positive result for nti-HBs,  test not normlly  prt of routine donor testin
. She will e
netive for HBsA nd nti-HBc. 11. A hospitl employee received the nl dose of
the heptitis

B vccine 3 weeks o. She wnts to donte lood. Which of the followin results
re expected
from the heptitis screen, nd will she e llowed to donte lood? A. HBsA, po
sitive; nti-HBc,
netiveshe my donte B. HBsA, netive; nti-HBc, positiveshe my not donte C.
positive; nti-HBc, positiveshe my not donte D. HBsA, netive; nti-HBc, ne
tiveshe my
donte Immunoloy/Correlte l ortory dt with physioloicl processes/Heptit
2828_Ch03_075-120 06/08/12 11:11 AM Pe 115 12. A prennt womn cme to her
physicin with 
mculoppulr rsh on her fce nd neck. Her temperture ws 37.7C (100F). Ru ell
tests for
oth IG nd IM nti ody were positive. Wht positive test(s) would revel  di
nosis of
conenitl ru ell syndrome in her  y fter irth? A. Positive ru ell tests f
or oth IG nd
IM nti ody B. Positive ru ell test for IM C. Positive ru ell test for IG D
. No positive
test is reveled in conenitl ru ell syndrome Immunoloy/Correlte l ortory
dt with
physioloicl processes/Ru ell/Testin/3 13. SITUATION: A ptient with RA hs 
cute pneumoni
ut  netive throt culture. Te physicin suspects n infection with Mycoplsm
 pneumonie nd
requests n IM-speci c nti ody test. Te test is performed directly on seril dil
utions of serum
less thn 4 hours old. Te result is positive, ivin  titer of 1:32. However, t
he test is
repeted 3 weeks lter, nd the titer remins t 1:32. Wht est explins these
results? A.
IM-speci c nti odies do not increse fourfold etween cute nd convlescent ser
um B. Te
results re not sini cnt ecuse the initil titer ws not ccompnied y  posi
tive test for
cold lutinins C. Rheumtoid fctor cused  flse-positive test result D. Ins
u cient time hd
elpsed etween mesurement of cute nd convlescent smples Immunoloy/Apply k
nowlede to
reconize sources of error/IM testin/3 14. A ptient hs  prostte-speci c nti
en level of 60
n/mL the dy efore surery to remove  loclized prostte tumor. One week foll
owin surery,
the serum PSA ws determined to e 8 n/mL y the sme method. Wht is the most
likely cuse of
these results? A. Incomplete removl of the mlinncy B. Cross rectivity of th
e nti ody with
nother tumor ntien C. Testin too soon fter surery D. Hook e ect with the PSA
Immunoloy/Apply knowlede to reconize inconsistent results/Tumor mrkers/3 116
Chpter 3 |
Immunoloy Answers to Questions 1214 12. B A ndin of IG is not de nitive for cone
ru ell syndrome ecuse IG crosses the plcent from the mother; however, demo
nstrtion of IM,
even in  sinle neontl smple, is dinostic. 13. C The IM-speci c nti ody te
st for M.
pneumonie detects nti odies to mycoplsml mem rne ntiens nd, unlike cold
lutinins, is

speci c for M. pneumonie. A positive result (titer of 1:32 or hiher) occurs duri
n the cute
phse in  out 87% of M. pneumonie infections nd does not need to e con rmed y
ssy of
convlescent serum. However, ptients with RA my show  flse-positive rection
rheumtoid fctor in their serum cn rect with the conjuted nti-IM used in
the test. For
this reson, serum from ptients known or suspected to hve rheumtoid fctor (R
F) must e
pretreted. The serum is heted to 56C to rete the RF, nd the reted im
munolo ulin is
removed y  chromtorphy minicolumn. 14. C When monitorin the level of  tum
or mrker for
tretment e ccy or recurrence, the hlf-life of the protein must e considered wh
en determinin
the testin intervl. PSA hs  hlf-life of lmost 4 dys nd would not rech n
orml levels
fter surery for pproximtely 34 weeks. The hook e ect is the result of very hih
levels ivin  lower thn expected result in  dou le nti ody sndwich ssy w
hen oth
nti odies nd smple re dded t the sme time. 2828_Ch03_075-120 06/08/12 1
1:11 AM Pe 116
15. A ptient with symptoms ssocited with SLE nd scleroderm ws evluted y
immuno uorescence microscopy for ANAs usin the HEp-2 cell line s su strte. Te c
ell line
displyed  mixed pttern of uorescence tht could not e seprted y seril dil
utions of the
serum. Which procedure would e most helpful in determinin the nti ody pro le of
this ptient?
A. Use of  di erent tissue su strte B. A sorption of the serum usin the ppropr
ite tissue
extrct C. Ouchterlony technique D. ELISA tests for speci c nti odies Immunoloy/
Apply knowlede
to identify l ortory tests/ANA/Testin/3 16. A ptient with joint swellin nd
pin tested
netive for serum RF y oth ltex lutintion nd ELISA methods. Wht other
test would help
est lish  dinosis of RA in this ptient? A. Anti CCP B. ANA testin C. Flow
cytometry D.
Complement levels Immunoloy/Correlte l ortory dt with physioloicl proces
17. Wht is the min dvnte of the recovery nd reinfusion of utoloous stem
cells? A. It
slows the rte of rejection of trnsplnted cells B. It prevents rft-versus-ho
st disese C. No
HLA testin is required D. Enrftment occurs in  more e cient sequence Immunolo
knowlede of fundmentl ioloicl chrcteristics/Trnsplnttion/2 18. A trn
splnt ptient
en to show sins of rejection 8 dys fter receipt of the trnsplnted orn,
nd the orn
ws removed. Wht immune elements miht e found in the rejected orn? A. Anti
ody nd
complement B. Primrily nti ody C. Mcrophes D. T cells Immunoloy/Correlte
l ortory dt
nd sic immune response/Trnsplnttion/Rejection/3 3.8 | Immunoloy Pro lem S
Answers to Questions 1518 15. D Mny ptients with multiorn utoimmune disese

symptoms tht overlp two or more diseses nd hve complex mixtures of serum u
tonti odies. The
HEp-2 su strte is the most sensitive cell line for immuno uorescent microscopy e
cuse it
contins cells in vrious mitotic stes, which exposes the serum to more ntie
ns. Use of 
nonhumn su strte such s Crithidi my help to identify dsDNA nti odies ut w
ould not id in
di erentitin ll of the nti odies in  complex mixture. Ouchterlony immunodi usio
n helps to
identify speci c ANAs ut hs limited sensitivity. The est method is ELISA ecus
e it is more
sensitive thn immuno uorescence microscopy nd cn quntitte nti odies to speci c
ELISA is often used to mesure nti odies to extrct le nucler ntiens, which
my e prtilly
or completely lost durin xtion of cells used for immuno uorescent microscopy. The
se nti odies
cuse  speckled pttern nd re seen in  wide rne of utoimmune diseses. Id
enti ction of
the nti ENA speci cities is helpful in di erentitin these diseses. 16. A Anti od
ies to cyclic
citruillinted peptide re often found in RF-netive ptients with rheumtoid 
rthritis. The
 sence of rheumtoid fctors from serum does not rule out  dinosis of RA, n
d more thn hlf
of ptients who re dinosed with RA present initilly with  netive serum re
sult. The serum
RF test will eventully e positive in 80%90% of ptients who meet the clinicl c
riteri for RA.
17. B The min dvnte to the ptient from the reinfusion of utoloous stem c
ells is tht the
procedure prevents rft-versus-host disese, especilly in the immunocompromise
d ptient.
Althouh HLA testin is not required, this is not the primry dvnte for pti
ent cre. 18. D
Acute rejection occurs within 3 weeks of trnsplnttion. The immune element mos
t likely to e
involved in n cute rejection is the T cell in  type IV, delyed hypersensitiv
(cell-medited) rection. Preformed nti ody, nd possi ly complement, is usull
y involved in
hypercute (immedite) rejection nd chronic rejection. 2828_Ch03_075-120 06/08
/12 11:11 AM
Pe 117 19. A ptient with ovrin cncer who hs een treted with chemotherp
y is ein
monitored for recurrence usin serum CA-125, CA-50, nd CA 153. Six months fter
tretment the
CA 153 is elevted, ut the CA-125 nd CA-50 remin low. Wht is the most likely
explntion of
these ndins? A. Ovrin mlinncy hs recurred B. CA 153 is speci c for rest cn
cer nd
indictes metsttic rest cncer C. Testin error occurred in the mesurement
of CA 153 cused
y poor nlyticl speci city D. Te CA 153 elevtion is spurious nd pro  ly eni
Immunoloy/Correlte l ortory dt with physioloicl processes/Tumor mrkers/
Testin/3 20. An
initil nd repet ELISA test for nti odies to HIV-1 re oth positive. A Weste

rn lot shows 
sinle nd t p160. Te ptient shows no clinicl sins of HIV infection, nd t
he ptients CD4
T-cell count is norml. Bsed upon these results, which conclusion is correct? A
. Ptient is
dinosed s HIV-1-positive B. Ptient is dinosed s HIV-2-positive C. Results
re inconclusive
D. Ptient is dinosed s HIV-1-netive Immunoloy/Apply knowlede to reconiz
e inconsistent
results/HIV/3 21. A womn who hs een prennt for 12 weeks is tested for toxop
lsmosis. Her IM
ELISA titer is 2.6 (reference rne < 1.6), nd her IG ELISA vlue is 66 (refer
ence rne < 8).
Te physicin sks you if these results indicted n infection durin the pst 12
weeks. Which of
the followin tests would you recommend to determine if the womn ws infected d
urin her
prenncy? A. Toxo PCR on mniotic uid B. Toxo IM on mniotic uid C. Toxo IG vi
dity D.
Amniotic uid culture Immunoloy/Correlte l ortory dt with physioloicl proc
course of immune response/Toxoplsmosis/Testin/3 118 Chpter 3 | Immunoloy Ans
wers to Questions
1921 19. A Althouh CA-125 is the most commonly used tumor mrker for ovrin cn
cer, not ll
ovrin tumors produce CA-125. Gretest sensitivity in monitorin for recurrence
is chieved when
severl mrkers known to e incresed in the mlinnt tissue type re mesured
nd when the mrkers re elevted ( y mlinncy) prior to tretment. In dditio
n to limited
sensitivity, no sinle tumor mrker is entirely speci c. Cr ohydrte nd other on
ntiens re produced y severl mlinnt nd enin conditions. Althouh testi
n errors my
occur in ny sitution, mesurements of cr ohydrte ntiens use puri ed monoclon
l nti odies
with very low cross rectivities. 20. C The Western lot test is used s  con rm
tory test for
HIV, ut it is not s sensitive s enzyme immunossy tests usin polyvlent HIV
ntiens derived
from cloned HIV enes. The Western lot test is considered positive only if nti
odies to t
lest two of three virl ntiensp24, p41, nd p160/120re detected. The presenc
e of  sinle
nd is indeterminte. Over the course of the next 3 months, two or more nti od
ies will e
detected if the ptient is HIV positive; however, nti odies to  sinle virl p
rotein my e
cused y  cross rection, nd this ptient my fil to seroconvert. This resul
t should e
reported s indeterminte, nd the ptient should e retested in 3 months. Alter
ntively,  more
sensitive con rmtory test such s PCR or immuno uorescence my e performed. 21. C
Althouh IM
is positive, in toxoplsmosis, speci c IM my remin detect le for  yer or mor
e followin
infection. IG vidity, or the strenth of indin of  serum to the ntien of
interest, is 
useful method to determine if n infection is recent or in the distnt pst. IG

vidity will
increse with time followin n infection. Amniotic uid testin is not useful for
when the mother miht hve een infected. 2828_Ch03_075-120 06/08/12 11:11 AM
Pe 118 22. On
Jnury 4,  serum protein electrophoresis on  specimen o tined t your hospit
l in North
Dkot from  58-yer-old ptient shows  nd t the - junction. The specimen ws
positive for rheumtoid fctor. You recommend tht n immunofixtion test e per
formed to
determine if the nd represents  monoclonl immunolo ulin. Another specimen i
s o tined 2
weeks lter y the physicin in his office 30 miles wy, nd the whole lood is
su mitted to you
for the IFE. The courier plced the whole lood specimen in n ice chest for tr
nsport. In this
specimen, no - nd is seen in the serum protein lne, nd the IM lne is very f
int. The
rheumtoid fctor on this specimen ws netive. The physicin wnts to know wh
ts wron with
your l ortory. Your response is: A. Nothins wron with our l ortory; the pt
ient hd n
infection 2 weeks o tht hs clered up B. Somethins wron with our l ortoryw
e likely
misl eled one of the specimens; plese resu mit  new specimen nd we will test
it t no chre
C. You will run  second specimen usin  2-mercptoethnol tretment tht will
eliminte IM
retes nd llow for more sensitive monoclonl IM detection D. Te physicin
should redrw
nother specimen from the ptient nd this time seprte the serum from the clot
in his o ce
efore sendin the specimen in y courier Immunoloy/Correlte l ortory dt w
ith physioloicl
processes/Specimen interity/3 23. A dilysis ptient is positive for oth hept
itis B surfce
ntien nd heptitis B surfce nti ody. Te physicin suspects  l ortory err
or. Do you ree?
A. Yes; the ptient should not test positive for oth HBsA nd HBsA B. No; inc
omplete dilysis
of  ptient in the core window phse of heptitis B infection will yield this r
esult C. No; it
is likely the ptient hs recently received  heptitis B ooster vccintion n
d could hve
these results D. Perhps;  new specimen should e su mitted to cler up the con
Immunoloy/Correlte l ortory dt with physioloicl processes/Heptitis/Test
in/3 3.8 |
Immunoloy Pro lem Solvin
119 Answers to Questions 2224 22. D The most likely
cuse of the
discrepnt results is the presence of  type II cryolo ulin. This is  monoclon
l rheumtoid
fctor. The protein likely precipitted durin the courier ride nd ws thus in
the clot when the
l ortory seprted the serum. 23. C Heptitis B surfce ntien will remin de
tect le t low
levels followin  vccintion for up to 12 weeks. Thus, ptients who hve receiv
ed  second
injection of heptitis B vccine my hve nti-heptitis B surfce ntien nd d

etect le ntien
for  rief period of time. This hs een reported more frequently in dilysis 
nd peditric
popultions. 24. D In this sitution, you hve lredy tested the specimens in d
uplicte. Testin
n dditionl 50 specimens will not chne the fct tht you hve 20 discrepnt
specimens. The
est course of ction is to determine wht nti odies re ctully present in th
ese specimens.
Then, you cn determine whether the ELISA or IFA is  etter procedure for detec
tin the most
cliniclly relevnt nti odies. You could perform clinicl chrt reviews s n 
lterntive, ut
o tinin tht dt would e difficult nd much of it my e su jective. 24. You
re evlutin
n ELISA ssy s  replcement for your immuno uorescent ntinucler nti ody tes
t. You test 50
specimens in duplicte on ech ssy. Te ELISA ssy uses  HEp-2 extrct s its
ntien source.
Te correltion etween the ELISA nd the IFA tests is only 60% (30 of 50 specime
ns ree). Which
of the followin is the next est course of ction? A. Test nother 50 specimens
B. Perform 
competency check on the technoloists who performed the tests C. Order  new lot
of oth kits nd
then retest on the new lots D. Refer the discrepnt specimens for testin y no
ther method
Immunoloy/Mnement principles/Method comprison/3 2828_Ch03_075-120 06/08/12
11:11 AM Pe
119 BI BL I OGRAPHY 1. Detrick B, Hmilton RG, nd Folds J. Mnul of Moleculr
nd Clinicl
L ortory Immunoloy. 7th edition, 2006. ASM Press, Wshinton, DC. 2. Folds J,
nd Normnsell
D. Pocket Guide to Clinicl Immunoloy. 1999. ASM Press, Wshinton, DC. 3. Kind
t TJ, Os orne BA,
nd Golds y RA. Ku y Immunoloy. 6th edition, 2006. WH Freemn, New York. 4. Mh
on C nd Tice D.
Clinicl L ortory Immunoloy. 2006. Prentice-Hll, Upper Sddle River, NJ. 120
Chpter 3 |
Immunoloy 5. Nkmur R, Burek L, Cook L, et l. Clinicl Dinostic Immunoloy
: Protocols in
Qulity Assurnce nd Stndrdiztion. 1998. Blckwell Pu lishin, Mlden, MA. 6
. Plyfir H.
Immunoloy t  Glnce. 2005. Blckwell Pu lishin, Mlden, MA. 7. Rosen F nd G
eh R. Cse
Studies in Immunoloy. A Clinicl Compnion. 4th edition, 2004. Grlnd Science,
New York. 8.
Stevens CD. Clinicl Immunoloy nd Seroloy,  L ortory Perspective. 2010. F.
A. Dvis,
Phildelphi. 2828_Ch03_075-120 06/08/12 11:11 AM Pe 120 121 Immunohemtolo
y CHAPTER 4 4.1
Genetics nd Immunoloy of Blood Groups 4.2 ABO Blood Group System 4.3 Rh Blood
Group System 4.4
Testin for Anti odies 4.5 Compti ility Testin 4.6 Trnsfusion Rections 4.7 C
omponents 4.8
Donors 4.9 Hemolytic Disese of the New orn (HDN) 4.10 Seroloicl Testin of Bl
ood Products 4.11
Immunohemtoloy Pro lem Solvin 2828_Ch04_121-170 06/08/12 11:16 AM Pe 121
2828_Ch04_121-170 06/08/12 11:16 AM Pe 122 Answers to Questions 15 1. B Ph
enotypin, or

the physicl expression of  enotype, is the type of testin routinely performe

d in the lood
nk. An individul, for exmple, my hve the AO enotype ut phenotypes s ro
up A. 2. A
Dose is de ned s n nti ody rectin stroner with homozyous cells (such s K
K) thn with
heterozyous cells (such s Kk). In ddition to Kell, dose e ect is seen commonl
y with ntiens
M, N, S, s, Fy  , Fy , Jk  , Jk , nd the ntiens of the Rh system. 3.
C The frequency
of Du y ntiens Fy  nd Fy vries with rce. The Fy(b) phenotype occurs in almo
st 70% of
African Americans and is very rare in whites. The Xg a antigen is Xlinked and,
expressed more frequently in women (who may inherit the antigen from either pare
nt) than in men.
4. B An individual having the BB genotype has inherited the B gene from both p
arents and,
therefore, is homozygous for B antigen. 5. A The genotype DCe/dce contains one
C and one c gene
and is heterozygous for C and c antigens. 5. Which genotype is heterozygous for
C? A. DCe/dce B.
DCE/DCE C. Dce/dce D. DCE/dCe Blood bank/Apply knowledge of fundamental biologic
characteristics/Genetics/Rh/2 1. What type of serological testing does the blood
technologist perform when determining the blood group of a patient? A. Genotypin
g B. Phenotyping
C. Both genotyping and phenotyping D. Polymerase chain reaction Blood bank/Apply
knowledge of
laboratory operations/Genetics/1 2. If antiK reacts 3+ with a donor cell with a
genotype KK and
2+ with a Kk cell, the antibody is demonstrating: A. Dosage B. Linkage disequili
brium C.
Homozygosity D. Heterozygosity Blood bank/Apply knowledge of fundamental biologi
characteristics/Genetics/Kell/3 3. Carla expresses the blood group antigens Fy a
, Fy b , and Xg
a . James shows expressions of none of these antigens. What factor(s) may accoun
t for the absence
of these antigens in James? A. Gender B. Race C. Gender and race D. Medication B
lood bank/Apply
knowledge of fundamental biological characteristics/Genetics/2 4. Which of the f
statements is true? A. An individual with the BO genotype is homozygous for B an
tigen B. An
individual with the BB genotype is homozygous for B antigen C. An individual wit
h the OO genotype
is heterozygous for O antigen D. An individual with the AB phenotype is homozygo
us for A and B
antigens Blood bank/Apply knowledge of fundamental biological characteristics/Ge
netics/ABO/1 4.1
Genetics and Immunology of Blood Groups 123 2828_Ch04_121170 06/08/12 11:16 A
M Page 123 6.
Which genotype(s) will give rise to the Bombay phenotype? A. HH only B. HH and H
h C. Hh and hh D.
hh only Blood bank/Apply knowledge of fundamental biological characteristics/ABO
/Bombay/1 7.
Meiosis in cell division is limited to the ova and sperm producing four gametes
containing what

complement of DNA? A. 1N B. 2N C. 3N D. 4N Blood bank/Apply knowledge of fundame

ntal biological
characteristics/Genetics/1 8. A cell that is not actively dividing is said to be
in: A.
Interphase B. Prophase C. Anaphase D. Telophase Blood bank/Apply knowledge of fu
biological characteristics/Genetics/1 9. Which of the following describes the ex
pression of most
blood group antigens? A. Dominant B. Recessive C. Codominant D. Corecessive Bloo
d bank/Apply
knowledge of fundamental biological characteristics/Genetics/1 10. What blood ty
pe is not
possible for an o spring of an AO and BO mating? A. AB B. A or B C. O D. All are p
ossible Blood
bank/Apply knowledge of fundamental biological characteristics/Genetics/ABO/2 11
. Te alleged
father of a child in a disputed case of paternity is blood group AB. Te mother i
s group O and the
child is group O. What type of exclusion is this? A. Direct/primary/ rst order B.
Probability C.
Random D. Indirect/secondary/second order Blood bank/Evaluate laboratory data to
verify test
results/Genotype/Paternity testing/2 124 Chapter 4 | Immunohematology Answers to
Questions 612
6. D The Bombay phenotype will be expressed only when no H substance is presen
t. The O h type
is expressed by the genotype hh. Bombays produce naturally occurring antiH, and
their serum
agglutinates group O red cells in addition to red cells from groups A, B, and AB
persons. 7. A
Meiosis involves two nuclear divisions in succession resulting in four gametocyt
es each
containing half the number of chromosomes found in somatic cells or 1N. 8. A I
nterphase is the
stage in between cell divisions. The cell is engaged in metabolic activity. Chro
mosomes are not
clearly discerned; however, nucleoli may be visible. 9. C The inheritance of m
ost blood group
genes is codominant, meaning that no gene or allele is dominant over another. Fo
r example, a
person who is group AB expresses both the A and B antigen on his or her red cell
s. 10. D A
mating between AO and BO persons can result in an o spring with a blood type of A,
B, AB, or O.
11. D An indirect/secondary/second order exclusion occurs when a genetic marke
r is absent in
the child but should have been transmitted by the alleged father. In this case,
either A or B
should be present in the child. 12. B Linkage disequilibrium is a phenomenon i
n which alleles
situated in close proximity on a chromosome associate with one another more than
would be
expected from individual allelic frequencies. 12. If the frequency of gene Y is
0.4 and the
frequency of gene Z is 0.5, one would expect that they should occur together 0.2
(20%) of the
time. In actuality, they are found together 32% of the time. Tis is an example o
f: A. Crossing
over B. Linkage disequilibrium C. Polymorphism D. Chimerism Blood bank/Apply pri
nciples of

genetics/3 2828_Ch04_121170 06/08/12 11:16 AM Page 124 13. In the HardyWeinbe

rg formula, p 2
represents: A. Te heterozygous population of one allele B. Te homozygous populat
ion of one allele
C. Te recessive allele D. Te dominant allele Blood bank/Apply knowledge of funda
mental biological
characteristics/Genetics/1 14. In this type of inheritance, the father carries t
he trait on his X
chromosome. He has no sons with the trait because he passed his Y chromosome to
his sons;
however, all his daughters will express the trait. A. Autosomal dominant B. Auto
somal recessive
C. Xlinked dominant D. Xlinked recessive Blood bank/Apply knowledge of fundame
ntal biological
characteristics/Genetics/1 15. Why do IgM antibodies, such as those formed again
st the ABO
antigens, have the ability to directly agglutinate red blood cells (RBCs) and ca
use visible
agglutination? A. IgM antibodies are larger molecules and have the ability to bi
nd more antigen
B. IgM antibodies tend to clump together more readily to bind more antigen C. Ig
M antibodies are
found in greater concentrations than IgG antibodies D. IgM antibodies are not li
mited by subclass
speci city Blood bank/Apply knowledge of fundamental biological characteristics/An
tibodies/1 16.
Which of the following enhancement mediums decreases the zeta potential, allowin
g antibody and
antigen to come closer together? A. LISS B. Polyethylene glycol C. Polybrene D.
ZZAP Blood
bank/Apply knowledge of fundamental biological characteristics/Antigens/1 17. Ti
s type of
antibody response is analogous to an anamnestic antibody reaction. A. Primary B.
Secondary C.
Tertiary D. Anaphylactic Blood bank/Apply knowledge of fundamental biological
characteristics/Antibodies/1 4.1 | Genetics and Immunology of Blood Groups 125
Answers to
Questions 1318 13. B In the HardyWeinberg formula p 2 + 2pq + q 2 , p 2 and q 2
homozygous expressions and 2pq represents heterozygous expression. This formula
is used in
population genetics to determine the frequency of di erent alleles. 14. C In Xl
inked dominant
inheritance, there is absence of maletomale transmission because a male passes
his Y chromosome
to all of his sons and his single X chromosome to all his daughters. All daughte
rs who inherit
the a ected gene will express the trait. An example of this type of inheritance is
the Xg a blood
group. 15. A An IgM molecule has the potential to bind up to 10 antigens, as c
ompared to a
molecule of IgG, which can bind only two. 16. A LISS contains a reduced concen
tration of NaCl
(0.2%) and results in a reduction in charged ions within the ionic cloud, decrea
sing the zeta
potential and facilitating antigen and antibody interaction. 17. B An anamnest
ic response is a
secondary immune response in which memory lymphocytes respond rapidly to foreign
antigen in
producing speci c antibody. The antibodies are IgG and are produced at lower doses

of antigen
than in the primary response. 18. B In the DAT (direct antiglobulin test), rab
bit polyspeci c
antisera contains both an antihuman IgG component and an antibody against the C
3d component of
complement. 18. Which antibodies to a component of complement are contained in t
he rabbit
polyspeci c antihuman globulin reagent for detection of in vivo sensitization? A.
AntiIgG and
antiC3a B. AntiIgG and antiC3d C. AntiIgG and antiIgM D. All of these optio
ns Blood
bank/Apply knowledge of fundamental biological characteristics/AHG/2 2828_Ch04_1
21170 06/08/12
11:16 AM Page 125 Answers to Questions 15 1. B The group A 1 comprises both A
1 and A
antigens. AntiA will react with both A 1  and A 2 positive RBCs. A person who
is group A 2 may
form antiA 1 , but an A 1 person will not form antiA 1 (which would cause auto
2. C Bombay is the only ABO phenotype incompatible with O cells. The red cells
of a Bombay show
a negative reaction to antiH because the cells contain no H substance. 3. D A
individual does not express A, B, or H antigens; therefore antiA, B, and H are
formed. Because a
Bombay individual has three antibodies, the only compatible blood must be from a
nother Bombay
donor. 4. D The acquired B phenomenon is only seen in group A persons. 5. C
The patient is
likely an A 2 with antiA 1 which is causing reactivity in the crossmatch. A neg
ative antibody
screen rules out the possibility of an antibody to a highfrequency antigen, and
two donor units
incompatible rules out an antibody to a lowfrequency antigen. 5. Blood is cross
matched on an A
positive person with a negative antibody screen. Te patient received a transfusi
on of A positive
RBCs 3 years ago. Te donors chosen for crossmatch were A positive. Te crossmatch
was run on the
Ortho Provue and yielded 3+ incompatibility. How can these results be explained?
A. Te patient
has an antibody to a lowfrequency antigen B. Te patient has an antibody to a hi
antigen C. Te patient is an A 2 with antiA 1 D. Te patient is an A 1 with anti
A 2 Blood
bank/Apply principles of special procedures/ ABO/3 1. Which of the following dis
tinguishes A 1
from A 2 blood groups? A. A 2 antigen will not react with antiA, A 1 will react
strongly (4+) B.
An A 2 person may form antiA 1 ; an A 1 person will not form antiA 1 C. An A 1
person may form
antiA 2 , an A 2 person will not form antiA 1 D. A 2 antigen will not react wi
th antiA from a
nonimmunized donor; A 1 will react with any antiA Blood bank/Apply knowledge of
biological characteristics/ABO blood group/2 2. A patients serum is incompatible
with O cells.
Te patient RBCs give a negative reaction to antiH lectin. What is the most like
ly cause of these
results? A. Te patient may be a subgroup of A B. Te patient may have an immunode c

iency C. Te
patient may be a Bombay D. Te patient may have developed alloantibodies Blood ba
principles of special procedures/ABO blood group/3 3. What antibodies are formed
by a Bombay
individual? A. AntiA and antiB B. AntiH C. AntiA,B D. AntiA, B, and H Blood
knowledge of fundamental biological characteristics/ABO blood group/Bombay/1 4.
Acquired B
antigens have been found in: A. Bombay individuals B. Group O persons C. All blo
od groups D.
Group A persons Blood bank/Apply knowledge of fundamental characteristics/ABO/1
4.2 ABO Blood
Group System 126 2828_Ch04_121170 06/08/12 11:16 AM Page 126 Answers to Ques
tions 611 6. C
The strong 4+ reaction in reverse grouping suggests the discrepancy is in forwar
d grouping.
Incubating washed red cells at room temperature with antiA and antiA,B will en
hance reactions.
7. C In forward typing, a 1+ reaction with antiB is suspicious because of the
weak reaction
and the normal reverse grouping that appears to be group A. This may be indicati
ve of an acquired
antigen. In the case of an acquired B, the reverse grouping is the same for a gr
oup A person.
Choice A is indicative of group AB; choice B is indicative of a group A who may
immunocompromised. Choice D may be caused by a mistyping or an antibody against
antigens on
reverse cells. 8. A The A 1 B blood group has the least amount of H antigen. T
his is due to
both A and B epitopes present on red cells compromising the availability of H ep
itopes. A 1 B
cells will yield weak reactions with antiH lectin. 9. B A person in need of a
n RBC transfusion
who is an A 2 with antiA 1 can be transfused A or O cells because the antiA 1
is typically only
reactive at room temperature. 10. A These results point to a cold autoantibody
. Washing the
cells with warm saline may elute the autoantibody, allowing a valid forward type
to be performed.
The serum should be adsorbed using washed cells until the autocontrol is negativ
e. Then the
adsorbed serum should be used for reverse typing. 11. B All negative results m
ay be due to
weakened antigens or antibodies. Room temperature or lower incubation temperatur
e may enhance
expression of weakened antigens or antibodies. 11. What should be done if all fo
rward and reverse
ABO results are negative? A. Perform additional testing such as typing with anti
A 1 lectin and
antiA,B B. Incubate at 22C or 4C to enhance weak expression C. Repeat the test wi
th new
reagents D. Run an antibody identi cation panel Blood bank/Evaluate laboratory and
clinical data
to specify additional tests/RBCs/ABO discrepancy/3 4.2 | ABO Blood Group System
127 6. A
patients red cells forward as group O, serum agglutinates B cells (4+) only. Your
next step
would be: A. Extend reverse typing for 15 minutes B. Perform an antibody screen

including a room
temperature incubation C. Incubate washed red cells with antiA 1 and antiA,B f
or 30 minutes at
room temperature D. Test patients red cells with Dolichos bi orus Blood bank/Apply
principles of
special procedures/ RBCs/ABO discrepancy/3 7. Which typing results are most like
ly to occur when
a patient has an acquired B antigen? A. AntiA 4+, antiB3+, A 1 cells neg, B c
ells neg B.
AntiA 3+, antiB neg, A 1 cells neg, B cells neg C. AntiA 4+, antiB 1+, A 1 c
ells neg, B cells
4+ D. AntiA 4+, antiB 4+, A 1 cells 2+, B cells neg Blood bank/Evaluate labora
tory data to
recognize problems/ABO discrepancy/2 8. Which blood group has the least amount o
f H antigen? A. A
1 B B. A 2 C. B D. A 1 Blood bank/Apply knowledge of fundamental biological prin
ciples/ABO/1 9.
What type RBCs can be transfused to an A 2 person with antiA 1 ? A. A only B. A
or O C. B D. AB
Blood bank/Apply knowledge of fundamental biological principles/ABO/3 10. What s
hould be done if
all forward and reverse ABO results as well as the autocontrol are positive? A.
Wash the cells
with warm saline, autoadsorb the serum at 4C B. Retype the sample using a di erent
lot number of
reagents C. Use polyclonal typing reagents D. Report the sample as group AB Bloo
d bank/Evaluate
laboratory and clinical data to specify additional tests/RBCs/ABO discrepancy/3
06/08/12 11:16 AM Page 127 Answers to Questions 1217 12. C The immunodominan
t sugar
Nacetylgalactosamine confers A antigen speci city when present at the terminus o
f the type 2
precursor chain on the RBC membrane. Therefore, its presence would cause RBCs to
react with
antiA 1 lectin, Dolichos bi orus. 13. C A transplant patient is probably taking
immunosuppressive medication to increase graft survival. This can contribute to
the loss of
normal blood group antibodies as well as other types of antibodies. 14. D Anti
A,B should react
positively with group A or B and any subgroup of A or B (with exception of A m )
. An A 1 (not A 2
) would react with antiA 1 lectin; only an A 2 person with antiA 1 would give
a positive
reaction with A 1 cells; an A 2 would react more strongly with antiH than A 1.
15. B The
patient is most likely an AB person who has formed a coldreacting alloantibody
reacting with B
cells and O cells. An identi cation panel should be performed. An acquired B perso
n or someone
with hypogammaglobulinemia should not make antibody that would agglutinate O cel
ls. 16. C
Excessive A substance, such as may be found in some types of tumors, may be neut
ralizing the
antiA. Weak A subgroups may fail to react with antiA and require additional te
sting techniques
(e.g., roomtemperature incubation) before their expression is apparent. 17. C
The reverse
typing should agree with the forward typing in this result. The 4+ reaction with
antiB indicates

group B. A positive reaction is expected with A 1 cells in the reverse group. 17

. Which of the
following results is most likely discrepant? AntiA, neg AntiB, 4+ A 1 cells,
neg B cells,
neg A. Negative B cells B. Positive reaction with antiB C. Negative A 1 cells D
. No problem with
this typing Blood bank/Evaluate laboratory data to make identi cations/ABO discrep
ancy/3 128
Chapter 4 | Immunohematology 12. NacetylDgalactosamine is the immunodominant
carbohydrate that
reacts with: A. Arachis hypogaea B. Salvia sclarea C. Dolichos bi orus D. Ulex eur
opeaus Blood
bank/Apply knowledge of fundamental biological principles/ABO/2 13. A stem cell
patient was retyped when she was transferred from another hospital. What is the
most likely cause
of the following results? Patient cells: AntiA, neg AntiB, 4+ Patient serum
: A 1 cells, neg
B cells, neg A. Viral infection B. Alloantibodies C. Immunode ciency D. Autoimmu
ne hemolytic
anemia Blood bank/Evaluate laboratory data to recognize health and disease state
discrepancy/3 14. What reaction would be the same for an A 1 and an A 2 person?
A. Positive
reaction with antiA 1 lectin B. Positive reaction with A 1 cells C. Equal react
ion with antiH
D. Positive reaction with antiA,B Blood bank/Evaluate laboratory data to make i
denti cations/ABO
discrepancy/2 15. A female patient at 28 weeks gestation yields the following res
ults: Patient
cells: AntiA, 3+ AntiB, 4+ Patient serum: A 1 cells, neg B cells, 1+
O cells, 1+
Which of the following could be causing the ABO discrepancy? A. Hypogammaglobuli
nemia B.
Alloantibody in patient serum C. Acquired B D. Weak subgroup Blood bank/Evaluate
laboratory data
to make identi cations/ABO discrepancy/3 16. Which condition would most likely be
responsible for
the following typing results? Patient cells: AntiA, neg AntiB, neg Patient
serum: A 1
cells, neg B cells, 4+ A. Immunode ciency B. Masking of antigens by the presence
of massive
amounts of antibody C. Weak or excessive antigen(s) D. Impossible to determine B
lood bank/Apply
principles of basic laboratory procedures/ABO discrepancy/3 2828_Ch04_121170 0
6/08/12 11:16 AM
Page 128 Answer to Question 18 18. D In a transplant scenario, there are no m
ethods to employ
to solve the discrepancy. The technologist must rely on the patient history of d
onor type and
recipient type, and the present serological picture. A Bpositive recipient give
n an Opositive
transplant constitutes a minor ABO mismatch. The forward type resembles the dono
r. The reverse
type still resembles the recipient. The ABO type reported out does not t a patter
n resulting in
an undetermined type. 4.2 | ABO Blood Group System 129 18. A 61yearold male
with a history of
multiple myeloma had a stem cell transplant 3 years ago. Te donor was O positive
and the

recipient was B positive. He is admitted to a community hospital for fatigue and

nausea. Typing
results reveal the following: AntiA = 0 AntiB =0 AntiA,B = 0 AntiD = 4+ A 1
cells = 4+ B
cells = 0 How would you report this type? A. O positive B. B positive C. A posit
ive D.
Undetermined Blood bank/Evaluate laboratory data to recognize problems/ABO discr
2828_Ch04_121170 06/08/12 11:16 AM Page 129 130 4.3 Rh Blood Group System 1.
A complete Rh
typing for antigens C, c, D, E, and e revealed negative results for C, D, and E.
How is the
individual designated? A. Rh positive B. Rh negative C. Positive for c and e D.
Impossible to
determine Blood bank/Apply knowledge of fundamental biological characteristics/R
h typing/1 2. How
is an individual with genotype Dce/dce classi ed? A. Rh positive B. Rh negative C.
Rh null D.
Total Rh Blood bank/Apply knowledge of fundamental biological characteristics/Rh
typing/2 3. If a
patient has a positive direct antiglobulin test, should you perform a weak D tes
t on the cells?
A. No, the cells are already coated with antibody B. No, the cells are Rh null C
. Yes, the
immunoglobulin will not interfere with the test D. Yes, Rh reagents are enhanced
in protein media
Blood bank/Apply knowledge of fundamental biological characteristics/Rh typing/3
4. Which donor
unit is selected for a recipient with antic? A. rr B. R 0 R 1 C. R 2 r D. rr y Blo
bank/Apply knowledge of fundamental biological characteristics/Rh typing/3 5. Wh
ich genotype
usually shows the strongest reaction with antiD? A. DCE/DCE B. Dce/dCe C. D/D D.
CE/ce Blood
bank/Apply knowledge of fundamental biological characteristics/Rh typing/1 Answe
rs to Questions
15 1. B Rh positive refers to the presence of D antigen; Rh negative refers to
the absence of
the D antigen. These designations are for D antigen only and do not involve othe
r Rh antigens. 2.
A This individual has the D antigen and is classi ed as Rh positive. Any genotyp
e containing
the D antigen will be considered Rh positive. 3. A If a person has a positive
DAT, the red
cells are coated with immunoglobulin (antiIgG and anti C3d, or both). If a tes
t for weak D were
performed, the test would yield positive results independent of the presence or
absence of the D
antigen on the red cells. 4. D The designation r is dCe and r y is dCE, neither
of which
contains the c antigen. The other three Rh types contain the c antigen and could
not be used in
transfusion for a person with antic. 5. C The phenotype that results from D/D i
s classi ed
as enhanced D because it shows a stronger reaction than expected with antiD. Su
ch cells have a
greater amount of D antigen than normal. This is thought to result from a larger
quantity of
precursors being available to the D genes because there is no competition from o
ther Rh genes.

2828_Ch04_121170 06/08/12 11:16 AM Page 130 6. Why is testing for Rh antigen

s and antibodies
di erent from ABO testing? A. ABO reactions are primarily due to IgM antibodies an
d usually occur
at room temperature; Rh antibodies are IgG and agglutination usually requires a
37C incubation
and enhancement media B. ABO antigens are attached to receptors on the outside o
f the red cell
and do not require any special enhancement for testing; Rh antigens are loosely
attached to the
red cell membrane and require enhancement for detection C. Both ABO and Rh antig
ens and
antibodies have similar structures, but Rh antibodies are con gured so that specia
l techniques
are needed to facilitate binding to Rh antigens D. Tere is no di erence in ABO and
Rh testing;
both may be conducted at room temperature with no special enhancement needed for
reaction Blood
bank/Apply knowledge of fundamental biological characteristics/Rh system/1 7. Te
sting reveals a
weak D that reacts 1+ after indirect antiglobulin testing (IAT). How is this res
ult classi ed? A.
Rhpositive B. Rhnegative, Du positive C. Rhnegative D. Rhpositive, Du positi
ve Blood
bank/Apply knowledge of standard operating procedures/Components/Rh label/2 8. W
hat is one
possible genotype for a patient who develops antiC antibody? A. R1r B. R 1 R 1
C. rr D. rr
Blood bank/Apply knowledge of fundamental biological characteristics/Rh typing/2
9. A patient
developed a combination of Rh antibodies: antiC, antiE, and antiD. Can compat
ible blood be
found for this patient? A. It is almost impossible to nd blood lacking the C, E,
and D antigens
B. rr blood could be used without causing a problem C. R 0 R 0 may be used becau
se it lacks all
three antigens D. Although rare, r y r blood may be obtained from close relative
s of the patient
Blood bank/Apply knowledge of fundamental biological characteristics/Rh antibodi
es/1 4.3 | Rh
Blood Group System 131 Answers to Questions 611 6. A Detection of ABO and Rh
antigens and
antibodies requires di erent reaction conditions. ABO antibodies are naturally occ
urring IgM
molecules and react best at room temperature. Rh antibodies are generally immune
IgG molecules
that result from transfusion or pregnancy. Detection may require 37C incubation a
enhancement techniques. 7. A Blood tested for weak D that shows 1+ reaction af
ter IAT is
classi ed as Rh positive. The weak D designation is not noted in the reporting of
the result. 8.
D Only rr (dce/dce) does not contain C antigen. A person will form alloantibodi
es only to the
antigens he or she lacks. 9. B The genotype rr (dce/dce) lacks D, C, and E ant
igens and would
be suitable for an individual who has developed antibodies to all three antigens
. This is the
most common Rhnegative genotype and is found in nearly 14% of White blood donor
s. 10. D The D

antigen is comprised of di erent parts designated as a mosaic. If an individual la

cks parts of
the antigen, he or she may make antibodies to the missing parts if exposed to th
e whole D
antigen. 11. A DcE/DcE (R 2 R 2 ) is not possible because R 2 can be inherit
ed only from the
mother and is not present in the father. 10. A patient tests positive for weak D
but also appears
to have antiD in his serum. What may be the problem? A. Mixup of samples or tes
ting error B.
Most weak D individuals make antiD C. Te problem could be due to a disease stat
e D. A D mosaic
may make antibodies to missing antigen parts Blood bank/Apply knowledge to ident
ify sources of
error/Rh antibodies/2 11. Which o spring is not possible from a mother who is R 1
R 2 and a
father who is R 1 r? A. DcE/DcE B. Dce/DCe C. DcE/DCe D. Dce/dce Blood bank/Eval
uate laboratory
data to verify test results/Rh system/Paternity testing/2 2828_Ch04_121170 06/
08/12 11:16 AM
Page 131 18. Te Wiener nomenclature for the E antigen is: A. hr B. hrv C. rh D. Rh
0 Blood
bank/Apply knowledge of fundamental biological principles/Rh typing/1 132 Chapte
r 4 |
Immunohematology 12. Why is testing a pregnant woman for weak D not required? A.
An Rhnegative
fetus may yield false positive results in a fetal maternal bleed B. An Rhpositi
ve fetus may
yield false positive results in a fetal maternal bleed C. D antigen strength dec
reases during
pregnancy D. D antigen strength increases during pregnancy Blood bank/Apply know
ledge of
biological characteristics/Rh testing/3 13. What antibodies could an R 1 R 1 mak
e if exposed to R
2 R 2 blood? A. Antie and antiC B. AntiE and antic C. AntiE and antiC D. A
ntie and antic
Blood bank/Apply knowledge of fundamental biological characteristics/Rh antibodi
es/2 14. What
does the genotype /represent in the Rh system? A. Rh negative B. D mosaic C. Rh nu
ll D. Total
Rh Blood bank/Evaluate laboratory data to make identi cations/Rh system/Rh antigen
s/2 15. What
techniques are necessary for weak D testing? A. Saline + 22C incubation B. Albumi
n or LISS +
37C incubation C. Saline + 37C incubation D. 37C incubation + IAT Blood bank/Apply
of basic laboratory procedures/Rh system/2 16. A patient types as AB and appears
to be Rh
positive on slide typing. What additional tests should be performed for tube typ
ing? A. Rh
negative control B. Direct antiglobulin test (DAT) C. Lowprotein Rh antisera D.
No additional
testing is needed Blood bank/Evaluate laboratory data to verify test results/Rh
system/2 17.
According to the Wiener nomenclature and/or genetic theory of Rh inheritance: A.
Tere are three
closely linked loci, each with a primary set of allelic genes B. Te alleles are
named R 1 , R 2 ,
R 0 , r, r, r, R z , and r y C. Tere are multiple alleles at a single complex locu
s that

determine each Rh antigen D. Te antigens are named D, C, E, c, and e Blood bank/

Apply knowledge
of fundamental biological principles/Rh system/2 Answers to Questions 1218 12.
B If a weak D
test is performed on a pregnant woman with no previous history, a falsepositive
weak D test may
result from the presence of fetal blood if the fetus is Rh positive. A pregnant
woman with weak D
may be given Rh immune globulin without any harmful consequences. Therefore, wea
k D testing of
pregnant women is not necessary. 13. B The R 1 R 1 (DCe/DCe) individual does n
ot have the E or
c antigen, and could make antiE and antic antibodies when exposed to R 2 R 2 c
ells (DcE/DcE).
14. C A person who is Rh null shows no Rh antigens on his or her RBCs. Loss of
Rh antigens is
very unlikely to happen because Rh antigens are integral parts of the RBC membra
ne. The Rh null
phenotype can result from either genetic suppression of the Rh genes or inherita
nce of amorphic
genes at the Rh locus. 15. D Weak D testing requires both 37C incubation and th
procedure. AntiD is an IgG antibody, and attachment of the D antigen is optimiz
ed at warmer
temperatures. Antihuman globulin in the IAT phase facilitates lattice formation
by binding to the
antigenantibody complexes. 16. A An Rhnegative control (patient cells in salin
e or 6%
albumin) should be run if a sample appears to be AB positive. The ABO test serve
s as the Rh
control for other ABO types. 17. C Wiener proposed a singlelocus theory for R
h, with multiple
alleles determining surface molecules that embody numerous antigens. 18. C The
designation for the E antigen is rh. The Wiener designation hr denotes c, hr denote
s e, and Rh
0 is D. 2828_Ch04_121170 06/08/12 11:16 AM Page 132 4.3 | Rh Blood Group Sys
tem 133 19. A
physician orders 2 units of leukocytereduced red blood cells. Te patient is a 5
5yearold male
with anemia. He types as an AB negative, and his antibody screen is negative. Te
re is only 1 unit
of AB negative in inventory. What is the next blood type that should be given? A
. AB positive
(patient is male) B. A negative C. B negative D. O negative Blood bank/Evaluate
sources of
errors/Rh systems/3 20. Which technology may report an Rhweak D positive as Rh
negative? A. Gel
System B. Solid Phase C. Tube Testing D. None of these options Blood bank/Apply
knowledge of
laboratory procedures/ Rh system/2 Answers to Questions 1920 19. B While giving
RBCs to an Rhnegative patient would not harm the patient in this case, because
he is male,
giving A negative would be the rst choice. You should not expose a patient to the
D antigen, if
possible, and the residual antiB in a unit of Anegative packed cells is less i
mmunogenic than
giving B or O red cells. 20. A The Gel system cannot detect a weak D phenotype
because there is

no 37C or AHG phase with the ABD card. 2828_Ch04_121170 06/08/12 11:16 AM Pag
e 133 1. A
patient has the Lewis phenotype Le(ab). An antibody panel reveals the presence of
antiLe a .
Another patient with the phenotype Le(ab+) has a positive antibody screen; howeve
r, a panel
reveals no conclusive antibody. Should antiLe a be considered as a possibility
for the patient
with the Le(ab+) phenotype? A. AntiLe a should be considered as a possible antib
ody B. AntiLe
a may be a possible antibody, but further studies are needed C. AntiLe a is not
a likely
antibody because even Le b individuals secrete some Le a D. AntiLe a may be fou
nd in saliva but
not detectable in serum Blood bank/Apply knowledge of fundamental biological
characteristics/Blood groups/2 2. A technologist is having great di culty resolvin
g an antibody
mixture. One of the antibodies is anti Le a . Tis antibody is not clinically si
gni cant in this
situation, but it needs to be removed to reveal the possible presence of an unde
rlying antibody
of clinical signi cance. What can be done? A. Perform an enzyme panel B. Neutraliz
e the serum
with saliva C. Neutralize the serum with hydatid cyst uid D. Use DTT (dithiothrei
tol) to treat
the panel cells Blood bank/Apply knowledge of fundamental biological characteris
groups/3 3. What type of blood should be given to an individual who has an anti
Le b that reacts
1+ at the IAT phase? A. Blood that is negative for the Le b antigen B. Blood tha
t is negative for
both the Le a and Le b antigens C. Blood that is positive for the Le b antigen D
. Lewis
antibodies are not clinically signi cant, so any type of blood may be given Blood
knowledge of fundamental biological characteristics/Blood group antibodies/3 4.4
Testing for
Antibodies 134 4. Which of the following statements is true concerning the MN ge
notype? A.
Antigens are destroyed using bleachtreated cells B. Dosage e ect may be seen for
both M and N
antigens C. Both M and N antigens are impossible to detect because of crossinte
rference D. MN is
a rare phenotype seldom found in routine antigen typing Blood bank/Apply knowled
ge of fundamental
biological characteristics/Blood groups/2 Answers to Questions 14 1. C AntiLe
a is produced
primarily by persons with the Le(ab) phenotype because Le(ab+) persons still have s
ome Le a
antigen present in saliva. Although Le a is not present on their red cells, Le(ab
+) persons do
not form antiLe a . 2. B Saliva from an individual with the Le gene contains
the Le a antigen.
This combines with antiLe a , neutralizing the antibody. Panel cells treated wi
th DTT (0.2M)
lose reactivity with antiK and other antibodies, but not antiLe a . Hydatid cy
st uid
neutralizes antiP 1. 3. A Lewis antibodies are generally not considered clini
cally signi cant
unless they react at 37C or at the IAT phase. The antibody must be honored in thi

s scenario. 4.
B Dosage e ect is the term used to describe the phenomenon of an antibody that
reacts more
strongly with homozygous cells than with heterozygous cells. Dosage e ect is a cha
racteristic of
the genotype MN because the M and N antigens are both present on the same cell.
This causes a
weaker reaction than seen with RBCs of either the MMor NN genotype, which carry
a greater amount
of the corresponding antigen. 2828_Ch04_121170 06/08/12 11:16 AM Page 134 10
. Which group of
antibodies is commonly found as cold agglutinins? A. AntiK, antik, antiJs b B
. AntiD, antie,
antiC C. AntiM, antiN D. AntiFy a , antiFy b Blood bank/Apply knowledge of
biological characteristics/Blood group antibodies/1 11. Which of the following a
characteristically gives a refractile mixed eld appearance? A. AntiK B. AntiDi
a C. AntiSd a
D. Antis Blood bank/Apply knowledge of fundamental biological characteristics/B
lood group
antibodies/1 4.4 | Testing for Antibodies 135 5. AntiM is sometimes found wit
h reactivity
detected at the immediate spin (IS) phase that persists in strength to the IAT p
hase. What is the
main testing problem with a strong antiM? A. AntiM may not allow detection of
a clinically
signi cant antibody B. Compatible blood may not be found for the patient with a st
rongly reacting
antiM C. Te antiM cannot be removed from the serum D. Te antiM may react with
the patients
own cells, causing a positive autocontrol Blood bank/Apply knowledge of fundamen
tal biological
characteristics/Blood groups/2 6. A patient is suspected of having paroxysmal co
ld hemoglobinuria
(PCH). Which pattern of reactivity is characteristic of the Donath Landsteiner an
tibody, which
causes this condition? A. Te antibody attaches to RBCs at 4C and causes hemolysis
at 37C B. Te
antibody attaches to RBCs at 37C and causes agglutination at the IAT phase C. Te
attaches to RBCs at 22C and causes hemolysis at 37C D. Te antibody attaches to RBC
s and causes
agglutination at the IAT phase Blood bank/Apply knowledge of fundamental biologi
characteristics/Blood group antibodies/1 7. How can interfering antiP 1 antibod
y be removed from
a mixture of antibodies? A. Neutralization with saliva B. Agglutination with hum
an milk C.
Combination with urine D. Neutralization with hydatid cyst uid Blood bank/Apply p
rinciples of
special procedures/ Blood group antibodies/1 8. Which antibody is frequently see
n in patients
with warm autoimmune hemolytic anemia? A. AntiJk a B. Antie C. AntiK D. Anti
Fy b Blood
bank/Apply knowledge of fundamental biological characteristics/Blood group antib
odies/1 9. An
antibody shows strong reactions in all test phases. All screen and panel cells a
re positive. Te
serum is then tested with a cord cell and the reaction is negative. What antibod

y is suspected?
A. AntiI B. Antii C. AntiH D. Antip Blood bank/Apply principles of special p
Antibody ID/2 Answers to Questions 511 5. A While antiM may not be clinically
signi cant, a
strongly reacting antiM that persists through to the IAT phase may interfere wi
th detection of a
clinically signi cant antibody that reacts only at IAT. 6. A The DonathLandsteine
r antibody
has antiP speci city with biphasic activity. The antibody attaches to RBCs at 4C a
nd then
causes the red cells to hemolyze when warmed to 37C. 7. D Hydatid cyst uid conta
ins P 1
substance, which can neutralize antiP 1 antibody. 8. B Antie is frequently i
mplicated in
cases of warm autoimmune hemolytic anemia. The corresponding antigen is characte
rized as high
frequency in the Rh system and can mask the presence of other alloantibodies. 9.
A Adult cells
contain mostly I antigen, and antiI would react with all adult cells found on s
creen or panel
cells. Cord cells, however, contain mostly i antigen and would test negative or
only weakly
positive with antiI. 10. C Antibodies to the M and N antigens are IgM antibod
ies commonly
found as cold agglutinins. 11. C AntiSd a characteristically gives a refracti
le mixed eld
agglutination reaction in the IAT phase. The refractile characteristic is more e
vident under the
microscope. 2828_Ch04_121170 06/08/12 11:16 AM Page 135 16. A patient is adm
itted to the
hospital. Medical records indicate that the patient has a history of antiJk a .
When you
performed the type and screen, the type was O positive and screen was negative.
You should: A.
Crossmatch using units negative for Jk a antigen B. Crossmatch random units, sin
ce the antibody
is not demonstrating C. Request a new sample D. Repeat the screen with enzymetr
eated screening
cells Blood bank/Apply principles of basic laboratory procedures/Antibody ID/3 1
36 Chapter 4 |
Immunohematology 12. What does the 3+3 rule ascertain? A. An antibody is ruled i
n B. An antibody
is ruled out C. 95% con dence that the correct antibody has been identi ed D. 95% co
n dence that
the correct antibody has not been identi ed Blood bank/Apply principles of basic l
procedures/Antibody ID/1 13. Te k (Cellano) antigen is a highfrequency antigen
and is found on
most red cells. How often would one expect to nd the corresponding antibody? A. O
ften, because
it is a high frequency antibody B. Rarely, because most individuals have the ant
igen and
therefore would not develop the antibody C. It depends upon the population, beca
use certain
racial and ethnic groups show a higher frequency of antik D. Impossible to dete
rmine without
consulting regional blood group antigen charts Blood bank/Calculate/Hemotherapy/
1 14. Which
procedure would help to distinguish between an antie and antiFy a in an antibo

dy mixture? A.
Lower the pH of test serum B. Run an enzyme panel C. Use a thiol reagent D. Run
a LISS panel
Blood bank/Apply principles of special procedures/ Antibody ID/2 15. Which chara
cteristics are
true of all three of the following antibodies: antiFy a , antiJk a , and anti
K? A. Detected at
the IAT phase; may cause hemolytic disease of the newborn and hemolytic transfus
ion reactions B.
Not detected with enzymetreated cells C. Requires the IAT technique for detecti
on; usually not
associated with HDN D. Enhanced reactivity with enzymetreated cells; may cause
severe hemolytic
transfusion reactions Blood bank/Apply principles of special procedures/ Antibod
y ID/2 Answers to
Questions 1216 12. C The 3+3 rule ascertains correct identi cation of antibody at
a con dence
level of 95%. For this level to be met, reagent red cells are found containing t
arget antigen to
suspected antibody that react in test phase; likewise, reagent red cells devoid
of antigen will
not react in test phase. 13. B The k antigen is found with a frequency of 99.8
%; therefore, the
knegative person is rare. Because knegative individuals are very rare, the occ
urrence of antik
is also rare. 14. B Enzymetreated cells will not react with Du y antibodies. Rh
react more strongly with enzymetreated red cells. An enzyme panel, therefore, w
ould enhance
reactivity of antie and destroy reactivity to antiFy a . 15. A AntiFy a , a
ntiJk a , and
antiK are usually detected at IAT and all may cause HDN and transfusion reactio
ns that may be
hemolytic. Reactivity with antiFy a is lost with enzymetreated red cells, but
reactivity with
anti Jk a is enhanced with enzymetreated cells. Reactivity with antiK is una ec
ted by
enzymetreated cells. 16. A The Kidd antibodies are notorious for disappearing
from serum,
yielding a negative result for the antibody screen. If a patient has a history o
f a Kidd
antibody, blood must be crossmatched using antigennegative units. If the patien
t is transfused
with the corresponding antigen, an anamnestic response may occur with a subseque
nt hemolytic
transfusion reaction. 2828_Ch04_121170 06/08/12 11:16 AM Page 136 4.4 | Test
ing for
Antibodies 137 17. A technologist performs an antibody study and nds 1+ and wea
k positive
reactions for several of the panel cells. Te reactions do not t a pattern. Severa
l selected
panels and a patient phenotype do not reveal any additional information. Te seru
m is diluted and
retested, but the same reactions persist. What type of antibody may be causing t
hese results? A.
Antibody to a highfrequency antigen B. Antibody to a lowfrequency antigen C. H
igh titer low
avidity (HTLA) D. AntiHLA Blood bank/Evaluate laboratory data to make identi cati
ID/3 18. An antibody is detected in a pregnant woman and is suspected of being t

he cause of fetal
distress. Te antibody reacts at the IAT phase but does not react with DTTtreate
d cells. Tis
antibody causes in vitro hemolysis. What is the most likely antibody speci city? A
. AntiLe a B.
AntiLu a C. AntiLu b D. AntiXg a Blood bank/Evaluate laboratory data to make
identi cations/Antibody ID/3 19. What sample is best for detecting complement dep
antibodies? A. Plasma stored at 4C for no longer than 24 hours B. Serum stored at
4C for no
longer than 48 hours C. Either serum or plasma stored at 20C24C no longer than 6 ho
urs D.
Serum heated at 56C for 30 minutes Blood bank/Apply principles of basic laborator
procedures/Antibody ID/2 Answers to Questions 1721 17. C HTLA antibodies may pe
rsist in
reaction strength, even when diluted. These antibodies are directed against high
antigens (such as Ch a ). They are not clinically signi cant but, when present, ar
e responsible
for a high incidence of incompatible crossmatches. 18. C Of the antibodies lis
ted, only Lu b is
detected in the IAT phase, causes in vitro hemolysis, may cause HDN, and does no
t react with
DTTtreated cells. 19. B Serum stored at 4C for no longer than 48 hours preserv
es complement
activity. Plasma is inappropriate because most anticoagulants chelate calcium ne
eded for
activation of complement. Heating the serum to 56C destroys complement. 20. B A
BO antibodies
are not detected by group O screening cells, because O cells contain no A or B a
ntigens. 21. B
The pattern clearly ts that of antiJk b , an antibody that usually reacts best a
t IAT. The
weaker reactions are due to dosage e ect found on cells that are heterozygous for
the Jk b
antigen. Panel 1 Cell D C E c e K k Kp a Kp b Js a Js b Fy a Fy
b Jk a Jk b Xg a
Le a Le b S s M N P 1 Lu a Lu b 37 IAT 1 + + O O + O + O
+ O + O
+ O + + + O O + O + O O + O 2+ 2 + + O O
+ + + O
+ O + + + + + + O + + + O + + O + O 1+ 3 +
O + + O
O + O + O + + O + + O O + + + + + + O +
O 1+ 4 O +
O + + O + O + O + + + + + + O + O + + +
O O + O
 5 O O + + + + + O + O + + + + O O O + O
+ + + +
O + O O 6 O O O O + O + O + O + + + + + +
+ O + +
+ O + O + O  7 O O O + + + + O + O + O O
+ O + O
+ + O + O + O + O O 8 O O O + + O + O + O
+ O + O
+ + O O + + + O + O + O 2+ 9 + + O O + O +
O + O +
+ + + + + + O O + + + + O + O 1+ 10 + O O
+ + O +

O + O + O O + + + O O O O + O + O + O 1+ 2
0. Which antibody
would not be detected by group O screening cells? A. AntiN B. AntiA 1 C. Anti
Di a D. Antik
Blood bank/Apply principles of special procedures/ Antibody ID/1 21. Refer to Pa
nel 1. Which
antibody is most likely implicated? A. AntiFy b B. AntiJk b C. Antie D. Anti
c and antiK
Blood bank/Apply principles of special procedures/ Antibody ID/2 2828_Ch04_1211
70 06/08/12
11:16 AM Page 137 138 Chapter 4 | Immunohematology Answers to Questions 2224 22.
D The
pattern ts antiC at 37C, which becomes stronger at the IAT phase. The additional
antibody is
antiK, which appears only at the IAT phase. 23. B To rule out an antibody, th
ere should be a
homozygous cell with the corresponding antigen that fails to react with the seru
m. Of the
choices, antiC was not ruled out on Panel 2. To rule this antibody out, a cell
that is
homozygous for C and negative for K (the other probable antibody) would be run a
gainst patient
serum. A positive reaction supports the presence of antiC, whereas a negative r
eaction would
rule out antiC. 24. B On panel cells 1, 2, and 9, the C antigen is present an
d the c antigen
is absent, rendering the cells homozygous for C. 22. Refer to Panel 2. Which ant
ibody speci city
is most likely present? A. AntiS and antiE B. AntiE and antiK C. AntiLe a a
nd antiFy b D.
AntiC and antiK Blood bank/Apply principles of special procedures/ Antibody ID
/3 23. On Panel
2, which of the following antibodies could not be ruled out? A. AntiJk b B. Ant
iC C. AntiM D.
AntiFy b Blood bank/Apply principles of special procedures/ Antibody ID/3 24. O
n Panel 2, which
cells are homozygous for C? A. 1, 2, 3 B. 1, 2, 9 C. 3, 4, 7 D. 7, 8, 10 Blood b
principles of special procedures/ Antibody ID/2 Panel 2 Cell D C E c e
K k Kp a
Kp b Js a Js b Fy a Fy b Jk a Jk b Xg a Le a Le b S s M N P 1 Lu a Lu b
37 IAT 1 + +
O O + O + O + O + O + O + + + O O + O +
O O + 1+
2+ 2 + + O O + + + O + O + + + + + + O +
+ + O + +
O + 1+ 2+ 3 + O + + O O + O + O + + O + +
O O + +
+ + + + O + O O 4 O + O + + O + O + O + +
+ + + +
O + O + + + O O + 
+ 5 O O + + + + + O +
O + + +
+ O O O + O + + + + O + O 2+ 6 O O O O + O
+ O + O
+ + + + + + + O + + + O + O + O O 7 O O O
+ + + +
O + O + O O + O + O + + O + O + O + O 2+
8 O O O +
+ O + O + O + O + O + + O O + + + O + O
+ O O 9 +


O O + O + O + O + + + + + + + O O + +
+ O +
1+ 1+ 10 + O O + + O + O + O + O O + + + O
O O O +
O + O + O O 2828_Ch04_121170 06/08/12 11:16 AM Page 138 25. A 77y
earold female is
admitted to a community hospital after a cardiac arrest. History includes an abd
ominal aortic
aneurysm 2 years ago in which she received 6 units of packed cells. Her blood ty
pe is A positive
and antibody screen is positive at AHG phase in screening cells II and III. A pa
nel is performed
using LISS. Referring to panel 3, which antibodies are likely implicated? A. C a
nd K B. Jk a and
c C. E and c D. Fy a and M Blood bank/Apply principles of special procedures/ An
tibody ID/3 26.
What observation is apparent with one of the antibodies present on Panel 3? A. O
ne antibody is
only reacting with heterozygous cells B. Both antibodies are only reacting with
homozygous cells
C. One antibody is only reacting with homozygous cells D. Both antibodies are ex
hibiting dosage
Blood bank/Apply principles of special procedures/ Antibody ID/3 4.4 | Testing f
or Antibodies
139 Answers to Questions 2526 25. C The antibodies evident in the panel are E a
nd c. Every
positive reaction at 37C and IAT phases are positive for either the E antigen and
/or for cells
homozygous for c antigen. 26. C Antic is only reacting with homozygous cells.
Panel 3 Cell D
C E c e K k Kp a Kp b Js a Js b Fy a Fy b Jk a Jk b Xg a Le a Le b
S s M N
P 1 Lu b 37 IAT 1 0 + 0 + + 0 + 0 + 0 + + + + 0
+ 0 + +
+ + + 0 + 0 0 2 + 0 0 + + + + 0 + 0 + 0 +
0 + + +
0 0 + 0 0 0 + + + 3 + + + 0 0 0 + 0 + 0 +
0 0 + +
0 0 + + + + + 0 + + + 4 + + 0 0 + + + 0 +
0 + + +
+ + + + + 0 0 + + + + 0 0 5 + + 0 + + 0 +
0 + 0 +
0 + 0 + 0 0 + + + + + + + 0 0 6 0 + + + +
0 + 0 +
0 + + 0 0 + + + + + + + + 0 + + + 7 0 + 0
0 + + +
0 + 0 + + + + + + + 0 0 + 0 + + + 0 0 8 0
+ + 0 +
0 + 0 + 0 + 0 + 0 + + + + + + + + + + +
+ 9 0 0 0
+ + 0 + 0 + 0 + + + + + + + 0 0 + + + +
+ + + 10 +
+ 0 + + + + 0 + 0 + + + 0 + + 0 + + + +
+ + + 0
0 2828_Ch04_121170 06/08/12 11:16 AM Page 139 140 4.5 Compatibility Testing
emergency trauma patient requires transfusion. Six units of blood are ordered st
at. Tere is no
time to draw a patient sample. Onegative blood is released. When will compatibi
lity testing be

performed? A. Compatibility testing must be performed before blood is issued B.

testing will be performed when a patient sample is available C. Compatibility te
sting may be
performed immediately using donor serum D. Compatibility testing is not necessar
y when blood is
released in emergency situations Blood bank/Apply knowledge of laboratory operat
2. How would autoantibodies a ect compatibility testing? A. No e ect B. Te DAT would
be positive
C. ABO, Rh, antibody screen, and crossmatch may show abnormal results D. Results
would depend on
the speci city of autoantibody Blood bank/Evaluate laboratory data to make
identi cations/Antibody ID/3 3. An antibody screen is reactive at IAT phase of tes
ting using a
threecell screen and the autocontrol is negative. What is a possible explanatio
n for these
results? A. A cold alloantibody B. Highfrequency alloantibody or a mixture of a
lloantibodies C.
A warm autoantibody D. A cold and warm alloantibody Blood bank/Evaluate laborato
ry data to make
identi cations/Antibody ID/3 4. What does a minor crossmatch consist of? A. Recipi
ent plasma and
recipient red cells B. Recipient plasma and donor red cells C. Recipient red cel
ls and donor
plasma D. Donor plasma and donor red cells Blood bank/Apply knowledge of laborat
ory operations/
Crossmatch/1 Answers to Questions 15 1. B When patient serum is available, it w
ill be
crossmatched with donor cells. Patient serum might contain antibodies against an
tigens on donor
cells that may destroy donor cells. If an incompatibility is discovered, the pro
blem will be
reported immediately to the patients physician. 2. C Autoantibodies may cause p
reactions with screening cells, panel cells, donor cells, and patient cells. The
DAT will be
positive; however, the DAT is not included in compatibility testing. 3. B High
alloantibodies or a mixture of alloantibodies may cause all three screening cell
s to be positive.
A negative autocontrol would rule out autoantibodies. 4. C A minor crossmatch
consists of
recipient red cells and donor serum or plasma. 5. A Compatibility testing may
be performed on a
patient sample within 3 days of the scheduled transfusion; however, if the patie
nt is pregnant or
was transfused within 3 months, the sample must be less than 3 days old. 5. Can
crossmatching be
performed on October 14th using a patient sample drawn on October 12th? A. Yes,
a new sample
would not be needed B. Yes, but only if the previous sample has no alloantibodie
s C. No, a new
sample is needed because the 2day limit has expired D. No, a new sample is need
ed for each
testing Blood bank/Apply knowledge of standard operating procedures/Crossmatch/2
2828_Ch04_121170 06/08/12 11:16 AM Page 140 4.5 | Compatibility Testing 14
1 6. A type and
screen was performed on a 32yearold woman, and the patient was typed as AB neg
ative. Tere are

no ABnegative units in the blood bank. What should be done? A. Order ABnegativ
e units from a
blood supplier B. Check inventory of A, B, and Onegative units C. Ask the pat
ient to make a
preoperative autologous donation D. Nothingthe blood will probably not be used Bl
ood bank/Apply
principles of basic laboratory procedures/Crossmatch/2 7. What ABO types may don
ate to any other
ABO type? A. A negative, B negative, AB negative, O negative B. O negative C. AB
negative D. AB
negative, A negative, B negative Blood bank/Apply knowledge of fundamental biolo
characteristics/Crossmatch/2 8. What type(s) of red cells is (are) acceptable to
transfuse to an
Onegative patient? A. A negative, B negative, AB negative, or O negative B. O n
egative C. AB
negative D. AB negative, A negative, B negative Blood bank/Apply knowledge of fu
biological characteristics/Crossmatch/2 9. A technologist removed 4 units of blo
od from the blood
bank refrigerator and placed them on the counter. A clerk was waiting to take th
e units for
transfusion. As she checked the paperwork, she noticed that one of the units was
leaking onto the
counter. What should she do? A. Issue the unit if the red cells appear normal B.
Reseal the unit
C. Discard the unit D. Call the medical director and ask for an opinion Blood ba
knowledge of standard operating procedures/Crossmatch/3 10. A donor was found to
contain antiK
using pilot tubes from the collection procedure. How would this a ect the compatib
ility test? A.
Te AHG major crossmatch would be positive B. Te IS (immediate spin) major crossm
atch would be
positive C. Te recipients antibody screen would be positive for antiK D. Compati
bility testing
would not be a ected Blood bank/Apply principles of basic laboratory procedures/Cr
ossmatch/2 11.
Which of the following is not a requirement for the electronic crossmatch? A. Te
computer system
contains logic to prevent assignment and release of ABO incompatible blood B. Te
re are concordant
results of at least two determinations of the recipients ABO type on record, one
of which is
from the current sample C. Critical elements of the system have been validated o
n site D. Tere
are concordant results of at least one determination of the recipients ABO type o
n le Blood
bank/Apply principles of basic laboratory procedures/Crossmatch/1 12. A patient
showed positive
results with screening cells and 4 donor units. Te patient autocontrol was negat
ive. What is the
most likely antibody? A. AntiH B. AntiS C. AntiKp a D. Antik Blood bank/Eval
uate laboratory
data to make identi cations/Incompatible crossmatch/3 Answers to Questions 612 6.
person is the universal recipient and may receive any blood type; because only a
type and screen
were ordered and blood may not be used, check inventory for A, B, and Onegati
ve units. 7. B

An Onegative individual has no A or B antigens and may donate red cells to any
other ABO type.
8. B An Onegative individual has both antiA and antiB and may receive only
Onegative red
cells. 9. C Leaking may indicate a broken seal or a puncture, which indicates
contamination of the unit, even if the red cells appear normal. The unit should
be discarded. 10.
D Compatibility testing would not be a ected if the donor has antiK in his or h
er serum. This
is because the major crossmatch uses recipient serum and not donor serum. Other
tests such as
ABO, Rh, and antibody screen on the recipient also would not be a ected. 11. D A
determinations must be concordant on at least two occasions, including the curre
nt sample. 12.
D Antik (cellano) is a highfrequency alloantibody that would react with screen
ing cells and
most donor units. The negative autocontrol rules out autoantibodies. AntiH and
antiS are cold
antibodies and antiKp a is a lowfrequency alloantibody. 2828_Ch04_121170 06/
08/12 11:16 AM
Page 141 Answers to Questions 1319 13. A A cold alloantibody would show a react
ion with
screening cells and donor units only at IS phase. The negative autocontrol rules
autoantibodies and abnormal protein. 14. C The incompatible donor unit may hav
e an antibody
coating the red cells, or the patient may have an alloantibody to a lowfrequenc
y antigen. An
alloantibody to a highfrequency antigen would agglutinate all units and screeni
ng cells. 15. A
The incompatible unit may have red cells coated with antibody and/or complement.
If red cells are
sensitized, then some problem exists with the donor. Discard the unit. 16. C A
n abnormal
protein or nonspeci c autoantibody would cause antibody screen, crossmatch, and pa
autocontrol to be positive. Alloantibodies would not cause a positive patient au
tocontrol. 17.
B Antigen typing or phenotyping of the patients cells con rms the antibody identi cat
antigen typing of donor cells helps ensure the crossmatch of compatible donor un
its. 18. D The
unit may be used in the general blood inventory, if it is properly labeled and o
nly cellular
elements are used. 19. C A positive DAT using antiIgG indicates that antibodi
es are coating
the patient cells. An eluate would be helpful to remove the antibody, followed b
y a cell panel in
order to identify it. 13. Screening cells and major crossmatch are positive on I
S only, and the
autocontrol is negative. Identify the problem. A. Cold alloantibody B. Cold auto
antibody C.
Abnormal protein D. Antibody mixture Blood bank/Evaluate laboratory data to make
identi cations/Incompatible crossmatch/3 14. Six units are crossmatched. Five unit
s are
compatible, one unit is incompatible, and the recipients antibody screen is negat
ive. Identify
the problem: A. Patient may have an alloantibody to a highfrequency antigen B.

Patient may have

an abnormal protein C. Donor unit may have a positive DAT D. Donor may have a hi
antigen Blood bank/Evaluate laboratory data to make identi cations/Incompatible cr
ossmatch/3 15.
An incompatible donor unit is found to have a positive DAT. What should be done
with the donor
unit? A. Discard the unit B. Antigen type the unit for highfrequency antigens C
. Wash the donor
cells and use the washed cells for testing D. Perform a panel on the incompatibl
e unit Blood
bank/Apply principles of special procedures/ Incompatible crossmatch/3 16. Scree
ning cells, major
crossmatch, and patient autocontrol are positive in all phases. Identify the pro
blem. A. Speci c
cold alloantibody B. Speci c cold autoantibody C. Abnormal protein or nonspeci c aut
oantibody D.
Cold and warm alloantibody mixture Blood bank/Evaluate laboratory data to make
identi cations/Incompatible crossmatch/3 17. A panel study has revealed the presen
ce of patient
alloantibodies. What is the rst step in a major crossmatch? A. Perform a DAT on p
atient cells
and donor units B. Antigen type patient cells and any donor cells to be crossmat
ched C. Adsorb
any antibodies from the patient serum D. Obtain a di erent enhancement medium for
testing Blood
bank/Apply principles of special procedures/ Incompatible crossmatch/2 18. What
is the
disposition of a donor red blood cell unit that contains an antibody? A. Te unit
must be
discarded B. Only the plasma may be used to make components C. Te antibody must
be adsorbed from
the unit D. Te unit may be labeled indicating it contains antibody and released
into inventory
Blood bank/Apply knowledge of laboratory operations/ Hemotherapy/Blood component
s/1 19. Given a
situation where screening cells, major crossmatch, autocontrol, and DAT (antiIg
G) are all
positive, what procedure should be performed next? A. Adsorption using rabbit st
roma B. Antigen
typing of patient cells C. Elution followed by a cell panel on the eluate D. Sel
ected cell panel
Blood bank/Apply principles of special procedures/ Incompatible crossmatch/3 142
Chapter 4 |
Immunohematology 2828_Ch04_121170 06/08/12 11:16 AM Page 142 4.5 | Compatibi
lity Testing
143 Answers to Questions 2027 20. B The reaction pattern ts that of a cold antib
ody reacting
at the IS phase and of su cient titer to persist at 37C incubation. The reactions d
isappear in
the IAT phase. 21. A Rouleaux may be dispersed or lessened by using the saline
technique. This involves recentrifuging the tube, then withdrawing serum and rep
lacing it with 2
drops of saline. The tube is respun and examined for hemolysis. 22. D Antibodi
es causing a
positive DAT would be coating red cells and would require an elution, not an ads
orption, to
identify them. 23. C According to AABB standards, the recipient sample must be
kept for 7 days

following compatibility testing. 24. B For transfusion of platelets and plasma

, there is no
required protocol for crossmatching. 25. A The only requirement for transfusin
g an autologous
unit is a check of the ABO and Rh type. 26. A The type chosen should be Aposi
tive red cell
units. Although all choices would be compatible, the rst choice should be Aposit
ive because
this unit will contain residual plasma antiB. AntiB is less immunogenic than a
ntiA, which
would be present, albeit in small amounts, in Bpositive and Opositive units. 2
7. B The
abbreviated crossmatch usually consists of a type and screen and an immediate sp
in crossmatch.
20. A major crossmatch and screening cells are 2+ at IS, 1+ at 37C, and negative
at the IAT
phase. Identify the most likely problem. A. Combination of antibodies B. Cold al
loantibody C.
Rouleaux D. Test error Blood bank/Evaluate laboratory data to make identi cations/
crossmatch/3 21. What corrective action should be taken when rouleaux causes pos
itive test
results? A. Perform a saline replacement technique B. Perform an autoabsorption
C. Run a panel D.
Perform an elution Blood bank/Apply principles of special procedures/ Testing pr
oblems/3 22. All
of the following are reasons for performing an adsorption, except: A. Separation
of mixtures of
antibodies B. Removal of interfering substances C. Con rmation of weak antigens on
red cells D.
Identi cation of antibodies causing a positive DAT Blood bank/Apply principles of
procedures/ Antibody identi cation/2 23. How long must a recipient sample be kept
in the blood
bank following compatibility testing? A. 3 days B. 5 days C. 7 days D. 10 days B
lood bank/Apply
principles of basic laboratory procedures/Compatibility/1 24. What is the crossm
atching protocol
for platelets and/or plasma? A. Perform a reverse grouping on donor plasma B. No
testing is
required C. Perform a reverse grouping on recipient plasma D. Platelets must be
HLA compatible
Blood bank/Apply principles of basic laboratory procedures/Compatibility/2 25. W
hat are the
compatibility requirements for an autologous unit? A. ABO and Rh typing B. Type
and screen C.
Major crossmatch D. All of these options Blood bank/Apply principles of basic la
procedures/Compatibility/1 26. A patient types as AB positive. Two units of bloo
d have been
ordered by the physician. Currently, the inventory shows no AB units, 10 Aposit
ive units, 1
Anegative unit, 5 Bpositive units, and 20 Opositive units. Which should be se
t up for the
major crossmatch? A. Apositive units B. Opositive units C. Bpositive units D.
Call another
blood supplier for typespeci c blood Blood bank/Apply principles of basic laborat
procedures/Compatibility/2 27. Which of the following comprises an abbreviated c
rossmatch? A.

ABO, Rh, and antibody screen B. ABO, Rh, antibody screen, IS crossmatch C. Type
and screen D.
ABO, Rh, IS crossmatch Blood bank/Apply principles of basic laboratory procedure
2828_Ch04_121170 06/08/12 11:16 AM Page 143 28. When may an IS crossmatch be
performed? A.
When a patient is being massively transfused B. When there is no history of anti
bodies and the
current antibody screen is negative C. When blood is being emergency released D.
When a patient
has not been transfused in the past 3 months Blood bank/Apply principles of basi
c laboratory
procedures/Crossmatch/1 Answer to Question 28 28. B The IS crossmatch may be p
erformed when the
patient has no history of antibodies and the current antibody screen is negative
. 144 Chapter 4 |
Immunohematology 2828_Ch04_121170 06/08/12 11:16 AM Page 144 145 4.6 Transfu
sion Reactions 1.
A patient had a transfusion reaction to packed red blood cells. Te medical labor
atory scientist
began the laboratory investigation of the transfusion reaction by assembling pre
posttransfusion specimens and all paperwork and computer printouts. What should
he do next? A.
Perform a DAT on the posttransfusion sample B. Check for a clerical error(s) C.
Repeat ABO and
Rh typing of patient and donor unit D. Perform an antibody screen on the post t
ransfusion sample
Blood bank/Apply knowledge of standard operating procedures/Transfusion reaction
s/2 2. What is
the pathophysiological cause surrounding anaphylactic and anaphylactoid reaction
s? A. Antibody in
patient serum is detected 37 days after transfusion, and is attached to donor red
blood cells B.
Donor plasma has reagins (IgE or IgA) that combine with allergens in patient pla
sma C. Patient is
de cient in IgE and develops IgE antibodies via sensitization from transfusion or
pregnancy D.
Patient is de cient in IgA and develops IgA antibodies via sensitization from tran
sfusion or
pregnancy Blood bank/Apply knowledge of fundamental biological principles/Transf
usion reactions/1
3. A patient has a hemolytic reaction to blood transfused 8 days ago. What is th
e most likely
cause? A. Immediate, nonimmunologic probably due to volume overload B. Delayed i
probably due to an antibody such as antiJk a C. Delayed nonimmunologic, probabl
y due to iron
overload D. Immediate, immunologic, probably due to clerical error, ABO incompat
ibility Blood
bank/Apply knowledge of fundamental biological characteristics/Transfusion react
ions/2 Answers to
Questions 14 1. B Over 90% of transfusion reactions are due to some type of cle
rical error.
The most timesaving approach would be to check all paperwork before performing
any laboratory
testing. 2. D Anaphylactic or anaphylactoid reactions are the most severe form
of allergic
transfusion reaction and are associated with de cient or absent IgA in the patient
s, allowing

them the capability to form anti IgA. These patients must be transfused with wa
shed cellular
products where the plasma has been removed. 3. B A transfusion reaction that o
ccurs several
days after a transfusion of blood products is probably a delayed immunologic rea
ction due to an
antibody formed against donor antigens. This is a classic example of a reaction
caused by an
antibody such as antiJk a . 4. C TRALI is associated with antibodies to human
antigens or neutrophil antigens, which react with patient granulocytes and cause
respiratory insu ciency. 4. What may be found in the serum of a person who is exhi
biting signs of
TRALI (transfusionrelated acute lung injury)? A. Red blood cell alloantibody B.
IgA antibody C.
Antileukocyte antibody D. Allergen Blood bank/Apply knowledge of fundamental bio
characteristics/Transfusion reactions/1 2828_Ch04_121170 06/08/12 11:16 AM P
age 145 146
Chapter 4 | Immunohematology 5. Which type of transfusion reaction occurs in abo
ut 1% of all
transfusions, results in a temperature rise of 1C or higher, is associated with b
lood component
transfusion, and is not related to the patients medical condition? A. Immediate h
emolytic B.
Delayed hemolytic C. Febrile nonhemolytic reaction D. Transfusionrelated acute
lung injury Blood
bank/Apply knowledge of fundamental biological characteristics/Transfusion react
ions/1 6. What
would be the result of group A blood given to an O patient? A. Nonimmune transfu
sion reaction B.
Immediate hemolytic transfusion reaction C. Delayed hemolytic transfusion reacti
on D. Febrile
nonhemolytic transfusion reaction Blood bank/Apply knowledge of fundamental biol
characteristics/Transfusion reactions/2 7. Patient DB received 2 units of group
Apositive red
cells 2 days ago. Two days later, he developed a fever and appeared jaundiced. H
is blood type was
A positive. A transfusion reaction workup was ordered. Tere were no clerical err
ors detected. A
posttransfusion specimen was collected and a DAT performed. Te DAT was positive
with monospeci c
antiIgG. Te plasma was also hemolyzed. An antibody screen and panel studies rev
ealed the
presence of antiJk b (postspecimen). Te antibody screen on the pretransfusion s
pecimen was
negative. Which of the following explain the positive DAT? A. Te donor cells had
a positive DAT
B. Te donor cells were polyagglutinable C. Te donor cells were likely positive f
or the Jk b
antigen D. Te recipient cells were likely positive for the Jk b antigen Blood ba
knowledge of fundamental biological characteristics/Transfusion reactions/3 8. A
ll of the
following are part of the preliminary evaluation of a transfusion reaction, exce
pt: A. Check pre
and posttransfusion samples for color of serum B. Perform ABO and Rh recheck C.
DAT on the

posttransfusion sample D. Panel on pre and posttransfusion samples Blood bank

/Apply knowledge
of standard operating procedures/Transfusion reactions/1 Answers to Questions 59
5. C A
febrile nonhemolytic transfusion reaction (FNHTR) is de ned by a rise in temperatu
re of 1C or
higher within 24 hours posttransfusion, and unexplained by other causes. The pa
tient has formed
antibodies to HLA, which react with donor cells and result in release of pyrogen
s. 6. B Group A
blood given to a group O patient would cause an immediate hemolytic transfusion
reaction because
a group O patient has antiA and antiB antibodies and would destroy A cells. 7.
C This is an
example of an anamnestic reaction where the patient was most likely exposed to t
he Jk b antigen
at some point in his life, and upon reexposure to the antigen, the antibody tit
er rose to
detectable levels. This resulted in a positive DAT and posttransfusion antibody
screen. 8. D
The preliminary evaluation of a transfusion reaction includes checking the color
of serum, and
performing ABO and Rh checks and a DAT on the posttransfusion sample. A panel w
ould not be part
of the preliminary workup. 9. C The temperature rose from 37.1C to 38.1C. The DA
T was
negative, and while blood was found on the urinalysis, microscopic red cells wer
e also found.
Since intact RBCs are not caused by a transfusion reaction, the cause of hematur
ia was not likely
transfusion related. A febrile nonhemolytic reaction is highly consistent with b
oth symptoms and
post transfusion test results. 9. A 68yearold female diagnosed with neutropen
ia and
in ammation of the left hand was typed as A positive, and received 1 packed red bl
ood cell unit.
Te antibody screen was negative and crossmatch was compatible. During the transf
usion, her pulse
was 94, and blood pressure rose from 114/59 to 132/64. Her temperature rose from
pretransfusion to 37.8C 60 minutes after starting transfusion, then to 38.1C upon
completion. A
posttransfusion specimen yielded plasma that was neither hemolyzed nor icteric,
and a negative
DAT. Posttransfusion urinalysis gave a 1+ blood and protein with 10 RBCs/hpf mi
croscopically. Te
clerical check was acceptable. What type of reaction most likely occurred as a r
esult of
transfusion? A. Allergic B. Circulatory overload C. Febrile nonhemolytic D. Dela
yed hemolytic
Blood bank/Correlation of laboratory and clinical data/Transfusion reactions/3 2
06/08/12 11:16 AM Page 146 4.6 | Transfusion Reactions 147 10. A 92yearold
male diagnosed
with anemia and episodes of frequent falling was typed as B negative and transfu
sed 1 unit of
packed red blood cells, also B negative. He was not recently transfused, and the
antibody screen
was negative. During the transfusion, his temperature rose from 36.2C to 36.4C, hi
s pulse rose

from 96 to 124, respirations from 18 to 20, and BP from 127/81 to 174/83. He was
transfused with
205 mL before a reaction was called by the transfusionist. Te postspecimen DAT w
as negative and
clerical check acceptable. Urinalysis yielded 1+ blood with 5 RBCs microscopical
ly. Other
symptoms included tachycardia and ushing. What reaction had most likely taken pla
ce? A. Febrile
nonhemolytic B. Acute hemolytic C. Anaphylactic D. Volume overload Blood bank/Co
rrelation of
laboratory and clinical data/Transfusion reaction/3 11. A 76yearold female dia
gnosed with
urosepsis was transfused 2 units of packed red blood cells. Her type was AB posi
tive with a
negative antibody screen. Te units transfused were AB positive. Upon receiving t
he second unit,
the patient became hypoxic with tachypnea. Te clerical check was acceptable and
DAT negative. She
received 269 mL from the second unit before a reaction was called. Her temperatu
re fell from 38C
to 36.4C, her pulse increased from 72 to 90, and respirations rose from 35 to 41.
Her BP was
110/70. Te patient expired approximately 12 hours from the time the reaction was
called. What
type of reaction was most likely present? A. Febrile B. Symptoms not related to
transfusion C.
Allergic D. TRALI Blood bank/Correlate laboratory and clinical data/ Transfusion
Answers to Questions 1012 10. D The tachycardia, increased pulse, and volume tr
ansfused before
a reaction was called are consistent with volume overload. The temperature chang
e did not meet
criteria for a febrile reaction, and evidence for a hemolytic reaction is lackin
g. 11. B This
case emphasizes the statistic that not all causes of death are related to transf
usion. The
temperature dropped ruling out a febrile reaction; there was no evidence of pulm
onary edema or
hypotension seen with TRALI (and plasma products are more associated with TRALI
than red cells);
and there was no sign of hives or itching, which are often associated with an al
lergic reaction.
12. A This case represents an acute hemolytic reaction where the patient had p
sensitization to E and c antigens. Given the history of antiFy a , an assumptio
n was made that
antiFy a was the cause of the positive reverse type with A 1 cells, even though
this antibody
does not react at IS. This brings to light the importance of running a panel whe
never the patient
has a positive antibody screen regardless of previous results. Hemoglobinuria, p
ositive DAT, and
the hemolyzed postspecimen all are consistent with an acute hemolytic reaction.
12. A 52yearold
male received 2 units of packed red blood cells as an outpatient in the IV thera
py unit. He had a
20year history of head trauma and was quadriplegic. He had recurrent pneumonia
and hematuria due
to removal of a Foley catheter. His blood type was A positive with a previously
identi ed antiFy

a . Tere was an ABO discrepancy in that the A 1 cells were positive. Te technolo
gist attributed
the reaction to the Fy a antigen being present on the A 1 cells. Te patient also
had a cold
autoantibody. Two units of Apositive packed cells were crossmatched that were F
y a negative, and
were compatible. One unit was transfused at 11:30 a.m. without incident. Te seco
nd unit was
transfused at 2:16 p.m., and stopped at 3:55 p.m. due to reddish browntinged urin
e discovered in
his collection bag. A posttransfusion specimen yielded a positive DAT, and plas
ma that was
grossly hemolyzed. A prewarm crossmatch was incompatible in both the pre and po
AntiE and c were present in the postspecimen. What reaction was most likely pre
sent? A. Acute
hemolytic B. Febrile C. Allergic D. TRALI Blood bank/Correlate laboratory and cl
inical data/
Transfusion reactions/3 2828_Ch04_121170 06/08/12 11:16 AM Page 147 148 Chap
ter 4 |
Immunohematology 13. An 82yearold male was admitted for renal failure. His typ
e was B positive,
and his antibody screen was negative. Two units of red cells were ordered. Te rst
unit was
transfused at 1:00 p.m. without incident. Te second was started at 4:15 p.m. an
d stopped at 5:12
p.m., after the nurse observed the patient had expired. Vital signs were taken a
t 4:30 p.m. with
no abnormalities. A transfusion reaction was called and the blood unit, tubing,
and paperwork
sent to the blood bank. Tere were no clinical manifestations noted on the paperw
ork and no
posttransfusion specimen was sent to the blood bank. What type of reaction most
likely occurred?
A. Symptoms not related to transfusion B. Acute hemolytic reaction C. Anaphylact
ic reaction D.
Volume overload Blood bank/Correlate clinical and laboratory data/ Transfusion r
eactions/3 Answer
to Question 13 13. A This example represents a situation where the pathologist
was not provided
with all information needed to interpret the reaction. There were no patient sym
ptoms, the
patient had received another unit of red cells hours previously with no problems
, and a
postreaction specimen was not collected. Therefore, any serological abnormalitie
s could not be
identi ed. The FDA recommends collecting a specimen postmortem if a reaction is ca
lled, so that
the transfusion reaction investigation can be completed. In this case, the patho
interpreted the reaction as symptoms not related to transfusion because no sympt
oms were
documented. 2828_Ch04_121170 06/08/12 11:16 AM Page 148 149 4.7 Components 1
. A male cancer
patient with a hemoglobin of 6 g/dL was admitted to the hospital with acute abdo
minal pain. Small
bowel resection was indicated, but the attending physician wanted to raise the p
hemoglobin to 12 g/dL before surgery. How many units of RBCs would most likely b
e required to

accomplish this? A. 2 B. 3 C. 6 D. 8 Blood bank/Apply knowledge of fundamental b

characteristics/Blood components/RBCs/2 2. Which of the following is not a viabl
e method for
removing leukocytes from red blood cells? A. Prestorage ltration B. Bedside ltrati
on C.
Poststorage ltration D. Bu y coat removal Blood bank/Apply knowledge of fundamental
characteristics/Blood components/RBCs/1 3. Four units of packed RBCs were brough
t to the nurses
station at 10:20 a.m. Two units were transfused immediately, and 1 unit was tran
sfused at 10:40
a.m. Te remaining unit was returned to the blood bank at 11:00 a.m. Te units wer
e not
refrigerated after leaving the blood bank. What problem(s) is (are) present in t
his situation? A.
Te only problem is with the returned unit; the 30minute limit has expired and t
he unit cannot be
used B. Te unit should not have been transfused at 10:40 a.m. because the time l
imit had expired;
this unit and the remaining unit should have been returned to the blood bank C.
Te returned unit
may be held for this patient for 48 hours but cannot be used for another patient
D. No problems;
all actions were performed within the allowable time limits Blood bank/Select co
urse of
action/Blood components/ RBCs/3 Answers to Questions 14 1. C One unit of RBCs w
ill raise the
hemoglobin level by approximately 1 to 1.5 g/dL, and the hematocrit by 3%4%. Resu
lts vary
depending upon the age of the blood, and the patients blood volume and hydration
status. Six
units will raise the hemoglobin to at least 12 g/dL. 2. D Removal of the bu y co
at, which
contains both platelets and WBCs, is not an approved method for leukoreduction o
f red blood
cells. The other methods can be employed to achieve a leukoreduction of <5x10 6.
3. A There is
a 30minute time limit for a unit of RBCs that is not kept under proper storage
(1C6C). 4. B Platelets preparation from whole blood must be done within 8 hours o
collection. 4. A unit of whole blood is collected at 10:00 a.m. and stored at 20C2
4C. What is
the last hour platelet concentrates may be made from this unit? A. 4:00 p.m. B.
6:00 p.m. C. 7:00
p.m. D. 8:00 p.m. Blood bank/Apply knowledge of standard operating procedures/Bl
ood components/3
2828_Ch04_121170 06/08/12 11:16 AM Page 149 150 Chapter 4 | Immunohematology
5. Which of the
following is acceptable according to AABB standards? A. Rejuvenated RBCs may be
made within 3
days of outdate and transfused or frozen within 24 hours of rejuvenation B. Froz
en RBCs must be
prepared within 30 minutes of collection and may be used within 10 years C. Irra
diated RBCs must
be treated within 8 hours of collection and transfused within 6 hours D. Leukocy
tereduced RBCs
must be prepared within 6 hours of collection and transfused within 6 hours of p
reparation Blood

bank/Apply knowledge of laboratory operations/ Blood components/RBCs/2 6. Which

of the following
is true regarding apheresis platelets? A. Te minimum platelet count must be 3.0
10 11 , pH must
be 6.0 B. Te minimum platelet count must be 3.0 10 10 , pH must be 6.2 C. Te minim
um platelet
count must be 3.0 10 11 , pH must be 6.2 D. Te minimum platelet count must be 5.5
10 10 , pH
must be 6.0 Blood bank/Apply knowledge of laboratory operations/ Blood components
/Platelets/1 7.
What is the component of choice for a patient with chronic granulomatous disease
(CGD)? A. FFP B.
Granulocytes C. Cryoprecipitate D. RBCs Blood bank/Apply knowledge of laboratory
Blood components/3 8. What method can be employed to detect bacteria in random d
onor platelets?
A. pH B. Glucose C. Pan genera detection (PGD) assay D. Gram stain Blood bank/Ap
ply knowledge of
laboratory operations/ Blood components/Preparation of components/1 9. All of th
e following
statements regarding FFP are true, except: A. FFP must be prepared within 24 hou
rs of collection
B. After thawing, FFP must be transfused within 24 hours C. Storage temperature
for FFP with a
1year shelf life is 18C D. When thawed, FFP must be stored between 1C6C Blood bank/Ap
knowledge of standard operating procedures/Blood components/RBCs/1 Answers to Qu
estions 510 5.
A Rejuvenated RBCs may be prepared within 3 days of the outdate of the unit and
washed and
transfused or frozen within 24 hours. A unit of RBCs may be frozen within 6 days
of collection.
An RBC unit can be irradiated any time prior to expiration date; once irradiated
, the unit must
be transfused within 28 days of irradiation or the original outdate, whichever c
omes rst.
Leukocytereduced RBCs should be prepared within 6 hours of collection, but must
be given within
24 hours, if prepared using an open system. Leukocytereduced RBCs prepared usin
g a closed system
may be kept until the original outdate. 6. C Singledonor platelets prepared b
y apheresis must
contain a minimum of 3.0 10 11 platelets and the pH must be 6.2 or higher throug
hout the shelf
life of the product. 7. B Patients with CGD cannot ght bacterial infections due
dysfunctional phagocytic enzymes; granulocyte concentrates are the product of ch
oice for these
patients. 8. C The FDA has mandated that pH and glucose can no longer be used
as a screening
test for platelets. The Verax PGD assay has been FDA approved for both singledo
nor platelets and
randomdonor platelets for bacteria screening. 9. A FFP must be prepared withi
n 8 hours after
collection if the anticoagulant is citrate phosphate dextrose (CPD), citrate pho
sphate double
dextrose (CP2D), or citrate phosphate dextrose adenine (CPDA1); or within 6 hou
rs if the
anticoagulant is ACD. 10. C A patient having cold agglutinins might have a rea
ction to a cold

blood product. The product should be warmed to 37C before transfusion. 10. What m
ay be done to
RBCs before transfusion to a patient with cold agglutinin disease in order to re
duce the
possibility of a transfusion reaction? A. Irradiate to prevent graftversushost
disease (GVHD)
B. Wash with 0.9% percent saline C. Warm to 37C with a blood warmer D. Transport
so that
temperature is maintained at 20C24C Blood bank/Apply knowledge of standard operatin
procedures/Hemotherapy/RBCs/2 2828_Ch04_121170 06/08/12 11:16 AM Page 150 4.
7 | Components
151 11. A unit of packed RBCs is split using the open system. One of the half un
its is used. What
may be done with the second half unit? A. Must be issued within 24 hours B. Must
be issued within
48 hours C. Must be irradiated D. Must retain the original expiration date Blood
knowledge of laboratory operations/ Blood components/RBCs/2 12. What should be d
one if a
noticeable clot is found in an RBC unit? A. Issue the unit; the blood will be lte
red B. Issue
the unit; note the presence of a clot on the release form C. Filter the unit in
the blood bank
before issue D. Do not issue the unit Blood bank/Select course of action/Hemothe
rapy/ RBCs/2 13.
Cryoprecipitate may be used to treat all of the following, except: A. von Willeb
rands disease B.
Hypo brinogenemia C. Idiopathic thrombocytopenic purpura (ITP) D. Factor XIII de cie
ncy Blood
bank/Select best course of action/Hemotherapy/ Cryo/3 14. SITUATION: A transplan
t patient may
receive only type A or AB platelets. Tere are only type O apheresis platelets av
ailable. What
devices may be used to deplete the incompatible plasma and replace with sterile
saline? A.
Cytospin/irradiator B. Water bath/centrifuge C. Centrifuge/sterile connecting de
vice D. Cell
washer/heat sealer Blood bank/Apply knowledge of standard operating procedures/B
components/Platelets/2 15. What component(s) is (are) indicated for patients who
have antiIgA
antibodies? A. Whole blood B. Packed RBCs C. Washed or deglycerolized RBCs D. Gr
anulocytes Blood
bank/Select course of action/Hemotherapy/2 16. FFP can be transfused without reg
ard for: A. ABO
type B. Rh type C. Antibody in product D. All of these options Blood bank/Apply
knowledge of
standard operating procedures/Blood components/FFP/1 Answers to Questions 1118 11
. A The other
half unit must be issued within 24 hours, if an open system is used to split the
unit. 12. D A
unit having a noticeable clot should not be issued for transfusion to a patient.
The clot may be
an indication of contamination or bacterial growth. 13. C Cryoprecipitate may
be used to treat
von Willebrands disease, hypo brinogenemia, and factor XIII de ciency, but is not ind
icated in
ITP. IVIG is the product of choice for ITP. 14. C In the event of an ABO misma
tched stem cell

transplant, special attention must be paid to the choice of transfused blood pro
ducts. Type A or
AB platelets may be given to a transplant in which the donor is A and the recipi
ent is O; once
the stem cells engraft, platelets/plasma must be compatible with type A cells. I
f only type O
singledonor platelets are available, the product can be spun down using a centr
ifuge and plasma
can be removed. Then, a sterile connecting device can be used to aseptically tra
nsfer sterile
isotonic saline to the platelet product, replacing the incompatible plasma. 15.
C Patients with
antiIgA antibodies should not receive components containing plasma. Washed or d
eglycerolized red
cells can be issued. 16. B FFP can be transfused without regard for Rh type be
cause FFP is not
a cellular product. 17. C Washed RBCs renders the system open and shortens the e
time to 24 hours. 18. D Platelets require constant agitation and are stored be
tween 20C24C.
17. All of the following are true regarding washed RBCs, except: A. RBCs are was
hed with 12 L of
normal saline B. Volume is 180 mL C. Shelf life is extended D. Leukocytes are re
moved Blood
bank/Apply knowledge of standard operating procedures/Blood components/Processin
g/1 18. What is a
special condition for the storage of platelets? A. Room temperature, 20C24C B. No o
components may be stored with platelets C. Platelets must be stored upright in s
containers D. Platelets require constant agitation at 20C24C Blood bank/Apply knowl
edge of
standard operating procedures/Blood components/Processing/1 2828_Ch04_121170 0
6/08/12 11:16 AM
Page 151 152 Chapter 4 | Immunohematology 19. Transfusion of an irradiated prod
uct is indicated
in all of the following conditions except: A. Exchange transfusion B. Bone marro
w transplant C.
Severe combined immunode ciency syndrome (SCIDS) D. Warm autoimmune hemolytic anem
ia (WAIHA)
Blood bank/Select course of action/Hemotherapy/ Irradiation/2 20. What percentag
e of red cells
must be retained in leukocytereduced red cells? A. 75% B. 80% C. 85% D. 100% Bl
ood bank/Apply
knowledge of standard operating procedures/Blood components/1 21. Which of the f
ollowing is true
regarding granulocyte concentrates? A. Te product must contain a maximum of 1.0
10 10
granulocytes B. Te pH must be 6.0 C. Te product must be crossmatched D. Te produ
ct must be
irradiated Blood bank/Apply knowledge of standard operating procedures/Blood com
ponents/2 22.
What course of action should be taken if a medical laboratory scientist inadvert
ently irradiates
a unit of red cells twice? A. Issue the unit B. Discard the unit C. Change the e
xpiration date;
then issue the unit D. Note on the irradiation sticker that the unit was irradia
ted twice and
issue Blood bank/Apply knowledge of standard operating procedures/Irradiation/2
23. What

components(s) may be shipped together with FFP? A. Frozen RBCs and cryoprecipita
te B. Platelets
C. Packed RBCs and granulocytes D. Double red cell Blood bank/Apply knowledge of
operating procedures/Blood components/FFP/1 24. A blood supplier ships 3 units o
f pooled
cryoprecipitate. Each pool consists of 5 units of cryoprecipitate. If one unit i
s thawed at 5:00
p.m., when must it be dispensed from the blood bank? A. Before 9:00 p.m. B. Befo
re 11:00 p.m. C.
Before 12:00 a.m. D. Before 5:00 p.m. the next day Blood bank/Apply knowledge of
operating procedures/Blood components/FFP/1 Answers to Questions 1926 19. D WAI
HA would not
require irradiation unless the patient had an underlying immunosuppressive disor
der. 20. C A
red cell unit that has been leukocyte reduced must retain 85% of original red ce
lls. 21. C
Granulocyte concentrates contain a large amount of red cells and must be crossma
tched with the
recipients serum. 22. B If a technologist mistakenly irradiates a unit of red c
ells more than
once, the unit must be discarded due to subsequent potassium accumulation. This
does not apply to
platelets. 23. A FFP requires dry ice for shipment. Frozen RBCs and cryoprecip
itate also
require dry ice. 24. A Pooled cryoprecipitate is a closed system; however, it
has an outdate of
4 hours once thawed. 25. A Gamma rays or xrays have the ability to prohibit a
ability to divide, preventing TAGVHD. 26. C Frozen RBCs may be kept for up to
10 years. FFP
and Cryo stored at 18C or lower expire in 1 year. If FFP is kept at 65C or lower
, the
expiration time is 7 years. Platelet concentrates expire in 5 days. 25. How does
prevent transfusion associated graftversushost disease (TAGVHD)? A. Gamma ray
s and xrays
destroy the lymphocytes ability to divide B. Xrays cause lysis of the lymphocyte
s C. Gamma rays
enhance lymphocyte reactivity D. Ultraviolet radiation induces apoptosis of lymp
hocytes Blood
bank/Apply knowledge of standard operating procedures/Blood components/Stem cell
s/1 26. Which
component has the longest expiration date? A. Cryoprecipitate B. FFP C. Frozen R
BCs D. Platelet
concentrates Blood bank/Apply knowledge of standard operating procedures/Blood b
date/1 2828_Ch04_121170 06/08/12 11:16 AM Page 152 4.7 | Components 153 27
. All of the
following are advantages of using single donor platelets as opposed to random d
onor platelets,
except: A. Less preparation time B. Less antigen exposure for patients C. May be
HLA matched D.
No pooling is required Blood bank/Apply principles of special procedures/ Blood
components/Platelets/1 28. What is the expiration of cryoprecipitate once pooled
? A. 4 hours B. 6
hours C. 8 hours D. 24 hours Blood bank/Apply knowledge of standard operating pr
components/Expiration date/1 29. What is the number of white blood cells permitt

ed in a unit of
leukoreduced red cells? A. <5 10 10 B. <5 10 6 C. <8.3 10 5 D. <8.3 10 6 Blood b
knowledge of standard operating procedures/Blood components/1 30. SITUATION: A c
ancer patient
recently developed a severe infection. Te patients hemoglobin is 8 g/dL owing to
with a drug known to cause bone marrow depression and immunode ciency. Which blood
products are
indicated for this patient? A. Liquid plasma and cryoprecipitate B. Crossmatched
platelets and
washed RBCs C. Factor IX concentrates and FFP D. Irradiated RBCs, platelets, and
Blood bank/Correlate clinical and laboratory data/Blood and components/3 Answers
to Questions
2730 27. A Singledonor platelets require more preparation time than randomdon
or platelets
because they are prepared by apheresis, which may require 13 hours depending on t
instrumentation used. Pooling random donor platelets in equivalent amounts may r
equire only a few
minutes. 28. A When individual Cryo units are pooled in an open system, the ex
piration time is
4 hours; if Cryo is pooled using a sterile connecting device, the expiration tim
e is 6 hours. 29.
B Red cells that have been leukoreduced must have fewer than 5 10 6 white cell
s per unit. 30.
D This cancer patient may be immunocompromised from the medication but needs t
o receive RBCs
for anemia; therefore, irradiated RBCs are indicated. Platelets may be needed to
bleeding, and granulocytes may be indicated for shortterm control of severe inf
2828_Ch04_121170 06/08/12 11:16 AM Page 153 154 4.8 Donors 1. Which of the f
individuals is acceptable as a blood donor? A. A 29yearold man who received th
e hepatitis B
vaccine last week B. A 21yearold woman who had her nose pierced last week C. A
30yearold man
who lived in Zambia for 3 years and returned last month D. A 54yearold man who
tested positive
for hepatitis C last year, but has no active symptoms of disease Blood bank/Appl
y knowledge of
standard operating procedures/Donor requirements/2 2. SITUATION: A 53yearold w
oman donates
blood at her place of employment. She weighs 150 lb and has a hemoglobin of 13 g
/dL. She is
currently on warfarin and vitamin B 12 . Is she an acceptable donor? A. Yes B. N
o, she is on
warfarin C. Yes, for red cells only D. No, her hemoglobin is too low Blood bank/
Apply knowledge
of standard operating procedures/Donor requirements/2 3. Which immunization has
the longest
deferral period? A. HBIG B. Rubella vaccine C. In uenza vaccine D. Yellow fever va
ccine Blood
bank/Apply knowledge of standard operating procedures/Donor requirements/1 4. Te
following whole
blood donors regularly give blood. Which donor may donate on September 10th? A.
A 40yearold
woman who last donated on July 23rd B. A 28yearold man who had plateletpheresi

s on August 24th
C. A 52yearold man who made an autologous donation 2 days ago D. A 23yearold
woman who
donated blood for her aunt on August 14th Blood bank/Apply knowledge of standard
procedures/Donor requirements/2 Answers to Questions 15 1. A If the donor is sy
mptom free,
there is no deferral period for the hepatitis B vaccine. Persons who have had bo
dy piercing are
given a 12month deferral. Persons who lived in an area endemic for malaria or w
ho received
antimalarial drugs are deferred for 3 years. A positive test for the HCV is caus
e for permanent
deferral. 2. C Her age and hemoglobin meet donor criteria. However, because sh
e is currently on
warfarin, only red cells can be prepared from her donation. 3. A Deferral for
HBIG injection is
12 months. Deferral for rubella vaccine is 4 weeks. The deferral period for in uen
za and yellow
fever vaccines is 2 weeks. 4. B A plateletpheresis donor must wait at least 48
hours between
donations. The waiting period following an autologous donation is at least 3 day
s. An 8week
interval must pass between all other types of donations. 5. A To be eligible f
plateletpheresis, the platelet count should be >150 10 9 for a frequent platelet
donor. Plasma
loss exceeding 1,000 mL would be cause for rejection, 800 mL would not. A donor
may donate 24
times a year, but not as frequent as once every 2 days in a 7day period. A dono
r cannot ingest
aspirin within 36 hours of platelet donation. 5. Which of the following preclude
s acceptance of a
plateletpheresis donor? A. Platelet count of 75 10 9
L in a donor who is a
frequent platelet donor B. Plasma loss of 800 mL from plasmapheresis 1 w
eek ago C.
Plateletpheresis performed 4 days ago D. Aspirin ingested 7 days ago Blood bank/
Apply knowledge
of standard operating procedures/Donor requirements/1 2828_Ch04_121170 06/08/1
2 11:16 AM Page
154 4.8 | Donors 155 6. Which of the following donors could be accepted for wh
donation? A. A construction worker who was incarcerated for opiate abuse B. A tr
iathlete with a
pulse of 45 C. A man who is currently taking nasteride (Propecia) D. A woman in h
er 14th week of
pregnancy Blood bank/Apply knowledge of standard operating procedures/Donor requ
irements/2 7.
Which physical examination result is cause for rejecting a wholeblood donor? A.
Weight of 105 lb
B. Pulse of 75 C. Temperature of 99.3 F D. Diastolic pressure of 110 mm Hg Blood
knowledge of standard operating procedures/Donor requirements/1 8. Which situati
on is not a cause
for inde nite deferral of a donor? A. Male currently on dutasteride (Avodart) B. D
onation of a
unit of blood that transmitted hepatitis B virus to a recipient C. History of Cr
disease D. Accidental needle stick 1 year ago; negative for infectious disease B

lood bank/Apply
knowledge of standard operating procedures/Donor requirements/1 9. A wholeblood
donor currently
on clopidogrel (Plavix) is precluded from donating which product? A. Platelets B
. Red blood cells
C. FFP D. Cryoprecipitate Blood bank/Select course of action/Donor processing/ U
donors/3 10. How much anticoagulant would have to be removed from the collection
bag given a
donor who weighs 90 lb? A. 12 mL B. 15 mL C. 20 mL D. 23 mL Blood bank/Apply kno
wledge of
standard operating procedures/Donor collection/3 Answers to Questions 611 6. B
Athletes may
have a pulse below 50 and may still be acceptable as blood donors. Drug addictio
n is cause for
permanent deferral, as is a major illness. The deferral period following treatme
nt for syphilis
or gonorrhea is 12 months. 7. D Diastolic pressure must not be higher than 100
mm Hg. Donors
weighing less than 110 lb may donate up to 12% of their blood volume (volume = w
eight in kg/50
450 mL). Oral temperature must not be greater than 99.5 F. Blood pressure limits
for donation
are 180 mmHg for systolic and 100 mmHg for diastolic pressure. The limit for hem
oglobin is 12.5
g/dL, and for hematocrit 38%. 8. D An accidental needle stick would not be a c
ause for
inde nite deferral of a donor. The deferral period is 1 year. 9. A Clopidogrel r
platelets nonfunctional and therefore potential donors on this medication cannot
platelets. 10. A To determine the amount of anticoagulant to remove when the d
onor is less than
110 lb, divide weight by 110 lb and multiply by 450 mL; divide that number by 10
0 and multiply by
14 (this gives the anticoagulant volume needed); then subtract this from 63 mL,
which is the
standard volume of anticoagulant in a 450 mL bag. The result is the amount of an
ticoagulant to
remove. 11. C This woman is hyperventilating; therefore, the donation should b
e discontinued. A
paper bag should be provided for the donor to breathe into in order to increase
the carbon
dioxide in the donors air. 11. A woman begins to breathe rapidly while donating b
lood. Choose
the correct course of action. A. Continue the donation; rapid breathing is not a
reason to
discontinue a donation B. Withdraw the needle, raise her feet, and administer am
monia C.
Discontinue the donation and provide a paper bag D. Tell her to sit upright and
apply a cold
compress to her forehead Blood bank/Select course of action/Donor processing/ Do
nor adverse
reactions/3 2828_Ch04_121170 06/08/12 11:16 AM Page 155 156 Chapter 4 | Immu
nohematology 12.
A donor bag is half lled during donation when the blood ow stops. Select the corre
ct course of
action. A. Closely observe the bag for at least 3 minutes; if blood ow does not r
esume, withdraw
the needle B. Remove the needle immediately and discontinue the donation C. Chec

k and reposition
the needle if necessary; if blood ow does not resume, withdraw the needle D. With
draw the needle
and perform a second venipuncture in the other arm Blood bank/Select course of
action/Collection/3 13. Who is the best candidate for a predeposit autologous do
nation? A. A
45yearold man who is having elective surgery in 2 weeks; he has alloantik B.
A 23yearold
female leukemia patient with a hemoglobin of 10 g/dL C. A 12yearold boy who ha
s hemophilia D. A
53yearold woman who has septicemia Blood bank/Select course of action/Donor pr
Autologous donation/2 14. Can an autologous donor donate blood on Monday, if he
is having surgery
on Friday? A. Yes, he or she can donate up to 72 hours before surgery B. No, he
or she cannot
donate within 7 days of surgery C. Yes, he or she can donate, but only a half a
unit D. No, he or
she cannot donate within 5 days of surgery Blood bank/Apply knowledge of standar
d operating
procedures/Autologous donation/2 15. Which of the following is an acceptable tim
e in which a unit
of whole blood is collected? A. 33 minutes B. 25 minutes C. 20 minutes D. 13 min
utes Blood
bank/Apply knowledge of standard operating procedures/Collection/1 16. Which of
the following is
true regarding acute normovolemic hemodilution? A. One or more units of blood ar
e withdrawn from
the patient and replaced with FFP B. Units removed may be stored in the operatin
g room at room
temperature for 8 hours C. Units removed may be stored in the operating room at
room temperature
for 24 hours D. Unused units can be added to the general donor blood inventory B
lood bank/Apply
knowledge of standard operating procedures/Autologous donation/2 Answers to Ques
tions 1217 12.
C If blood ow has stopped, check the needle rst. If blood ow does not resume after
repositioning, then withdraw the needle and discontinue the donation. Do not per
form a second
venipuncture on the donor. 13. A The 45yearold man with alloantik is the be
st candidate for
predeposit autologous donation because compatible blood will be hard to nd if he
needs blood
after surgery. The other candidates may not be good choices for donation because
the process may
prove harmful to them. 14. A An autologous donor can donate up to 72 hours bef
ore expected
surgery. 15. D A unit of whole blood should be collected within 15 minutes. 16
. B In acute
normovolemic hemodilution, one or more units of blood are removed from the donor
and replaced
with crystalloid or colloid. Blood may be stored at room temp for up to 8 hours
or at 1C6C for
up to 24 hours. Bleeding during surgery results in less RBC loss after hemodilut
ion, and the
autologous red cells are infused after bleeding stops. Such units are for autolo
gous transfusion
only. 17. A The minimum hematocrit for a double red cell donation is 40%. 17.
All of the
following apply to a double red cell unit apheresis collection except: A. Te hem

atocrit must be
at least 38% B. Te weight for a female is at least 150 lb C. Te height for a mal
e is at least 5
ft 1 in. D. Te deferral period following collection is 16 weeks Blood bank/Apply
knowledge of
standard operating procedures/Apheresis/1 2828_Ch04_121170 06/08/12 11:16 AM
Page 156 4.8 |
Donors 157 18. An autologous unit of whole blood was collected on a 33yearol
d woman in
preparation for a knee replacement procedure in 3 weeks. Te whole blood unit had
her hyphenated
last name, rst name, and last four digits of her social security number for ident
i cation. Te
lab computer system, however, only had her married name and rst name, medical rec
ord number, and
social security number. What should be done with this blood product? A. Discard
the unit B. Make
the unit available for transfusion C. Confirm the name with donor and have admis
sions make the
correction in the computer system, then make the unit available for transfusion
D. Ensure that
social security numbers match, con rm the name with donor and have admissions make
the correction
in the computer system with the medical directors approval, then make the unit av
ailable for
transfusion Blood bank/Standard operating procedures/Autologous donation/3 19. W
hat is the
youngest age a person can make an allogeneic wholeblood donation? A. 14 B. 15 C
. 16 D. 17 Blood
bank/Apply knowledge of standard operating procedures/Donation/1 20. Which of th
e following
vaccinations carries no deferral period? A. Rubella B. Varicella zoster C. Recom
binant HPV D.
Smallpox Blood bank/Apply knowledge of standard operating procedures/Donors/1 An
swers to
Questions 1820 18. D This is a common scenario with women who have recently mar
ried, and have
not changed their license or other form of identi cation given to the collection f
Checking that other demographic information matches is su cient if approved by the
director, because an autologous unit is very di cult to replace in time for surger
y. 19. C In
most states, the youngest age a person can donate is 16 with parental permission
. 20. C
Vaccines developed by recombinant technology carry no deferral period. 2828_Ch04
06/08/12 11:16 AM Page 157 158 4.9 Hemolytic Disease of the Newborn (HDN) 1. A
ll of the
following are reasons for a positive DAT on cord blood cells of a newborn except
: A. High
concentrations of Whartons jelly on cord cells B. Immune antiA from an O mother
on the cells of
an A baby C. Immune antiD from an Rh negative mother on the cells of an Rhposi
tive baby D.
Immune antiK from an Knegative mother on the cells of a Knegative baby Blood
clinical and laboratory data/ Hemolytic disease of the newborn/DAT/2 2. A fetal
screen yielded
negative results on a mother who is O negative and infant who is O positive. Wha

t course of
action should be taken? A. Perform a KleihauerBetke test B. Issue one full dose o
f RhIg C.
Perform a DAT on the infant D. Perform an antibody screen on the mother Blood ba
nk/Select course
of action/Hemolytic disease of the newborn/Rosette test/3 3. What should be done
when a woman who
is 24 weeks pregnant has a positive antibody screen? A. Perform an antibody iden
ti cation panel;
titer if necessary B. No need to do anything until 30 weeks gestation C. Adminis
ter Rh immune
globulin (RhIg) D. Adsorb the antibody onto antigenpositive cells Blood bank/Ap
ply knowledge of
standard operating procedures/Hemolytic disease of the newborn/Antibody testing/
2 4. All of the
following are interventions for fetal distress caused by maternal antibodies att
acking fetal
cells except: A. Intrauterine transfusion B. Plasmapheresis on the mother C. Tra
nsfusion of
antigenpositive cells to the mother D. Early induction of labor Blood bank/Appl
y knowledge of
standard operating procedures/Hemolytic disease of the newborn/Clinical interven
tions/2 Answers
to Questions 15 1. D Immune antiK from the mother would not coat the babys red
cells if they
did not contain the K antigen; therefore, the DAT would be negative. 2. B If t
he fetal screen
or rosette test is negative, indicating the fetal maternal blood is negligible i
n a possible RhIg
candidate, standard practice is to issue one dose of RhIg. 3. A The identi catio
n of the
antibody is very important at this stage of the pregnancy. If the antibody is de
termined to be
clinically signi cant, then a titer may determine the strength of the antibody and
the need for
clinical intervention. 4. C Transfusion of antigenpositive cells to the mothe
r who already has
an antibody might cause a transfusion reaction and/or evoke an even stronger ant
ibody response,
possibly causing more harm to the fetus. 5. A If the cord cells contain excess
ive Whartons
jelly, then further washing or obtaining another cord sample will not solve the
problem. A
heelstick sample will not contain Whartons jelly and should give a valid DAT resu
lt. 5. Cord
cells are washed six times with saline and the DAT and negative control are stil
l positive. What
should be done next? A. Obtain a heelstick sample B. Record the DAT as positive
C. Obtain another
cord sample D. Perform an elution on the cord cells Blood bank/Select course of
disease of the newborn/DAT/3 2828_Ch04_121170 06/08/12 11:16 AM Page 158 4.9
| Hemolytic
Disease of the Newborn (HDN) 159 6. What can be done if HDN is caused by mater
nal antiK? A.
Give Kell immune globulin B. Monitor the mothers antibody level C. Prevent format
ion of
Kpositive cells in the fetus D. Not a problem; antiK is not known to cause HDN
Blood bank/Apply
principles of special procedures/ Hemolytic disease of the newborn/Antibody form

ation/2 7. Should
an Onegative mother receive RhIg if a positive DAT on the newborn is caused by
immune antiA? A.
No, the mother is not a candidate for RhIg because of the positive DAT B. Yes, i
f the babys type
is Rh negative C. Yes, if the babys type is Rh positive D. No, the babys problem i
s unrelated
to Rh blood group antibodies Blood bank/Correlate clinical and laboratory data/
Hemolytic disease
of the newborn/RhIg/3 8. Should an Anegative woman who has just had a miscarria
ge receive RhIg?
A. Yes, but only if she does not have evidence of active AntiD B. No, the type
of the baby is
unknown C. Yes, but only a minidose regardless of trimester D. No, RhIg is given
for term
pregnancies only Blood bank/Apply knowledge of standard operating procedures/Hem
9. SITUATION: The Ortho Provue reports a type on a woman who is 6 weeks pregnant
with vaginal
bleeding as O negative. The woman tells the emergency department physician she i
s O positive and
presents a blood donor card. The medical laboratory scientist performs a test fo
r weak D and
observes a 1+ reaction in AHG phase. A KleihauerBetke test is negative. Is this w
oman a
candidate for RhIg? A. No, she is Rh positive B. Yes, she is a genetic weak D C.
No, there is no
evidence of a fetal bleed D. Yes, based upon the Provue results Blood bank/Corre
late clinical and
laboratory results/ Hemolytic disease of the newborn/RhIg/3 Answers to Questions
610 6. B
AntiD is the only antibody for which prevention of HDN is possible. If a pregna
nt woman develops
antiK, she will be monitored to determine if the antibody level and signs of fe
tal distress
necessitate clinical intervention. 7. C RhIg is immune antiD and is given to
mothers who give birth to Rhpositive babies and who do not have antiD already
formed from
previous pregnancies or transfusion. 8. A When the fetus is Rh positive or the
Rh status of the
fetus is unknown, termination of a pregnancy from any cause presents a situation
in which an
Rhnegative patient should receive RhIg. A minidose is used if the pregnancy is
terminated in the
rst trimester. 9. A The negative KleihauerBetke test con rms that the positive rea
ction of
the womans RBCs with antiD at IAT is not the result of a fetalmaternal bleed. T
he woman is
weak D positive, and, therefore, is not a candidate for RhIg. Typically, a test
for weak D is not
done as part of the obstetric workup. In such cases, if the rosette test is posi
tive, the mother
is given RhIg. 10. B An Onegative mother who gives birth to an Apositive bab
y and has no
antiD formed from a previous pregnancy would be a candidate for RhIg. A mother
who already has
active antiD or a mother who gives birth to an Rhnegative baby is not a candid
ate for RhIg.
AntiD formation via active immunization typically has a titer >4, compared with

administration of antiD, which has a titer <4. 10. Which of the following patie
nts would be a
candidate for RhIg? A. Bpositive mother; Bnegative baby; rst pregnancy; no anti
D in mother B.
Onegative mother; Apositive baby; second pregnancy; no antiD in mother C. An
egative mother;
Onegative baby; fourth pregnancy; antiD in mother D. ABnegative mother; Bpos
itive baby;
second pregnancy; antiD in mother Blood bank/Correlate clinical and laboratory
data/ Hemolytic
disease of the newborn/RhIg/2 2828_Ch04_121170 06/08/12 11:16 AM Page 159 16
0 Chapter 4 |
Immunohematology 11. A KleihauerBetke acid elution test identi es 40 fetal cells in
maternal red cells. How many full doses of RhIg are indicated? A. 1 B. 2 C. 3 D.
4 Blood
bank/Calculate/Hemolytic disease of the newborn/RhIg/2 12. Kernicterus is caused
by the e ects
of: A. Anemia B. Unconjugated bilirubin C. Antibody speci city D. Antibody titer B
lood bank/Apply
knowledge of biological principles/ Hemolytic disease of the newborn/1 13. Anti
E is detected in
the serum of a woman in the rst trimester of pregnancy. Te rst titer for antiE is
32. Two
weeks later, the antibody titer is 64 and then 128 after another 2 weeks. Clinic
ally, there are
beginning signs of fetal distress. What may be done? A. Induce labor for early d
elivery B.
Perform plasmapheresis to remove antiE from the mother C. Administer RhIg to th
e mother D.
Perform an intrauterine transfusion using Enegative cells Blood bank/Correlate
clinical and
laboratory data/ Hemolytic disease of the newborn/3 14. What testing is done for
transfusion when the mothers serum contains an alloantibody? A. Crossmatch and an
tibody screen
B. ABO, Rh, antibody screen, and crossmatch C. ABO, Rh, antibody screen D. ABO a
nd Rh only Blood
bank/Apply knowledge of standard operating procedures/Hemolytic disease of the n
Hemotherapy/1 15. Which blood type may be transfused to an ABpositive baby who
has HDN caused by
antiD? A. AB negative, CMV negative, Hgb S negative; irradiated or O negative,
CMV negative, Hgb
S negative B. AB positive, CMV negative; irradiated or O positive, CMV negative
C. AB negative
only D. O negative only Blood bank/Select course of action/Hemolytic disease of
newborn/Hemotherapy/2 Answers to Questions 1116 11. D To calculate the number o
f vials of RhIg
to infuse, divide 40 by 2,000 and multiply by 5,000, which is the estimated tota
l blood volume of
the mother in milliliters. Divide this number by 30 to arrive at the number of d
oses. When the
number to the right of the decimal point is less than 5, round down and add one
dose of RhIg.
Conversely, when the number to the right of the decimal point is 5 or greater, r
ound up and add
one dose of RhIg. In this example, the number of doses is 3.3. Rounding down and

adding 1 vial
gives an answer of 4 vials. 12. B Kernicterus occurs because of high levels of
bilirubin. High levels of this pigment cross into the central nervous system, ca
using brain
damage to the infant. 13. B Plasmapheresis removes excess antiE from the moth
er and provides a
temporary solution to the problem until the fetus is mature enough to be deliver
ed. The procedure
may need to be performed several times, depending upon how quickly and how high
the levels of
antiE rise. Administration of RhIg would not contribute to solving this problem
caused by
antiE. Intrauterine transfusion would not be performed before week 20, and woul
d be considered
only if there is evidence of severe hemolytic disease. 14. B ABO (forward) and
Rh are required.
An antibody screen using either the neonatal serum or maternal serum is required
. A crossmatch is
necessary as long as maternal antibody persists in the infants blood. 15. A Eit
her ABnegative
or Onegative RBCs may be given to an ABpositive baby because both types are AB
O compatible and
lack the D antigen. 16. B An antibody screen is not performed routinely on a c
ord blood sample
because a baby does not make antibodies until about 6 months of age. Any antibod
ies detected in a
cord blood sample come from the mother. 16. All of the following are routinely p
erformed on a
cord blood sample except: A. Forward ABO typing B. Antibody screen C. Rh typing
D. DAT Blood
bank/Apply knowledge of laboratory operations/ Hemolytic disease of the newborn/
Cord blood/1
2828_Ch04_121170 06/08/12 11:16 AM Page 160 4.9 | Hemolytic Disease of the N
ewborn (HDN)
161 17. Why do Rhnegative women tend to have a positive antibody screen compare
d to Rhpositive
women of childbearing age? A. Tey have formed active antiD B. Tey have received
RhIg C. Tey have
formed antiK D. Tey have a higher rate of transfusion Blood bank/Apply knowledg
e of biological
principles/ Hemolytic disease of the newborn/3 18. SITUATION: An Onegative moth
er gave birth to
a Bpositive infant. Te mother had no history of antibodies or transfusion. Tis
was her rst
child. Te baby was mildly jaundiced and the DAT weakly positive with polyspeci c a
ntisera. What
could have caused the positive DAT? A. AntiD from the mother coating the infant
red cells B. An
alloantibody, such as antiK, coating the infant red cells C. Maternal antiB co
ating the infant
cells D. Maternal antiA, B coating the infant cells Blood bank/Correlate clinic
al and laboratory
data/ Hemolytic disease of the newborn/3 19. SITUATION: RhIg is requested on a 2
8yearold woman
with suspected abortion. When the nurse arrives in the blood bank to pick up the
RhIg, she asks
the medical laboratory scientist (MLS) if it is a minidose. Te MLS replies that
it is a full
dose, not a minidose. Te nurse then requests to take 50 mcg from the 300 mcg syr

inge to satisfy
the physicians orders. What course of action should the MLS take? A. Let the nurs
e take the
syringe of RhIg, so that she may withdraw 50 mcg B. Call a supervisor or patholo
gist C. Instruct
the nurse that the blood bank does not stock minidoses of RhIg and manipulating
the full dose
will compromise the purity of the product D. Instruct the nurse that the blood b
ank does not
stock minidoses of RhIg, and relay this information to the patients physician Blo
od bank/Select
course of action/Hemolytic disease of the newborn/RhIg/3 Answers to Questions 171
9 17. B The
most common reason an Rhnegative woman has a positive antibody screen is becaus
e of previously
receiving RhIg or passive antiD. 18. D AntiA,B is an IgG antibody and can cr
oss the placenta
and attach to infant cells. It is known as a single entity as opposed to separat
e antibodies.
AntiD would not be the cause because this is the rst pregnancy. AntiK is not th
e cause because
there is no history of alloantibodies or past transfusions. 19. D Blood banks
operate by strict
standard operating procedures. These include which products are supplied from th
e blood bank.
While B may also be a solution, D is the best answer because the patients physici
an can
communicate with the pathologist once he or she receives this information from t
he nurse.
2828_Ch04_121170 06/08/12 11:16 AM Page 161 162 4.10 Serological Testing of
Blood Products 1.
What protocol is followed when screening whole blood donors for HIV1 RNA? A. Po
ols of 10 are
tested; if the pool is nonreactive, donors are accepted B. Pools of 20 are teste
d; if the pool is
reactive, samples are tested individually C. Pools of up to 16 donors are tested
; if pool is
reactive, individual samples are screened D. All donors are screened individuall
y; if samples are
reactive, blood is discarded Blood bank/Standard operating procedures/Processing
/3 2. Currently,
nucleic acid ampli cation testing (NAT) testing is performed to detect which virus
es? A. HIV and
HTLV1 B. HTLV I/II C. HIV, HCV, and WNV D. HIV, HBV, and WNV Blood bank/Apply k
nowledge of
standard operating procedures/Processing/1 3. John comes in to donate a unit of
whole blood at
the collection center of the community blood supplier. Te EIA screen is reactive
antiHIV1/2. Te test is repeated in duplicate and is nonreactive. John is: A. C
leared for
donation B. Deferred for 6 months C. Status is dependent on con rmatory test D. De
ferred for 12
months Blood bank/Select course of action/Processing/3 4. What marker is the rst
to appear in
hepatitis B infection? A. AntiHBc (IgM) B. HbsAg C. AntiHBs D. AntiHBc (IgG)
Blood bank/Apply
knowledge of biological principles/ Processing/1 Answers to Questions 15 1. C P
ools of up to
16 donors are tested by nucleic acid ampli cation technology. If the pool is react

ive, samples
from each individual donor are tested. 2. C According to AABB standards, NAT t
esting is
required for viruses HIV1, HCV, and WNV. 3. A If the initial EIA screen for a
ntiHIV is
reactive, and the test is repeated in duplicate and found to be nonreactive, the
blood components
may be used. 4. B The rst viral marker of hepatitis B to appear in the serum on
ce exposed is
the HBSAg, which appears in as few as 5 days (528 days postexposure). 5. C Anti
HBs is
indicative of immunity or vaccination to hepatitis B. AntiHBc (IgM) occurs in t
he early stage of
infection; antiHBc (IgG) follows and may persist for years following infection.
HBsAg is a
marker of HBV infection, not immunity. 5. What marker indicates immunity to hepa
titis B
infection? A. AntiHBc (IgM) B. HBsAg C. AntiHBs D. AntiHBc (IgG) Blood bank/A
pply knowledge of
standard operating procedures/Processing/1 2828_Ch04_121170 06/08/12 11:16 AM
Page 162 4.10 |
Serological Testing of Blood Products 163 6. An EIA screening test for HTLV I/
II was performed
on a wholeblood donor. Te results of the EIA were repeatedly reactive but the c
on rmatory test
was negative. On the next donation, the screening test was negative by two di eren
t EIA tests. Te
donor should be: A. Accepted B. Deferred C. Told that only plasma can be made fr
om his donation
D. Told to come back in 6 months Blood bank/Select best course of action/Process
ing/3 7. A unit
tests positive for syphilis using the rapid plasma reagin test (RPR). Te microhe
assayTreponema pallidum (MHATP) on the same unit is negative. What is the disp
osition of the
unit? A. Te unit may be used to prepare components B. Te donor must be contacted
and questioned
further; if the RPR result is most likely a false positive, then the unit may be
used C. Te unit
must be discarded D. Cellular components may be prepared but must be irradiated
before issue
Blood bank/Apply knowledge of standard operating procedures/Processing/2 8. SITU
ATION: John Smith
donated a unit of whole blood in May. Red blood cells made from the whole blood
were transfused
to a recipient of a community hospital in June with no apparent complications. T
e blood supplier
noti ed the medical director of the hospital that the donor reported highrisk beh
avior with
another male in April, although viral tests remain negative and the donor is hea
lthy. What course
of action should be taken? A. No action should be taken B. Te recipients physicia
n should be
noti ed C. Te recipients physician and the recipient should be noti ed D. Te recipien
t should be
noti ed Blood bank/Apply knowledge of biological principles/ Market withdrawal/3 9
. All of the
following are required tests on donor blood, except: A. HBsAg B. AntiCMV C. HIV
1 D. AntiHTLV
I/II Blood bank/Apply knowledge of standard operating procedures/Processing/1 An

swers to
Questions 610 6. A If screening results are repeatedly reactive and the con rmato
ry test is
negative for antiHTLV and upon the next donation the EIA is negative by two di er
ent methods,
the donor may be accepted. 7. A This is a case of a falsepositive screening t
est (RPR). The
con rmatory test for treponemal antibodies was negative. The donor unit is accepta
ble and may be
used to prepare blood components. 8. B The recipients physician should be noti ed
by the
medical director to ascertain the current health status of the recipient, if kno
wn, and determine
what treatment, if any, the recipient should receive. 9. B Testing of donor bl
ood for
antibodies to CMV is not required. However, testing may be done on units intende
d for transfusion
to low birth weight infants born to seronegative mothers or units used for intra
transfusion; units intended for immunocompromised patients who are seronegative;
transplant recipients who are seronegative; or transplant recipients who have re
ceived a
seronegative organ. Leukoreduced RBCs carry a reduced risk of transmitting CMV a
nd are
recommended for such patients when CMV testing has not been performed on donor u
nits. The
prevalence of antiCMV in the population ranges from 40%90%. 10. A According to
current FDA
and CDC criteria, a sample is de ned as antiHIV positive if at least two of the f
ollowing bands
are present on a Western Blot: p24, gp41, and/or GP120/160. 10. Which of the fol
lowing bands
would constitute a positive Western Blot for HIV? A. p24, gp41, p17 B. p55, gp12
0, p51 C. gp160,
p31, p56 D. p24, p30, p55 Blood bank/Apply knowledge of standard operating
procedures/Processing/1 2828_Ch04_121170 06/08/12 11:16 AM Page 163 1. Is th
ere a discrepancy
between the following blood typing and secretor study results? Blood typing resu
lts: AntiA
AntiB A 1 cells B cells 4+ 0 0 4+ Secretor results: AntiA + saliva
+ A 1 cells = 0
AntiB + saliva + B cells = 4+ AntiH + saliva + O cells = 0 A. No problem, the
sample is from a
group A secretor B. Blood types as A and saliva types as B C. Blood types as A,
but the secretor
study is inconclusive D. No problem, the sample is from a group A nonsecretor Bl
ood bank/Evaluate
laboratory data to make identi cations/Saliva neutralization/3 2. What is the best
course of
action given the following test result? (Assume the patient has not been transfu
sed recently.)
AntiA AntiB A 1 cells B cells Mixed eld 0 1+ 4+ A. Nothing, typing
is normal B.
Type patient cells with antiA 1 lectin and type serum with A 2 cells C. Retype
patient cells;
type with antiH and antiA,B; use screen cells or A 2 cells on patient serum; r
un patient
autocontrol D. Wash patient cells four times with saline, then repeat the forwar
d type Blood

bank/Apply principles of special procedures/ RBCs/ABO discrepancy/3 Answers to Q

uestions 13 1.
A The blood typing result demonstrates A antigen on the red cells and antiB in
the serum. The
secretor result reveals the A antigen in the saliva. The A antigen neutralized t
he antiA,
preventing agglutination when A 1 cells were added. Each blood type (except a Bo
mbay) contains
some H antigen; therefore, the H antigen in the saliva would be bound by antiH
reagent. No
agglutination would occur when the O cells are added. 2. C The mixed eld reacti
on with antiA
suggests a subgroup of A, most likely A 3. The reverse grouping shows weak agglu
tination with A 1
cells, indicating antiA 1. A positive reaction with antiA,B would help to di ere
ntiate an A
subgroup from group O. If A 2 cells are not agglutinated by patient serum, the r
esult would
indicate the presence of antiA 1. If the patients serum agglutinates A 2 cells,
then an
alloantibody or autoantibody should be considered. 3. B The scenario showed an
antibody in the
patient serum directed toward the M antigen, and the M antigen happened to be on
the A 1 cells in
reverse grouping. To solve this problem, nd A 1 cells negative for the M antigen
or enzyme treat
the A 1 cells to resolve the ABO discrepancy. 3. Te following results were obtai
ned on a
41yearold female: AntiA AntiB A 1 cells B cells O cells 4+ 0 3+
4+ 3+ Due to
the discrepant reverse grouping, a panel was performed on patient serum revealin
g the presence of
antiM. How can the reverse grouping be resolved? A. Repeat the reverse grouping
with a 10minute
incubation at room temperature B. Repeat the reverse grouping using A 1 cells th
at are negative
for M antigen C. Repeat the reverse grouping using A 1 cells that are positive f
or M antigen D.
No further work is necessary Blood bank/Evaluate laboratory data to recognize pr
discrepancy/3 164 4.11 Immunohematology Problem Solving 2828_Ch04_121170 06/08
/12 11:16 AM
Page 164 4.11 | Immunohematology Problem Solving 165 4. A 59yearold male cam
e through the
emergency department of a community hospital complaining of dizziness and fatigu
e. History
included no transfusions and a positive rheumatoid factor 1 year ago. His CBC co
n rmed anemia. A
sample was sent to the blood bank for a type and crossmatch. Upon receipt of the
sample in the
blood bank, the MLS noticed the EDTA sample appeared very viscous. Fearing the s
ample would clog
the ProVue, testing was performed using the tube method. Initial results reveale
d the following:
AntiA AntiB AntiD Rh Control A 1 cells B cells 0 0 4+ 2+ 4+
4+ Te patients
red cells were washed eight times with saline, and testing was repeated giving t
he following
results: AntiA AntiB AntiD Rh Control A 1 cells B cells 0 0 4+
0 4+ 4+ Te

antibody screen was negative at IS, 37C, and AHG phases; check cells were positiv
e. Crossmatch
testing using two Opositive donor units revealed a 1+ at immediate spin, and ne
gative results at
37C and AHG phases. Te check cells were positive. In light of the crossmatch resu
lts, what is
the next course of action? A. Use other donor cells for the crossmatch B. Perfor
m a saline
replacement for the crossmatch C. Run the crossmatch using the Gel system D. Res
ult the
crossmatch as incompatible Blood bank/Correlate clinical and laboratory data/Rh
discrepancy/3 5.
Te following results were obtained on a 51yearold male with hepatitis C: Anti
A AntiB
AntiD A 1 cells B cells 4+ 4+ 3+ 0 0 What should be done next? A. R
etype the
patients sample to con rm group AB positive B. Repeat the Rh typing C. Run a saline
control in
forward grouping D. Report the patient as group AB, Rh positive Blood bank/Apply
knowledge of
routine laboratory procedures/ABO/2 Answers to Questions 47 4. B The history of
the patient
correlates with abnormal plasma proteins causing a positive result with the Rh c
ontrol. Perform a
saline replacement technique to rectify the incompatible crossmatches at immedia
te spin. 5. C
In the case of an ABpositive person, a saline control must be run in forward gr
ouping to obtain
a negative reaction; this will ensure agglutination is speci c in the other reacti
ons. 6. C The
most likely genotype is R 1 R 1 . The possibilities are DCe/DCe or DCe/dCe, whic
h translates to R
1 R 1 or R 1 r. The former is more common. 7. C Because the patient has never b
een transfused
or pregnant, she probably has not formed any atypical antibodies. Because she is
Rh negative she
would have received a dose of RhIg at 28 weeks (antenatal dose) if her prenatal
antibody screen
had been negative. Although technical error cannot be ruled out, it is far less
likely than RhIg
administration. 6. An Rh phenotyping shows the following results: AntiD Anti
C AntiE
Antic Antie 4+ 2+ 0 0 3+ What is the most likely Rh genotype? A. R 1
r B. R 0 r C. R
1 R 1 D. R 1 r Blood bank/Apply knowledge of fundamental biological characterist
ics/Rh typing/3
7. An obstetric patient, 34 weeks pregnant, shows a positive antibody screen at
the indirect
antiglobulin phase of testing. She is group B, Rh negative. Tis is her rst pregna
ncy. She has no
prior history of transfusion. What is the most likely explanation for the positi
ve antibody
screen? A. She has developed an antibody to fetal red cells B. She probably does
not have
antibodies because this is her rst pregnancy, and she has not been transfused; ch
eck for
technical error C. She received an antenatal dose of RhIg D. Impossible to deter
mine without
further testing Blood bank/Correlate clinical and laboratory data/ Hemolytic dis
ease of the

newborn/3 2828_Ch04_121170 06/08/12 11:16 AM Page 165 166 Chapter 4 | Immuno

hematology 8. A
patients serum contains a mixture of antibodies. One of the antibodies is identi ed
as antiD.
AntiJk a or antiFy a and possibly another antibody are present. What technique
(s) may be
helpful to identify the other antibody(s)? A. Enzyme panel; select cell panel B.
Tio reagents C.
Lowering the pH and increasing the incubation time D. Using albumin as an enhanc
ement media in
combination with selective adsorption Blood bank/Apply principles of special pro
cedures/ Antibody
ID/3 9. An antiM reacts strongly through all phases of testing. Which of the fo
techniques would not contribute to removing this reactivity so that more clinica
lly signi cant
antibodies may be revealed? A. Acidifying the serum B. Prewarmed technique C. Ad
sorption with
homozygous cells D. Testing with enzymetreated red cells Blood bank/Apply princ
iples of special
procedures/ Antibody ID/3 10. Te reactivity of an unknown antibody could be anti
Jk a , but the
antibody identi cation panel does not t this pattern conclusively. Which of the fol
lowing would
not be e ective in determining if the speci city is antiJk a ? A. Testing with enzy
cells B. Select panel of homozygous cells C. Testing with AETtreated cells D. I
incubation time Blood bank/Apply principles of special procedures/ Antibody ID/3
11. A
coldreacting antibody is found in the serum of a recently transfused patient an
d is suspected to
be antiI. Te antibody identi cation panel shows reactions with all cells at room
including the autocontrol. Te reaction strength varies from 2+ to 4+. What proce
dure would help
to distinguish this antibody from other coldreacting antibodies? A. Autoadsorpt
ion technique B.
Neutralization using saliva C. Autocontrol using ZZAP reagenttreated cells D. R
eaction with cord
cells Blood bank/Apply principles of special procedures/ Antibody ID/3 Answers t
o Questions 811
8. A An enzyme panel would help to distinguish between antiJk a (reaction enh
anced) and
antiFy a (destroyed). AntiD, however, would also be enhanced and may mask reac
tions that may
distinguish another antibody. A select panel of cells negative for D may help to
reveal an
additional antibody or antibodies. 9. A Lowering the pH will actually enhance
reactivity of
antiM. Prewarming (antiM is a coldreacting antibody), cold adsorption with ho
mozygous M cells,
and testing the serum with enzymetreated red cells (destroys M antigens) are al
l techniques to
remove reactivity of antiM. 10. C AET denatures Kell antigens and has no e ect
on Kidd
antibodies. Because the detection of Kidd antibodies is subject to dosage e ect, s
election of
cells homozygous for the Jk a antigen (and longer incubation) would help to dete
ct the presence

of the corresponding antibody. Enzymetreated red cells would also react more st
rongly in the
presence of Kidd antibodies. 11. D Because RBCs contain variable amounts of I
reactions with antiI often vary in agglutination strength. However, because thi
s patient was
recently transfused, the variation in reaction strength may be the result of an
antibody mixture.
Although autoadsorption would remove antiI, this procedure does not con rm the an
speci city and can result in removal of other antibodies, as well. Cord cells expr
ess primarily i
antigen with very little I antigen. AntiI would react weakly or negatively with
cord RBCs. ZZAP
removes IgG antibodies from red cells. Because antiI is IgM, the use of ZZAP wo
uld not be of
value. 2828_Ch04_121170 06/08/12 11:16 AM Page 166 4.11 | Immunohematology P
roblem Solving
167 12. An antibody identi cation panel reveals the presence of antiLe b and a po
ssible second
speci city. Saliva from which person would best neutralize the Le b antibody? A. B
. C. D. Blood
bank/Apply principles of special procedures/ Antibody ID/3 13. Te Ortho Provue d
oes not detect
weak forms of the D antigen. Why would running type and screens on the Provue pr
event a patient
with a weak D phenotype from forming antiD? A. Weak D persons cannot form anti
D B. Te Provue
would result the sample as Rh negative; the patient would receive Rhnegative bl
ood C. Te Provue
would result the sample as Rh positive; the patient would receive Rhpositive bl
ood D. A and C
Blood bank/Correlate clinical and laboratory data/ Blood group antigens/2 14. A
cord blood workup
was ordered on Baby Boy Jones. Te mother is O negative. Results on the baby are
as follows:
AntiA AntiB AntiA, B AntiD DAT (poly) 4+ 0 4+ 0 2+ Te test f
or weak D was
positive at AHG. Is the mother an RhIg candidate? A. No, the baby is Rh positive
B. Yes, the
babys Rh type cannot be determined due to the positive DAT C. No, the baby is Rh
negative D.
Yes, the mother is Rh negative Blood bank/Evaluate laboratory data/Rh type/3 15.
Red cells from a
recently transfused patient were DAT positive when tested with antiIgG. Screen
cells and a panel
performed on a patients serum showed very weak reactions with inconclusive result
s. What
procedure could help to identify the antibody? A. Elution followed by a panel on
the eluate B.
Adsorption followed by a panel on the adsorbed serum C. Enzyme panel D. Antigen
typing the
patients red cells Blood bank/Apply principles of special procedures/ Antibody id
enti cation/3
Answers to Questions 1215 12. C Lewis antibodies are usually not clinically sig
ni cant but may
interfere with testing for clinically signi cant antibodies. Lewis antibodies are
most easily
removed by neutralizing them with soluble Lewis substance. The Lewis antigens ar
e secreted into

saliva and plasma and are adsorbed onto the red cells. Le b substance is made by
adding an
Lfucose to both the terminal and next to last sugar residue on the type 1 precu
rsor chain. This
requires the Le, H, and Se genes. Since some examples of antiLe b react only wi
th group O or A 2
RBCs, neutralization is best achieved if the saliva comes from a person who is g
roup O. 13. B
The Ortho Provue would result the patient with a weak D phenotype as Rh negative
, and if blood
were needed, the patient would receive Rhnegative blood. 14. B The baby forwa
rd types as an A
and the mother is O negative. It is possible that antiA,B from the mother is at
taching to the
babys red cells, causing a positive DAT. In the presence of a positive DAT, a wea
k test for D is
not valid. Therefore, the babys Rh type is unknown and the mother would be a cand
idate for RhIg.
15. A If the red cells show a positive DAT, then IgG antibody has coated incom
antigenpositive red cells. If screening cells and panel cells show missing or w
eak reactions,
most of the antibody is on the red cells and would need to be eluted before it c
an be detected.
An elution procedure followed by a panel performed on the eluate would help to i
dentify the
antibody. Genes Lewis ABO Secretor Le H sese Le hh Se Le H Se le
le hh sese
2828_Ch04_121170 06/08/12 11:16 AM Page 167 168 Chapter 4 | Immunohematology
16. A patient
types as O positive. All three screen and red cells from two Opositive donor un
its show
agglutination after incubation at 37C, and increase in reactivity at the IAT phas
e of testing.
What action should be taken next? A. Perform an autocontrol and direct antiglobu
lin test on the
patient B. Perform an enzyme panel C. Perform an elution D. Choose another 2 uni
ts and repeat the
crossmatch Blood bank/Select course of action/Incompatible crossmatch/3 17. Four
units of blood
are ordered for a patient. Blood bank records are checked and indicate that 5 ye
ars ago this
patient had an antiJk b . What is the next course of action? A. Antigen type un
its for the Jk b
antigen and only crossmatch units positive for Jk b B. Antigen type units for th
e Jk b antigen
and only crossmatch units negative for Jk b C. Randomly pull 4 units of blood th
at are ABO
compatible and crossmatch D. Perform an immediate spin crossmatch on 4 Jk b neg
ative units Blood
bank/Apply principles of laboratory operations/ Compatibility testing/3 18. A 56
yearold patient
diagnosed with colon cancer demonstrates a positive antibody screen in all three
screen cells at
the antiglobulin phase. A panel study is done and shows 10 cells positive as wel
l as the
autocontrol at the antiglobulin phase. Te reactions varied from 1+ to 3+. Tis pa
tient had a
history of receiving 2 units of blood approximately 1 month ago. What should be
done next? A.

Perform a DAT on the patient cells B. Perform an autoadsorption C. Perform an al

loadsorption D.
Issue Onegative cells Blood bank/Evaluate laboratory data to determine best cou
rse of
action/Panel study/3 Answers to Questions 1619 16. A All screening cells and al
l units are
positive at both 37C and the IAT phase. This indicates the possibility of a high
alloantibody or a warm autoantibody. An autocontrol would help to make this dist
inction. A
positive autocontrol indicates an autoantibody is present; a negative autocontro
l and positive
screen cells indicates an alloantibody. A DAT would be performed to determine if
an antibody has
coated the patients red cells, and is directed against screening cells and donor
cells. 17. B
A patient with a history of a signi cant antibody like antiJk b must receive bloo
d that has been
completely crossmatched and negative for the corresponding antigen; otherwise, a
n anamnestic
reaction may occur with subsequent lysis of donor cells. 18. C In this situati
on, an allogeneic
adsorption must be performed to adsorb out the autoantibody and leave potential
alloantibodies in
the patients serum that will need to be identi ed before transfusion of blood to th
e patient. An
autoadsorption cannot be performed due to the fact that any alloantibodies would
be absorbed by
circulating donor cells from a month prior. 19. C AntiP 1 is a coldreacting
antibody. Warming
the plasma at 37C will dissipate the antibody, preventing its reactivity with P 1
antigen on the
A 1 cells. 19. A 33yearold maternity patient is drawn for a type and screen at
36 weeks
gestation. Te following results are found on the Ortho Provue: AntiA AntiB
AntiA, B
AntiD A 1 cells B cells 3+ 0 4+ 4+ 2+ 4+ SCI SCII SCIII A 1
lectin 0 0 0
3+ Te reference lab identi ed antiP 1 in the patient plasma using enzyme techni
ques. How could
the ABO discrepancy be solved? A. Wash the patients red cells and repeat the forw
ard grouping B.
Test the patients plasma against A 2 cells C. Warm the patient plasma at 37C for 1
0 minutes and
repeat the reverse grouping D. Treat the A 1 cells with dithiothreitol and repea
t the reverse
grouping Blood bank/Evaluate laboratory data to determine possible inconsistent
2828_Ch04_121170 06/08/12 11:16 AM Page 168 4.11 | Immunohematology Problem
Solving 169 20.
An Onegative mother with no record of any previous pregnancies gives birth to h
er rst child, a
Bpositive baby. Te babys DAT is weakly positive and the negative control is nega
tive. Te
antibody screen is also negative. Te baby appears healthy but develops mild jaun
dice after 2
days, which is treated with phototherapy. Te baby goes home after 4 days in the
hospital without
complications. What is the most likely explanation for the weakly positive DAT?
A. Technical

error B. A low titer antiD C. Immune antiB from the mother D. A maternal antib
ody against a
lowincidence antigen Blood bank/Correlate clinical and laboratory data/ Hemolyt
ic disease of the
newborn/2 Answer to Question 20 20. C In this case, the maternal antiA,B is p
robably coating
the infants B cells, causing a positive DAT and jaundice. AntiA,B from an O pers
on is a single
entity that cannot be separated. It is IgG and can cross the placenta. This anti
body may attach
to A, B, or AB red cells. BI BL I OGRAPHY 1. American Association of Blood Banks
. Standards for
Blood Banks and Transfusion Services. 27th edition, 2011. Bethesda, MD. 2. Harme
ning D. Modern
Blood Banking and Transfusion Practices. 5th edition, 2005. F.A. Davis, Philadel
phia. 3. Issitt
PD. Applied Blood Group Serology. 1998. Montgomery Scienti c Publications, Miami.
4. Quinley E.
Immunohematology: Principles and Practice. 3rd edi tion, 2010. Lippincott Willi
ams & Wilkins,
Philadelphia. 5. Roback JD. American Association of Blood Banks Technical Man u
al. 17th edition,
2011. American Association of Blood Banks, Bethesda, MD. 6. Rudmann SV. Textbook
of Blood Banking
and Transfusion Medi cine. 2nd edition, 2005. W.B. Saunders, Philadelphia. 7. T
urgeon ML.
Fundamentals of Immunohematology. 2nd edition, 1995. Lippincott Williams & Wilki
ns, Philadelphia.
2828_Ch04_121170 06/08/12 11:16 AM Page 169 2828_Ch04_121170 06/08/12 11:
16 AM Page 170
CHAPTER 5 5.1 Instrumentation 5.2 Blood Gases, pH, and Electrolytes 5.3 Glucose,
Iron, and Bilirubin 5.4 Calculations, Quality Control, and Statistics 5.5 Creati
nine, Uric Acid,
Bun, and Ammonia 5.6 Proteins, Electrophoresis, and Lipids 5.7 Enzymes and Cardi
ac Markers 5.8
Clinical Endocrinology 5.9 Toxicology and Terapeutic Drug Monitoring 5.10 Tumor
Markers 5.11
Clinical Chemistry Problem Solving 171 Clinical Chemistry 2828_Ch05_171326 06/
08/12 5:14 PM
Page 171 2828_Ch05_171326 06/08/12 5:14 PM Page 172 Answers to Questions 15 1
. D Absorbance
is proportional to the inverse log of transmittance. A = log T = log 1/T Multiply
ing the
numerator and denominator by 100 gives: A = log (100/100 X T) 100 X T = %T, subs
tituting %T for
100 X T gives: A = log 100/%T A = log 100 log %T A = 2.0 log %T For example, if
%T = 10.0,
then: A = 2.0 log 10.0 log 10.0 = 1.0 A = 2.01.0 = 1.0 2. B A = 2.0 log %T A = 2.
0 log 1.0
The log of 1.0 = 0 A = 2.0 3. D Beers law states that A = a b c, where a is the a
coe cient (a constant), b is the path length, and c is concentration. Absorbance i
s directly
proportional to both b and c. Doubling the path length results in incident light
contacting twice
the number of molecules in solution. This causes absorbance to double, the same
e ect as doubling
the concentration of molecules. 4. A A solution transmits light corresponding in
wavelength to

its color, and usually absorbs light of wavelengths complementary to its color.
A red solution
transmits light of 600650 nm and strongly absorbs 400500 nm light. 5. B Green ligh
t consists of
wavelengths from 500550 nm. A greencolored solution with a transmittance maximum
of 525 nm and
a 50nm bandpass transmits light of 525 nm and absorbs light below 475 nm and ab
ove 575 nm. A
solution that is green would be quantitated using a wavelength that it absorbs s
trongly, such as
450 nm. 1. Which formula correctly describes the relationship between absorbance
and %T ? A. A =
2 log %T B. A = log 1/T C. A = log T D. All of these options Chemistry/Identify b
principle(s)/Instrumentation/2 2. A solution that has a transmittance of 1.0 %T
would have an
absorbance of: A. 1.0 B. 2.0 C. 1% D. 99% Chemistry/Calculate/Beers law/2 3. In a
spectrophotometry: A. Absorbance is directly proportional to transmittance B. Pe
transmittance is directly proportional to concentration C. Percent transmittance
is directly
proportional to the light path length D. Absorbance is directly proportional to
Chemistry/De ne fundamental characteristics/ Beers law/1 4. Which wavelength would
be absorbed
strongly by a redcolored solution? A. 450 nm B. 585 nm C. 600 nm D. 650 nm Chem
istry/De ne
fundamental characteristics/ Spectrophotometry/2 5. A greencolored solution wou
ld show highest
transmittance at: A. 475 nm B. 525 nm C. 585 nm D. 620 nm Chemistry/De ne fundamen
characteristics/ Spectrophotometry/2 5.1 Instrumentation 173 2828_Ch05_171326
06/08/12 5:14 PM
Page 173 6. SITUATION: A technologist is performing an enzyme assay at 340 nm u
sing a
visiblerange spectrophotometer. After setting the wavelength and adjusting the
readout to zero
%T with the light path blocked, a cuvette with deionized water is inserted. With
the light path
fully open and the 100%T control at maximum, the instrument readout will not ris
e above 90%T.
What is the most appropriate rst course of action? A. Replace the source lamp B.
Insert a wider
cuvette into the light path C. Measure the voltage across the lamp terminals D.
Replace the
instrument fuse Chemistry/Select course of action/Spectrophotometry/3 7. Which t
ype of
monochromator produces the purest monochromatic light in the UV range? A. A di rac
tion grating
and a xed exit slit B. A sharp cuto
lter and a variable exit slit C. Interference lt
ers and a
variable exit slit D. A prism and a variable exit slit Chemistry/Select
component/Spectrophotometry/2 8. Which monochromator speci cation is required in o
rder to measure
the true absorbance of a compound having a natural absorption bandwidth of 30 nm
? A. 50nm
bandpass B. 25nm bandpass C. 15nm bandpass D. 5nm bandpass Chemistry/Select
component/Spectrophotometry/2 9. Which photodetector is most sensitive to low le
vels of light? A.

Barrier layer cell B. Photodiode C. Diode array D. Photomultiplier tube Chemistr

y/De ne
fundamental characteristics/ Instrumentation/1 10. Which condition is a common c
ause of stray
light? A. Unstable source lamp voltage B. Improper wavelength calibration C. Dis
persion from
secondorder spectra D. Misaligned source lamp Chemistry/Identify sources of
error/Spectrophotometry/2 174 Chapter 5 | Clinical Chemistry Answers to Question
s 610 6. A
Visible spectrophotometers are usually supplied with a tungsten or quartz haloge
n source lamp.
Tungsten lamps produce a continuous range of wavelengths from about 3202,000 nm.
increases as wavelength becomes longer peaking at around 1,000 nm, and is poor b
elow 400 nm. As
the lamp envelope darkens with age, the amount of light reaching the photodetect
or at 340 nm
becomes insufficient to set the blank reading to 100%T. Quartz halogen lamps pro
duce light from
300 nm through the infrared region. Deuterium or hydrogen lamps produce ultravio
letrich spectra
optimal for ultraviolet (UV) work. Mercury vapor lamps produce a discontinuous s
pectrum that
includes a high output at around 365 nm that is useful for fluorescent applicati
ons. Xenon lamps
generate a continuous spectrum of fairly uniform intensity from 3002,000 nm, maki
ng them useful
for both visible and UV applications. 7. D Diffraction gratings and prisms both
produce a
continuous range of wavelengths. A diffraction grating produces a uniform separa
tion of
wavelengths. A prism produces much better separation of highfrequency light bec
ause refraction
is greater for higherenergy wavelengths. Instruments using a prism and a variab
le exit slit can
produce UV light of a very narrow bandpass. The adjustable slit is required in o
rder to allow
sufficient light to reach the detector to set 100%T. 8. D Bandpass refers to the
range of
wavelengths passing through the sample. The narrower the bandpass, the greater t
he photometric
resolution. Bandpass can be made smaller by reducing the width of the exit slit.
absorbance measurements require a bandpass less than one fth the natural bandpass
of the
chromophore. 9. D The photomultiplier tube uses dynodes of increasing voltage to
amplify the
current produced by the photosensitive cathode. It is 10,000 times as sensitive
as a barrier
layer cell, which has no ampli cation. A photomultiplier tube requires a DCregula
ted lamp
because it responds to light uctuations caused by the AC cycle. 10. C Stray light
is caused by
the presence of any light other than the wavelength of measurement reaching the
detector. It is
most often caused by secondorder spectra, deteriorated optics, light dispersed
by a darkened
lamp envelope, and extraneous room light. 2828_Ch05_171326 06/08/12 5:14 PM
Page 174 11. A
linearity study is performed on a visible spectrophotometer at 650 nm and the fo

absorbance readings are obtained: Te study was repeated using freshly prepared s
tandards and
reagents, but results were identical to those shown. What is the most likely cau
se of these
results? A. Wrong wavelength used B. Insu cient chromophore concentration C. Matri
x interference
D. Stray light Chemistry/Identify sources of error/Spectrophotometry/3 12. Which
type of lter is
best for measuring stray light? A. Wratten B. Didymium C. Sharp cuto D. Neutral d
Chemistry/Select methods/Reagents/Media/ Spectrophotometry/2 13. Which of the fo
llowing materials
is best suited for verifying the wavelength calibration of a spectrophotometer?
A. Neutral
density lters B. Potassium dichromate solutions traceable to the National Bureau
of Standards
reference C. Wratten lters D. Holmium oxide glass Chemistry/Identify standard ope
procedure/ Spectrophotometry/2 14. Why do many optical systems in chemistry anal
yzers utilize a
reference light path? A. To increase the sensitivity of the measurement B. To mi
nimize error
caused by source lamp uctuation C. To obviate the need for wavelength adjustment
D. To reduce
stray light e ects Chemistry/De ne fundamental characteristics/ Spectrophotometry/2
5.1 |
Instrumentation 175 Answers to Questions 1114 11. D Stray light is the most com
mon cause of
loss of linearity at highanalyte concentrations. Light transmitted through the
cuvette is lowest
when absorption is highest. Therefore, stray light is a greater percentage of th
e detector
response when sample concentration is high. Stray light is usually most signi cant
measurements are made at the extremes of the visible spectrum because lamp outpu
t and detector
response are low. 12. C Sharp cutoff filters transmit almost all incident light
until the cutoff
wavelength is reached. At that point, they cease to transmit light. Because they
give an all or
none effect, only stray light reaches the detector when the selected wavelength i
s beyond the
cutoff. 13. D Wavelength accuracy is verified by determining the wavelength read
ing that gives
the highest absorbance (or transmittance) when a substance with a narrow natural
bandpass (sharp
absorbance or transmittance peak) is scanned. For example, didymium glass has a
sharp absorbance
peak at 585 nm. Therefore, an instrument should give its highest absorbance read
ing when the
wavelength dial is set at 585 nm. Holmium oxide produces a very narrow absorbanc
e peak at 361 nm;
likewise, the hydrogen lamp of a UV spectrophotometer produces a 656nm emission
line that can be
used to verify wavelength. Neutral density filters and dichromate solutions are
used to verify
absorbance accuracy or linearity. A Wratten filter is a wide bandpass filter ma
de by placing a
thin layer of colored gelatin between two glass plates and is unsuitable for spe

calibration. 14. B A reference beam is used to produce an electrical signal at t
he detector to
which the measurement of light absorption by the sample is compared. This safegu
ards against
measurement errors caused power fluctuations that change the source lamp intensi
ty. Although
reference beams increase the accuracy of measurements, they do so at the expense
of optical
sensitivity since some of the incident light must be used to produce the referen
ce beam.
Concentration of Standard Absorbance 10.0 mg/dL 0.20 20.0 mg/dL 0.41 30.0 mg/d
L 0.62 40.0 mg/dL
0.79 50.0 mg/dL 0.92 2828_Ch05_171326 06/08/12 5:14 PM Page 175 15. Which co
mponent is
required in a spectrophotometer in order to produce a spectral absorbance curve?
A. Multiple
monochromators B. A reference optical beam C. Photodiode array D. Laser light so
Chemistry/De ne fundamental characteristics/ Spectrophotometry/1 16. Te halfband
width of a
monochromator is de ned by: A. Te range of wavelengths passed at 50% maximum trans
mittance B.
Onehalf the lowest wavelength of optical purity C. Te wavelength of peak transm
ittance D.
Onehalf the wavelength of peak absorbance Chemistry/De ne fundamental characteris
Spectrophotometry/1 17. Te reagent blank corrects for absorbance caused by: A. T
e color of
reagents B. Sample turbidity C. Bilirubin and hemolysis D. All of these options
Chemistry/Identify basic principle(s)/Spectrophotometry/2 18. A plasma sample is
hemolyzed and
turbid. What is required to perform a sample blank in order to correct the measu
rement for the
intrinsic absorbance of the sample when performing a spectrophotometric assay? A
. Substitute
deionized water for the sample B. Dilute the sample 1:2 with a standard of known
concentration C.
Substitute saline for the reagent D. Use a larger volume of the sample Chemistry
/Identify basic
principle(s)/Spectrophotometry/2 19. Which instrument requires a highly regulate
d DC power
supply? A. A spectrophotometer with a barrier layer cell B. A colorimeter with m
interference lters C. A spectrophotometer with a photomultiplier tube D. A densit
ometer with a
photodiode detector Chemistry/Select component/Spectrophotometry/2 176 Chapter 5
| Clinical
Chemistry Answers to Questions 1519 15. C There are two ways to perform spectral
scanning for
compound identi cation. One is to use a stepping motor that continuously turns the
so that the wavelength aligned with the exit slit changes at a constant rate. A
more practical
method is to use a diode array detector. This consists of a chip embedded with a
s many as several
hundred photodiodes. Each photodiode is aligned with a narrow part of the spectr
um produced by a
di raction grating, and produces current proportional to the intensity of the band
of light

striking it (usually 12 nm in range). The diode signals are processed by a comput

er to create a
spectral absorbance or transmittance curve. 16. A Halfband width is a measure o
f bandpass made
using a solution or lter having a narrow natural bandpass (transmittance peak). T
he wavelength
giving maximum transmittance is set to 100%T (or 0 A). Then, the wavelength dial
is adjusted
downward, until a readout of 50%T (0.301 A) is obtained. Next, the wavelength is
adjusted upward
until 50%T is obtained. The wavelength di erence is the halfband width. The narro
wer the
halfband width, the better the photometric resolution of the instrument. 17. A
When a
spectrophotometer is set to 100%T with the reagent blank instead of water, the a
bsorbance of
reagents is automatically subtracted from each unknown reading. The reagent blan
k does not
correct for absorbance caused by interfering chromogens in the sample such as bi
hemolysis, or turbidity. 18. C A sample blank is used to subtract the intrinsic
absorbance of the
sample usually caused by hemolysis, icterus, turbidity, or drug interference. On
analyzers, this is accomplished by measuring the absorbance after the addition o
f sample and a
rst reagent, usually a diluent. For tests using a single reagent, sample blanking
can be done
prior to the incubation phase before any color develops. Substituting deionized
water for sample
is done to subtract the absorbance of the reagent (reagent blanking). Diluting t
he sample with a
standard (standard addition) may be done when the absorbance is below the minimu
m detection limit
for the assay. Using a larger volume of sample will make the interference worse.
19. C When AC
voltage regulators are used to isolate source lamp power, light output uctuates a
s the voltage
changes. Because this occurs at 60 Hz, it is not detected by eyesight or slowre
detectors. Photomultiplier tubes are sensitive enough to respond to the AC frequ
ency and require
a DCregulated power supply. 2828_Ch05_171326 06/08/12 5:14 PM Page 176 20.
Which statement
regarding re ectometry is true? A. Te relation between re ectance density and concen
tration is
linear B. Singlepoint calibration can be used to determine concentration C. 100
% re ectance is
set with an opaque lm called a white reference D. Te diode array is the photodete
ctor of choice
Chemistry/Apply principles of special procedures/ Instrumentation/2 21. Bichroma
tic measurement
of absorbance can correct for interfering substances if: A. Te contribution of t
he interferent to
absorbance is the same at both wavelengths B. Both wavelengths pass through the
simultaneously C. Te side band is a harmonic of the primary wavelength D. Te chr
omogen has the
same absorbance at both wavelengths Chemistry/Apply principles of special proced

Instrumentation/2 22. Which instrument requires a primary and secondary monochro

mator? A.
Spectrophotometer B. Atomic absorption spectrophotometer C. Fluorometer D. Nephe
Chemistry/Apply principles of special procedures/ Instrumentation/1 23. Which of
the following
statements about uorometry is accurate? A. Fluorometry is less sensitive than spe
B. Fluorometry is less speci c than spectrophotometry C. Unsaturated cyclic molecu
les are often
uorescent D. Fluorescence is directly proportional to temperature Chemistry/Apply
principles of
special procedures/ Instrumentation/2 24. Which of the following components is n
ot needed in a
chemiluminescent immunoassay analyzer? A. Source lamp B. Monochromator C. Photod
etector D. Wash
station Chemistry/De ne fundamental characteristics/ Instrumentation/1 5.1 | Instr
177 Answers to Questions 2024 20. C Re ectometry does not follow Beers law, but the
relationship between concentration and re ectance can be described by a logistic f
ormula or
algorithm that can be solved for concentration. For example, K/S = (1 R) 2
2R, where K = KubelkaMunk absorptivity
constant, S = scattering coe cient, R = re ectance density. K/S is proportio
nal to
concentration. The white reference is analogous to the 100%T setting in spectrop
hotometry and
serves as a reference signal. D r = log R 0
1 , where D r is the re ectance density, R 0 is the white reference signal
, and R 1 is the
photodetector signal for the test sample. 21. A In bichromatic photometry, the a
bsorbance of
sample is measured at two di erent wavelengths. The primary wavelength is at or ne
ar the
absorbance maximum. An interfering substance having the same absorbance at both
primary and
secondary (side band) wavelengths does not a ect the absorbance di erence (Ad). 22.
uorometer uses a primary monochromator to isolate the wavelength for excitation,
and a secondary
monochromator to isolate the wavelength emitted by the uorochrome. 23. C Increasi
ng temperature
results in more random collision between molecules by increasing their motion. T
his causes energy
to be dissipated as heat instead of uorescence. Temperature is inversely proporti
onal to
uorescence. Fluorescence is more sensitive than spectrophotometry because the det
ector signal
can be ampli ed when dilute solutions are measured. It is also more speci c than
spectrophotometry because both the excitation and emission wavelengths are chara
cteristics of the
compound being measured. 24. A Chemiluminescence is the production of light foll
owing a chemical
reaction. Immunoassays based upon chemiluminescence generate light when the chem
molecule becomes excited; therefore, a light source is not used. In immunoassay
chemiluminescent molecules such as acridinium can be used to label antigens or a

Alternatively, chemiluminescent substrates such as luminol or dioxetane phosphat

e may be used.
Light will be emitted when the enzymelabeled molecule reacts with the substrate
. In such assays,
free and bound antigen separation is required and is usually accomplished using
particles bound to either antibody or reagent antigen. 2828_Ch05_171326 06/08/
12 5:14 PM Page
177 25. Which substance is used to generate the light signal in electrochemilumi
nescence? A.
Acridinium B. Luminol C. Dioxetane phosphate D. Ruthenium Chemistry/Apply princi
ples of special
procedures/Instrumentation/2 26. Light scattering when the wavelength is greater
than 10 times
the particle diameter is described by: A. Rayleighs law B. Te BeerLambert law C. M
ies law D.
Te RayleighDebye law Chemistry/Apply principles of special procedures/ Instrument
ation/2 27.
Which statement regarding nephelometry is true? A. Nephelometry is less sensitiv
e than absorption
spectrophotometry B. Nephelometry follows Beers law C. Te optical design is ident
ical to a
turbidimeter except that a HeNe laser light source is used D. Te detector respon
se is directly
proportional to concentration Chemistry/Apply principles of special procedures/
28. Te purpose of the nebulizer in an atomic absorption spectrophotometer that u
ses a ame is to:
A. Convert ions to atoms B. Cause ejection of an outer shell electron C. Reduce
evaporation of
the sample D. Burn o organic impurities Chemistry/Apply principles of basic proce
Instrumentation/2 29. A ameless atomic absorption spectrophotometer dehydrates an
d atomizes a
sample using: A. A graphite capillary furnace B. An electron gun C. A thermoelec
semiconductor D. A thermospray platform Chemistry/Apply principles of special pr
Instrumentation/1 178 Chapter 5 | Clinical Chemistry Answers to Questions 2529 25
. D All of
these substances are chemiluminescent. Dioxetane phosphate is excited by alkalin
e phosphatase.
Acridinium and luminol are excited by hydrogen peroxide. In electrochemiluminese
nce, ruthenium is
used to label antibody or antigen. Antigenantibody complexes containing the ruthe
nium label are
bound to paramagnetic particles via a strepavidinbiotin reaction. The paramagneti
c particles are
attracted to an electrode surface. The owcell is washed with a solution containin
tripropylamine (TPA) to remove unbound ruthenium label. At the electrode surface
, the TPA is
oxidized and the electrons excite the ruthenium, causing production of 620nm li
ght. 26. A
Rayleighs law states that when the incident wavelength is much longer than the pa
diameter, there is maximum backscatter and minimum rightangle scatter. The Rayl
eighDebye law
predicts maximum rightangle scatter when wavelength and particle diameter appro
ach equality. In

nephelometry, the relationship between wavelength and diameter determines the an

gle at which the
detector is located. 27. D In nephelometry, the detector output is proportional
to concentration
(as opposed to turbidimetry where the detector is behind the cuvette). The detec
tor(s) is (are)
usually placed at an angle between 25 and 90 to the incident light, depending upon
application. Nephelometers, like uorometers, are calibrated to read zero with the
light path
blocked, and sensitivity can be increased up to 1,000 times by ampli cation of the
output or increasing the photomultiplier tube dynode voltage. 28. A The atomizer
of the atomic
absorption spectrophotometer consists of either a nebulizer and flame or a graph
ite furnace. The
nebulizer disperses the sample into a fine aerosol, distributing it evenly into
the flame. Heat
from the flame is used to evaporate water and break the ionic bonds of salts, fo
rming ground
state atoms. The flame also excites a small percentage of the atoms, which relea
se a
characteristic emission line. 29. A Flameless atomic absorption uses a hollow tu
be of graphite
with quartz ends. The tube is heated in stages by an electric current to success
ively dry, ash,
and atomize the sample. During the ash and atomization steps, argon is injected
into the tube to
distribute the atoms. The furnace is more sensitive than a ame atomizer and more
e cient in
atomizing thermostable salts. However, it is prone to greater matrix interferenc
e and is slower
than the ame atomizer because it must cool down before introduction of the next s
2828_Ch05_171326 06/08/12 5:14 PM Page 178 30. When measuring lead in whole
blood using
atomic absorption spectrophotometry, what reagent is required to obtain the need
ed sensitivity
and precision? A. Lanthanum B. Lithium C. Triton X100 D. Chloride Chemistry/App
ly principles of
special procedures/ Instrumentation/1 31. Interference in atomic absorption spec
caused by di erences in viscosity is called: A. Absorption interference B. Matrix
e ect C.
Ionization interference D. Quenching Chemistry/Evaluate sources of error/Instrum
entation/2 32.
All of the following are required when measuring magnesium by atomic absorption
except: A. A hollow cathode lamp with a magnesium cathode B. A chopper to preven
t optical
interference from magnesium emission C. A monochromator to isolate the magnesium
emission line at
285 nm D. A 285nm reference beam to correct for background absorption Chemistry
methods/Reagents/Media/ Electrolytes/2 33. When measuring calcium by atomic abso
spectrophotometry, which is required? A. An organic extraction reagent to deconj
ugate calcium
from protein B. An internal standard C. A magnesium chelator D. Lanthanum oxide
to chelate

phosphates Chemistry/Select methods/Reagents/Media/ Electrolytes/2 34. Ion selec

tive analyzers
using undiluted samples have what advantage over analyzers that use a diluted sa
mple? A. Can
measure over a wider range of concentration B. Are not subject to pseudohyponatr
emia caused by
high lipids C. Do not require temperature equilibration D. Require less maintena
Chemistry/Apply knowledge to identify sources of error/Electrolytes/2 5.1 | Inst
rumentation 179
Answers to Questions 3034 30. C A graphite furnace is preferred over a ame for mea
suring lead
because it is su ciently sensitive to detect levels below 5 g/dL, the cuto needed fo
r lead
screening of children. The matrix modi er consists of Triton X -100, ammonium phos
phate and
nitric acid. This allows for release of Pb from the RBCs, and solubilization of
cell stroma. The
matrix modi er also prevents loss of Pb caused by formation of lead halides and pr
interaction between Pb and the tube wall, preventing its loss during the ashing
cycle. 31. B
Signi cant di erences in aspiration and atomization result when the matrix of sample
and unknowns
di er. Di erences in viscosity and protein content are major causes of matrix error.
e ects can be reduced by using protein-based calibrators and diluting both standar
ds and samples
prior to assay. 32. D Atomic absorption requires a lamp with a cathode made from
the metal to be
assayed. The lamp emits the line spectrum of the metal, providing the wavelength
that the atoms
can absorb. The chopper pulses the source light, allowing it to be discriminated
from light
emitted by excited atoms. A monochromator eliminates light emitted by the ideal
gas in the lamp.
Deuterium (wide bandpass light) or Zeeman correction (splitting the incident lig
ht into side
bands by a magnetic field) may be used to correct for background absorption. 33.
D An acidic
diluent such as hydrochloric acid (HCl) will displace calcium bound to albumin.
However, calcium
forms a thermostable bond with phosphate that causes chemical interference in at
omic absorption.
Lanthanum displaces calcium, forming lanthanum phosphate, and eliminates interfe
rence from
phosphates. Unlike in some colorimetric methods for calcium (e.g., o-cresolphtha
lein complexone),
magnesium does not interfere because it does not absorb the 422.7 nm emission li
ne from the
calcium-hollow cathode lamp. 34. B Ion-selective analyzers measure the electroly
te dissolved in
the uid phase of the sample in millimoles per liter of plasma water. When undilut
ed blood is
assayed, the measurement is independent of colloids such as protein and lipid. H
samples cause falsely low sodium measurements when assayed by ame photometry and
analyzers requiring dilution because lipids displace plasma water containing the

One drawback to undiluted or direct measuring systems is that the electrodes req
uire more
frequent deproteinization and usually have a shorter duty cycle. 2828_Ch05_171-3
26 06/08/12
5:14 PM Page 179 35. Select the equation describing the potential that develops
at the surface
of an ion-selective electrode. A. van Deemter equation B. van Slyke equation C.
Nernst equation
D. HendersonHasselbalch equation Chemistry/De ne fundamental characteristics/ Instr
36. Te reference potential of a silversilver chloride electrode is determined by
the: A.
Concentration of the potassium chloride lling solution B. Surface area of the ele
ctrode C.
Activity of total anion in the paste covering the electrode D. Te concentration
of silver in the
paste covering the electrode Chemistry/De ne fundamental characteristics/ Instrume
ntation/1 37.
Te term RT/nF in the Nernst equation de nes the: A. Potential at the ion-selective
membrane B.
Slope of the electrode C. Decomposition potential D. Isopotential point of the e
Chemistry/De ne fundamental characteristics/ Instrumentation/1 38. Te ion-selectiv
e membrane used
to measure potassium is made of: A. High-borosilicate glass membrane B. Polyviny
l chloride
dioctylphenyl phosphonate ion exchanger C. Valinomycin gel D. Calomel Chemistry/
Apply principles
of basic laboratory procedures/Electrolytes/1 39. Te response of a sodium electr
ode to a 10-fold
increase in sodium concentration should be: A. A 10-fold drop in potential B. An
increase in
potential of approximately 60 mV C. An increase in potential of approximately 10
mV D. A decrease
in potential of approximately 10 mV Chemistry/Calculate/Electrolytes/2 180 Chapt
er 5 | Clinical
Chemistry Answers to Questions 3539 35. C The van Deemter equation describes the
between the velocity of mobile phase to column efficiency in gas chromatography.
HendersonHasselbalch equation is used to determine the pH of a solution containin
g a weak acid
and its salt. van Slyke developed an apparatus to measure CO 2 and O 2 content u
sing a manometer.
36. A The activity of any solid or ion in a saturated solution is unity. For a s
ilver electrode
covered with silver chloride paste, the Nernst equation is E = E RT/nF 2.3 log 10
[Ag Cl
[AgCl]. Because silver and silver
chloride have an activity of 1.0, and all components except chloride are
constants, the
potential of the reference electrode is determined by the chloride concentration
of the lling
solution. E = E o RT/nF 2.3 log 10 [Cl
= E 59.2 mV
(at room temperature)
37. B In the term RT/nF, R = the molar gas constant, T = temperature in
degrees Kelvin, F =
Faradays constant, and n = the number of electrons donated per atom of reductant.

The slope
depends upon the temperature of the solution and the valence of the reductant. A
t room
temperature, the slope is 59.2 mV for a univalent ion and 29.6 mV for a divalent
ion. 38. C
Valinomycin is an antibiotic with a highly selective reversible-binding a nity for
ions. Sodium electrodes are usually composed of a glass membrane with a high con
tent of aluminum
silicate. Calcium and lithium ion-selective electrodes are made from organic liq
uid ion
exchangers called neutral carrier ionophores. Calomel is made of mercury covered
with a paste of
mercurous chloride (Hg/Hg 2 Cl 2 ) and is used as a reference electrode for pH. 3
9. B The Nernst
equation predicts an increase of approximately 60 mV per 10-fold increase in sod
ium activity. For
sodium: E = E + RT/nF 2.3 log 10 [Na +
RT/nF 2.3 = 60 mV at 37C. Therefore: E = E + 60 mV log 10 [Na +
If sodium concentration is 10 mmol/L, then: E = E + 60 mV log 10 [10] = E
+ 60 mV. If
sodium concentration increases from 10 mmol/L to 100 mmol/L, then: E = E + 60 mV
log 10 [100]
= E + 60 mV 2 = E + 120 mV. 2828_Ch05_171-326 06/08/12 5:14 PM Page 180 40. Whi
ch of the
electrodes below is a current- producing (amperometric) rather than a voltage-pr
(potentiometric) electrode? A. Clark electrode B. Severinghaus electrode C. pH e
lectrode D.
Ionized calcium electrode Chemistry/De ne fundamental characteristics/ Instrumenta
tion/1 41.
Which of the following would cause a response error from an ion-selective electrod
e for sodium
when measuring serum but not the calibrator? A. Interference from other electrol
ytes B. Protein
coating the ion-selective membrane C. An overrange in sodium concentration D. Pr
otein binding to
sodium ions Chemistry/Identify sources of error/Electrolytes/2 42. In polarograp
hy, the voltage
needed to cause depolarization of the cathode is called the: A. Half-wave potent
ial B.
Isopotential point C. Decomposition potential D. Polarization potential Chemistr
y/De ne
fundamental characteristics/ Instrumentation/1 43. Persistent noise from an ionselective
electrode is most often caused by: A. Contamination of sample B. Blocked junctio
n at the salt
bridge C. Overrange from high concentration D. Improper calibration Chemistry/Id
entify sources of
error/Electrolytes/2 44. Which element is reduced at the cathode of a Clark pola
electrode? A. Silver B. Oxygen C. Chloride D. Potassium Chemistry/De ne fundamenta
characteristics/ Instrumentation/1 45. Which of the following statements accurat
ely characterizes
the coulometric titration of chloride? A. Te indicator electrodes generate volta
ge B. Constant
current must be present across the generator electrodes C. Silver ions are forme

d at the
generator cathode D. Chloride concentration is inversely proportional to titrati
on time
Chemistry/De ne fundamental characteristics/ Instrumentation/2 5.1 | Instrumentati
on 181
Answers to Questions 4045 40. A The Clark electrode is composed of two half cells
that generate
current, not voltage. It is used to measure partial pressure of oxygen (PO 2 ),
and is based upon
an amperometric method called polarography. When 0.8 V is applied to the cathode,
O 2 is
reduced, causing current to ow. Current is proportional to the PO 2 of the sample
. 41. B
Response is the time required for an electrode to reach maximum potential. Ion-s
analyzers use a microprocessor to monitor electrode response, slope, drift, and
noise. When an
electrode gives an acceptable response time when measuring an aqueous calibrator
, but not when
measuring serum, the cause is often protein buildup on the membrane. 42. C In po
larography, a
minimum negative voltage must be applied to the cathode to cause reduction of me
tal ions (or O 2
) in solution. This is called the decomposition potential. It is concentration d
ependent (dilute
solutions require greater negative voltage), and can be determined using the Ner
nst equation. 43.
B Electrode noise most often results from an unstable junction potential. Most r
electrodes contain a high concentration of KCl internal solution used to produce
the reference
potential. This forms a salt bridge with the measuring half cell by contacting s
ample, but is
kept from equilibrating via a barrier called a junction. When this junction beco
mes blocked by
salt crystals, the reference potential will be unstable, resulting in uctuation i
n the analyzer
readout. 44. B The Clark electrode is designed to measure oxygen. O 2 di uses thro
ugh a
gas-permeable membrane covering the electrode. It is reduced at the cathode, whi
ch is made of
platinum or other inert metal. Electrons are supplied by the anode, which is mad
e of silver. The
net reaction is: 4 KCl + 2 H 2 O + O 2 + 4 Ag 4 AgCl + 4 KOH 45. B The Cotlove chl
oridometer is
based upon the principle of coulometric titration with amperometric detection. C
harge in the form
of silver ions is generated by oxidation of silver wire at the generator anode.
Silver ions react
with chloride ions, forming insoluble silver chloride (AgCl). When all of the ch
loride is
titrated, free silver ions are detected by reduction back to elemental silver, w
hich causes an
increase in current across the indicator electrodes (a pair of silver electrodes
with a voltage
di erence of about 1.0 V DC). Charge or titration time is directly proportional to
concentration as long as the rate of oxidation remains constant at the generator
2828_Ch05_171-326 06/08/12 5:14 PM Page 181 46. In the coulometric chloride t

itration: A.
Acetic acid in the titrating solution furnishes the counter ion for reduction B.
Te endpoint is
detected by amperometry C. Te titrating reagent contains a phosphate bu er to keep
pH constant D.
Nitric acid (HNO 3 ) is used to lower the solubility of AgCl Chemistry/Apply pri
nciples of
special procedures/ Electrolytes/2 47. Which of the following compounds can inte
rfere with the
coulometric chloride assay? A. Bromide B. Ascorbate C. Acetoacetate D. Nitrate C
knowledge to identify sources of error/Electrolytes/2 48. All of the following c
contribute to the osmolality of plasma except: A. Lipids B. Creatinine C. Drug m
etabolites D.
Glucose Chemistry/Apply knowledge of fundamental biological characteristics/Osmo
lality/2 49. One
mole per kilogram H 2 O of any solute will cause all of the following except: A.
Lower the
freezing point by 1.86C B. Raise vapor pressure by 0.3 mm Hg C. Raise the boiling
point by
0.52C D. Raise osmotic pressure by 22.4 atm Chemistry/Apply knowledge of fundamen
tal biological
characteristics/Osmolality/2 50. What component of a freezing point osmometer me
asures the sample
temperature? A. Termistor B. Termocouple C. Capacitor D. Electrode Chemistry/App
ly principles of
special procedures/ Osmometry/1 51. What type of measuring circuit is used in a
freezing point
osmometer? A. Electrometer B. Potentiometer C. Wheatstone bridge D. Termal condu
ctivity bridge
Chemistry/Apply principles of special procedures/ Osmometry/1 182 Chapter 5 | Cl
inical Chemistry
Answers to Questions 4651 46. B Reduction of Ag + back to Ag generates the current
, which
signals the endpoint. The titrating reagent contains HNO 3 , acetic acid, H 2 O,
and either
gelatin or polyvinyl alcohol. The HNO 3 furnishes nitrate, which is reduced at t
he generator
cathode, forming ammonium ions. The ammonium becomes oxidized back to nitrate at
the indicator
anode. Gelatin or polyvinyl alcohol is needed to prevent pitting of the generato
r anode. Acetic
acid lowers the solubility of AgCl, preventing dissociation back to Ag + . 47. A
Chloride assays
based upon either coulometric or chemical titration are subject to positive inte
rference from
other anions and electronegative radicals that may be titrated instead of chlori
de ions. These
include other halogens such as bromide, cyanide, and cysteine. 48. A Osmolality
is the
concentration (in moles) of dissolved solute per kilogram solvent. Proteins and
lipids are not in
solution, and do not contribute to osmolality. The nonionized solutes such as gl
ucose and urea
contribute 1 osmole per mole per kilogram water, whereas dissociated salts contr
ibute 1 osmole
per mole of each dissociated ion or radical. 49. B Both freezing point and vapor
pressure are
lowered by increasing solute concentration. Boiling point and osmotic pressure a

re raised.
Increasing solute concentration of a solution opposes a change in its physical s
tate and lowers
the concentration of H 2 O molecules. 50. A A thermistor is a temperature-sensit
ive resistor. The
resistance to current ow increases as temperature falls. The temperature at which
a solution
freezes can be determined by measuring the resistance of the thermistor. Resista
nce is directly
proportional to the osmolality of the sample. 51. C The resistance of the thermi
stor is measured
using a network of resistors called a Wheatstone bridge. When the sample is froz
en, the bridge is
balanced using a calibrated variable resistor, so that no current ows to the read
out. The
resistance required to balance the meter is equal to the resistance of the therm
2828_Ch05_171-326 06/08/12 5:14 PM Page 182 52. Which measurement principle i
s employed in a
vapor pressure osmometer? A. Seebeck B. Peltier C. Hayden D. Darlington Chemistr
principles of special procedures/ Osmometry/1 53. Te freezing point osmometer di e
rs from the
vapor pressure osmometer in that only the freezing point osmometer: A. Cools the
sample B. Is
sensitive to ethanol C. Requires a thermoelectric module D. Requires calibration
with aqueous
standards Chemistry/Apply principles of special procedures/ Osmometry/2 54. Te m
ethod for
measuring iron or lead by plating the metal and then oxidizing it is called: A.
Polarography B.
Coulometry C. Anodic stripping voltometry D. Amperometry Chemistry/Apply princip
les of special
procedures/ Instrumentation/1 55. Te term isocratic is used in high-performance
chromatography (HPLC) to mean the: A. Mobile phase is at constant temperature B.
Stationary phase
is equilibrated with the mobile phase C. Mobile phase consists of a constant sol
vent composition
D. Flow rate of the mobile phase is regulated Chemistry/Apply principles of spec
ial procedures/
High-performance liquid chromatography/1 56. Te term reverse phase is used in HP
LC to indicate
that the mobile phase is: A. More polar than the stationary phase B. Liquid and
the stationary
phase is solid C. Organic and the stationary phase is aqueous D. A stronger solv
ent than the
stationary phase Chemistry/Apply principles of special procedures/ High-performa
nce liquid
chromatography/1 57. What is the primary means of solute separation in HPLC usin
g a C18 column?
A. Anion exchange B. Size exclusion C. Partitioning D. Cation exchange Chemistry
/Apply principles
of special procedures/ High-performance liquid chromatography/1 5.1 | Instrument
ation 183
Answers to Questions 5257 52. A The Seebeck e ect refers to the increase in voltage
across the
two junctions of a thermocouple caused by a di erence in the temperature at the ju
Increasing osmolality lowers the dew point of a sample. When sample is cooled to

its dew point,

the voltage change across the thermocouple is directly proportional to osmolalit
y. 53. B Alcohol
enters the vapor phase so rapidly that it evaporates before the dew point of the
sample is
reached. Therefore, ethanol does not contribute to osmolality as measured using
the vapor
pressure osmometer. Freezing-point osmometers measure alcohol and can be used in
department settings to estimate ethanol toxicity. 54. C Anodic stripping voltome
try is used to
measure lead and iron. The cation of the metal is plated onto a mercury cathode
by applying a
negative charge. The voltage of this electrode is reversed until the plated meta
l is oxidized
back to a cation. Current produced by oxidation of the metal is proportional to
55. C An isocratic separation uses a single mobile phase of constant composition
, pH, and
polarity, and requires a single pump. Some HPLC separations use a gradient mobil
e phase to
increase distance between peaks. Gradients are made by mixing two or more solven
ts using a
controller to change the proportions of solvent components. 56. A In reverse-pha
se HPLC, the
separation takes place using a nonpolar sorbent (stationary phase) such as octad
ecylsilane (C18).
Solutes that are nonpolar are retained longer than polar solutes. Most clinical
separations of
drugs, hormones, and metabolites use reverse phase because aqueous mobile phases
are far less
toxic and ammable. 57. C Stationary phases (column packings) used in HPLC separat
e solutes by
multiple means, but in reverse-phase HPLC the relative solubility between the mo
bile phase and
stationary phase is most important and depends upon solvent polarity, pH, and io
nic strength.
2828_Ch05_171-326 06/08/12 5:14 PM Page 183 58. Te most commonly used detecto
r for clinical
gasliquid chromatography (GLC) is based upon: A. Ultraviolet light absorbance at
254 nm B. Flame
ionization C. Refractive index D. Termal conductance Chemistry/Apply principles
of special
procedures/ Gas chromatography/1 59. What type of detector is used in high-perfo
rmance liquid
chromatography with electrochemical detection (HPLCECD)? A. Calomel electrode B.
electrode C. Glassy carbon electrode D. Polarographic electrode Chemistry/Apply
principles of
special procedures/ High-performance liquid chromatography/1 60. In gas chromato
graphy, the
elution order of volatiles is usually based upon the: A. Boiling point B. Molecu
lar size C.
Carbon content D. Polarity Chemistry/Apply principles of special procedures/ Gas
61. Select the chemical that is used in most HPLC procedures to decrease solvent
polarity. A.
Hexane B. Nonane C. Chloroform D. Acetonitrile Chemistry/Apply principles of spe
cial procedures/
Biochemical/2 62. In thin-layer chromatography (TLC), the distance the solute mi

grates divided by
the distance the solvent migrates is the: A. t R B. K d C. R f D. pK Chemistry/A
pply principles
of special procedures/ High-performance liquid chromatography/1 63. Which reagen
t is used in
thin-layer chromatography (TLC) to extract cocaine metabolites from urine? A. Ac
id and sodium
chloride B. Alkali and organic solvent C. Chloroform and sodium acetate D. Neutr
al solution of
ethyl acetate Chemistry/Apply principles of special procedures/ Biochemical/2 18
4 Chapter 5 |
Clinical Chemistry Answers to Questions 5863 58. B Volatile solutes can be detect
ed in GLC using
ame ionization, thermal conductivity, electron capture, and mass spectroscopy. In
ionization, energy from a ame is used to excite the analytes as they elute from t
he column. The
ame is made by igniting a mixture of hydrogen, carrier gas, and air. Current is p
roduced when an
outer shell electron is ejected from the excited analyte. 59. C HPLCECD uses a gl
assy carbon
measuring electrode and a silversilver chloride reference. The analyte is oxidize
d or reduced by
holding the glassy carbon electrode at a positive voltage (oxidization) or negat
ive voltage
(reduction). The resulting current ow is directly proportional to concentration.
Phenolic groups
such as catecholamines can be measured by HPLCECD. 60. A The order of elution is
dependent upon
the velocity of the analyte. Usually, the lower the boiling point of the compoun
d, the greater
its velocity or solubility in carrier gas. 61. D All of the compounds mentioned
have nonpolar
properties. Because most HPLC is reverse phase (a polar solvent is used), hexane
and nonane are
too nonpolar. Acetonitrile is more polar and less toxic than chloroform and alon
g with methanol
is a common polarity modi er for HPLC. 62. C R f is the distance migrated by the s
olute divided
by the distance migrated by the solvent. The t R refers to the retention time of
the solute in
HPLC or gas chromatography (GC). The K d is the partition coe cient, and is a meas
ure of the
relative a nity of solutes for the stationary phase. The solute with the greater K
d will be
retained longer. The pK is the negative logarithm of K, the ionization constant,
and is a measure
of ionization. 63. B Alkaline drugs such as cocaine, amphetamine, and morphine a
re extracted at
alkaline pH. Ideally, the pH for extracting alkaline drugs into an organic solve
nt should be 2 pH
units greater than the negative log of dissociation constant (pK a ) of the drug
. More than 90%
of the drug will be nonionized and will extract in ethyl acetate or another orga
nic solvent.
2828_Ch05_171-326 06/08/12 5:14 PM Page 184 64. What is the purpose of an int
ernal standard in
HPLC and GC methods? A. To compensate for variation in extraction and injection
B. To correct for
background absorbance C. To compensate for changes in ow rate D. To correct for c

oelution of
solutes Chemistry/Apply principles of special procedures/ Chromatography/2 65. W
hat is the
con rmatory method for measuring drugs of abuse? A. HPLC B. Enzyme-multiplied immu
technique (EMIT) C. Gas chromatography with mass spectroscopy (GC-MS) D. TLC Che
instruments to perform test/Drugs of abuse/2 66. Te fragments typically produced
and analyzed in
methods employing mass spectroscopy are typically: A. Of low molecular size rang
ing from 10100
daltons B. Cations caused by electron loss or proton attachment C. Anions caused
by bombarding
the molecule with an electron source D. Neutral species formed after excited mol
ecules form a
stable resonance structure Chemistry/Identify basic principle(s)/Mass spectrosco
py/1 67. What
component is used in a GC-MS but not used in an LC-MS? A. Electron source B. Mas
s lter C.
Detector D. Vacuum Chemistry/De ne fundamental characteristics/ Instrumentation/1
5.1 |
Instrumentation 185 Answers to Questions 6467 64. A Internal standards should h
ave the same
a nity as the analyte for the extraction reagents. Dividing peak height (or area)
of all samples
(standards and unknowns) by the peak height (or area) of the internal standard r
educes error
caused by variation in extraction recovery and injection volume. 65. C GC-MS det
ermines the mass
spectrum of the compounds eluting from the analytic column. Each substance has a
unique and
characteristic spectrum of mass fragments. This spectrum is compared to spectra
in a library of
standards to determine the percent match. A match of greater than 95% is conside
red con rmatory.
66. B In almost all MS applications, cations of the molecule are measured. Catio
ns can be formed
by various methods, the most common of which is electron bombardment (electron i
onization). The
energy transferred to the molecule causes ejection of an outer shell electron. M
S can analyze
sizes from trace metals through macromolecules. Proteins are measured following
conversion to
cations by ionization procedures such as matrix-assisted laser desorption ioniza
tion (MALDI) in
which energy from a nitrogen laser causes transfer of a proton from the matrix (
an acid) to the
protein. 67. A The mass spectrometer requires a sample that is suspended in a ga
s phase, and
therefore, the sample from a GC can be directly injected into the mass spectrome
ter. While
chemical ionization of the sample is possible, most GC-MS instruments utilize el
ionization. Electrons are produced by applying 70 electron volts to a lament of t
ungsten or
rhenium under vacuum. The electrons collide with the neutral molecules coming fr
om the GC,
splitting them into fragments. The array of fragments is a unique identi er of eac
h molecule.
2828_Ch05_171-326 06/08/12 5:14 PM Page 185 68. What process is most often us

ed in LC-MS to
introduce the sample into the mass lter? A. Electrospray ionization B. Chemical i
onization C.
Electron impact ionization D. Fast atom bombardment Chemistry/Identify basic pri
spectroscopy/1 69. In mass spectroscopy, the term base peak typically refers to:
A. Te peak with
the lowest mass B. Te peak with the most abundance C. A natural isotope of the m
olecular ion D.
Te rst peak to reach the mass detector Chemistry/De ne fundamental characteristics/
Instrumentation/1 70. Which method is the most useful when screening for errors
of amino and
organic acid metabolism? A. Two-dimensional thin-layer chromatography B. Gas chr
omatography C.
Electrospray ionization tandem-mass spectroscopy D. Inductively charged coupledmass spectroscopy
Chemistry/Select instruments to perform test/Newborn screening/2 186 Chapter 5 |
Chemistry Answers to Questions 6870 68. A HPLC instruments use solvent rather tha
n gas to
separate molecules. The sample is converted into a gaseous state by electrospray
before it enters the mass lter. Electrospray ionization uses a small-bore tube th
at forms a 14
nozzle at the mass lter inlet and which is charged by several kilovolts. The samp
le enters the
tube along with inert drying gas. The tube is heated to help evaporate solvent,
but unlike
electron impact used in GC-MS, the ionizer is not under vacuum. When a droplet o
f the sample
reaches the nozzle, it becomes highly charged. The size of the droplet is decrea
sed owing to
evaporation. This causes the charge density to become excessive, and the droplet
s break apart.
The tiny charged droplets repel each other and break apart again, forming a plum
e. These
particles are drawn into the mass lter by ion optics (a system of repeller plates,
electrode, and magnets). ESI does not result in extensive fragmentation, produci
ng mostly the
parent or molecular ion, a process called soft ionization. 69. B The base peak is
typically the
molecular ion or parent ion, meaning that it is the initial fragment made by relea
sing an
electron. The cation thus formed has a charge of +1, and therefore, its m/z rati
o is equal to its
mass. The base peak is used for selective ion monitoring (SIM). It is the most a
bundant and most
stable ion, and gives the best sensitivity for quantitative analysis. 70. C Whil
e two-dimensional
thin-layer chromatography can separate both amino and organic acids, it is not s
u ciently
sensitive for newborn screening. Electrospray ionization allows a small alcoholextracted
whole-blood sample to be analyzed by two mass spectrometers without prior separa
tion by liquid or
gas chromatography. Disorders of both organic and fatty acid metabolism are iden
ti ed by the
speci c pattern of acylcarnitine ions produced. Amino acids are detected as amino
species that

have lost a carboxyl group during ionization, a process called neutral loss. 282
06/08/12 5:14 PM Page 186 71. In tandem-mass spectroscopy, the rst mass lter per
forms the
same function as: A. Te ion source B. Te chromatography column C. Extraction D.
Te vacuum system
Chemistry/Apply principles of special procedures/ Instrumentation/1 72. SITUATIO
analysis using nitrogen as the carrier gas shows an extensively noisy baseline.
A sample of the
solvent used for the extraction procedure, ethyl acetate, was injected and showe
d the same noise.
Results of an Autotune test showed the appearance of a base peak at 16 with two
smaller peaks at
17 and 18. Tese results indicate: A. Te solvent is contaminated B. Te carrier ga
s is contaminated
C. Tere is electrical noise in the detector D. Te ion source is dirty Chemistry/
Evaluate sources
of error/GC-MS/3 73. Why is vacuum necessary in the mass lter of a mass spectrome
ter? A.
Ionization does not occur at atmospheric pressure B. It prevents collision betwe
en fragments C.
It removes electrons from the ion source D. It prevents contamination Chemistry/
Identify basic
principle(s)/Mass spectroscopy/2 5.1 | Instrumentation 187 Answers to Question
s 7173 71. B A
tandem mass spectrometer uses two or more mass lters in sequence. The rst lter func
tions as an
ion trap. Once the sample is ionized, the lter selects molecular or parent ions o
f interest by
excluding ions outside a speci ed size range. Therefore, it e ectively separates the
of interest from unwanted compounds. Tandem MS uses ESI to introduce the sample
into the rst
mass lter, usually a quadrapole. The RF and DC voltages of the quadrapole are set
to optimize
the trajectory of the parent ions of interest and cause ejection of unwanted ion
s. The parent
ions are drawn into a second mass lter where they are bombarded by argon atoms. T
he collisions
result in the formation of mass fragments called daughter ions. This process is
collision-induced dissociation and the second lter is called a collision chamber.
The process
can be repeated in a third mass lter that generates granddaughter ions. A total-i
on chromatogram
is produced from these, enabling the compound of interest to be identi ed and quan
ti ed. Tandem
MS is used to screen for inborn errors of fatty acid, amino acid, and organic ac
id metabolism.
72. B All of these situations are sources of baseline noise in GC-MS. However, t
he peak at 16
indicates the presence of oxygen in the carrier gas. Oxygen in the atmosphere al
so contains small
quantities of two isotopes with molecular weights of 17 and 18 owing to one and
two extra
neutrons, respectively. 73. B Vacuum is needed in the mass lter of the MS to prev
ent random
collisions between ions that would alter their trajectory or time of ight. It is
also needed in

CG-MS instruments that use electron ionization. The vacuum prevents collision be
tween the carrier
gas molecules and the ions. In spectrometers that use electrospray ionization, c
ionization, and laser desorption ionization (MALDI and SELDI TOF), the ion sourc
e is not under
vacuum. 2828_Ch05_171-326 06/08/12 5:14 PM Page 187 74. What method is used t
o introduce the
sample into a mass spectrometer for analysis of a trace element? A. Electrospray
ionization B.
Laser desorption C. Inductively charged plasma (ICP) ionization D. Direct inject
Chemistry/Apply principles of special procedures/ Instrumentation/2 75. Which co
mponent is needed
for a thermal cycler to amplify DNA? A. Programmable heating and cooling unit B.
Vacuum chamber
with zero head space C. Sealed airtight constant-temperature chamber D. Temperat
ionization chamber Chemistry/De ne fundamental characteristics/ Instrumentation/1
76. In
real-time PCR, what value is needed in order to determine the threshold? A. Back
ground signal B.
Melt temperature C. Maximum uorescence D. Treshold cycle Chemistry/Apply principl
es of special
procedures/ Instrumentation/1 188 Chapter 5 | Clinical Chemistry Answers to Ques
tions 7476 74. C
Mass spectrometers can be used to measure trace metals, but the atoms need to be
vaporized and
ionized like molecules before they enter the mass lter. This is done by introduci
ng the sample
into a very hot plasma (6,00010,000K) called a torch. The torch is made by circula
ting argon
through inner and outer quartz tubes. The tubes are wrapped with a coil of wire
that receives a
radio frequency. This creates current ow through the wire and a magnetic eld at th
e torch end.
Argon atoms are excited by the current and magnetic eld and ionize. When the argo
n is ignited by
a spark, it forms the plasma. The sample is mixed with argon at the other end to
create an
aerosol. When it reaches the torch, the solvent is evaporated and the energy fro
m the torch and
collisions with argon ions cause ejection of outer- shell electrons, forming cat
ions of the
element. ICP-MS is used to measure any trace element that readily forms cations.
75. A The
polymerase chain reaction for DNA ampli cation consists of three phases. Denaturat
ion requires a
temperature of 90C94C and separates the double-stranded DNA. Annealing requires a t
between 40C65C and allows the primers to bind to the target base sequence. Extensio
n requires
a temperature of 72C and allows the heat-stable polymerase to add complementary b
ases to the
primer in the 5 to 3 direction. A cycle consists of each temperature stage for a s
peci c number
of minutes and most procedures require 30 or more cycles to generate a detectabl
e quantity of
target DNA. Rapid heating and cooling is usually achieved using a thermoelectric
block that is

cooled by forced air ow. 76. A In real-time PCR, the uorescence of the reporter pr
obe is
proportional to the concentration of PCR products. For quantitation of PCR produ
cts, a well
factor and background uorescence must be determined. Well-factor values are analo
gous to cuvette
blanks. They are used to correct the measurements from each well so that the sam
e concentration
of uorescent dye gives the same signal intensity regardless of the well. The thre
shold is the
lowest signal that indicates the presence of product. It can be calculated manua
lly from a
real-time ampli cation curve by nding the average standard deviation of the uorescen
t signal
(RFU) from cycles 210. This is multiplied by 10 to give the threshold value in RF
2828_Ch05_171-326 06/08/12 5:14 PM Page 188 77. Given the following real-time
PCR ampli cation
curve, what is the threshold cycle? 5.1 | Instrumentation 189 Answers to Quest
ions 7780 77. C
The maximum curvature of the plot approximates the threshold cycle. A line is dr
awn from the
threshold value on the y-axis through the curve, and a perpendicular dropped to
the x-axis. The
Ct is determined by the intersection point on the x-axis. The threshold is usual
ly determined by
an algorithm but can be calculated manually as 10 times the average standard dev
iation of the
RFUs for cycles 210. 78. A The relative centrifugal force (number times the force
of gravity) is
proportional to the square of the rotor speed in revolutions per minute and the
radius in
centimeters of the head (distance from the shaft to the end of the tube). RCF =
s 2 x r x 1.118 x
10 5 where s is the speed in RPM, r is the radius in cM, and 1.118 x 10 5 is a con
constant. 79. B Electronic balances do not use substitution weights or knife edg
es to balance the
weight on the pan. Instead, they measure the displacement of the pan by the weig
ht on it using
electromagnetic force to return it to its reference position. Regardless of the
type of balance
used, all need to be located on a rm weighing table free of vibration. Doors must
be closed to
prevent air currents from in uencing the weighing, and the pan and platform must b
e clean and
free of dust and chemical residue. 80. D Gravimetric and spectrophotometric anal
ysis are the two
methods used to verify pipet volume accuracy and precision. Since spectrophotome
tric analysis
involves dilution, gravimetric analysis is associated with greater certainty. At
20C, the
density of pure water is 0.99821 g/mL. Therefore, each microliter weighs almost
exactly 1.0 mg.
A. 15 B. 20 C. 25 D. 30 Chemistry/Apply principles of special procedures/PCR/2 7
8. In addition to
velocity, what variable is also needed to calculate the relative centrifugal for
ce (g force) of a
centrifuge? A. Head radius B. Angular velocity coe cient C. Diameter of the centri
fuge tube D.

Ambient temperature in degrees Centigrade Chemistry/De ne fundamental characterist

Instrumentation/1 79. Which of the following situations is likely to cause an er
ror when weighing
with an electronic analytical balance? A. Failure to keep the knife edge clean B
. Failure to
close the doors of the balance before reading the weight C. Oxidation on the sur
face of the
substitution weights D. Using the balance without allowing it to warm up for at
least 10 minutes
Chemistry/Identify sources of error/Balances/3 80. When calibrating a semiautoma
tic pipet that
has a xed delivery of 10.0 L using a gravimetric method, what should be the averag
e weight of
deionized water transferred? A. 10.0 g B. 100.0 g C. 1.0 mg D. 10.0 mg Chemistry/D
e ne
fundamental characteristics/ Instrumentation/1 2828_Ch05_171-326 06/08/12 5:14
PM Page 189 190
5.2 Blood Gases, pH, and Electrolytes 1. Which of the following represents the
HendersonHasselbalch equation as applied to blood pH? A. pH = 6.1 + log HCO 3
2 B. pH = 6.1 + log HCO 3
(0.03 PCO
2 ) C. pH = 6.1 + log dCO 2
3 D. pH = 6.1 + log (0.03 PCO 2 )/HCO 3 Chemistry/Calculate/Acidbase/1 2.
What is the
PO 2 of calibration gas containing 20.0% O 2 , when the barometric pressure is 3
0 in.? A. 60 mm
Hg B. 86 mm Hg C. 143 mm Hg D. 152 mm Hg Chemistry/Calculate/Blood gas/2 3. What
is the blood pH
when the partial pressure of carbon dioxide (PCO 2 ) is 60 mm Hg and the bicarbo
concentration is 18 mmol/L? A. 6.89 B. 7.00 C. 7.10 D. 7.30 Chemistry/Calculate/
Acidbase/2 4.
Which of the following best represents the reference (normal) range for arterial
pH? A. 7.357.45
B. 7.427.52 C. 7.387.68 D. 6.857.56 Chemistry/Apply knowledge of fundamental biolog
characteristics/Acidbase/1 5. What is the normal ratio of bicarbonate to dissolve
d carbon
dioxide (HCO 3
2 ) in arterial blood? A. 1:10 B. 10:1 C. 20:1 D. 30:1 Chemistry/Apply k
nowledge of
fundamental biological characteristics/Acidbase/1 Answers to Questions 15 1. B The
HendersonHasselbalch equation describes the pH of a bu er comprised of a weak acid
and its salt.
pH = pK a + log salt/acid, where pK a is the negative logarithm of the dissociat
ion constant of
the acid. In this case, the salt is sodium bicarbonate and the acid is the disso
lved CO 2 , which
is equal to 0.03 (mmol/L per mm Hg) x PCO 2 . The pK a includes both the hydrati
on and
dissociation constant for dissolved CO 2 in blood, 6.1 and is termed pK. 2. C Con
vert barometric
pressure in inches to mm Hg by multiplying by 25.4 (mm/in.). Next, subtract the
vapor pressure of
H 2 O at 37C, 47 mm Hg, to give dry gas pressure. Multiply dry gas pressure by th
e %O 2

25.4 mm/in. 30 in. = 762 mm Hg 762 mm Hg 47 mm Hg (vapor pressure) = 715
mm Hg (dry gas
pressure) 0.20 715 mm Hg = 143 mm Hg PO 2 3. C Solve using the HendersonHasselbal
ch equation.
pH = pK + log HCO 3
(0.03 PCO
2 ), where pK, the negative logarithm of the combined hydration and disso
ciation constants
for dissolved CO 2 and carbonic acid, is 6.1 and 0.03 is the solubility coe cient
for CO 2 gas.
pH = 6.1 + log 18/(0.03 60) = 6.1 + log 18/1.8 pH = 6.1 + log 10. Because log 10
= 1, pH = 7.10
4. A The reference range for arterial blood pH is 7.357.45 and is only 0.03 pH un
its lower for
venous blood owing to the bu ering e ects of hemoglobin (Hgb) known as the chloride
shift. Most laboratories consider less than 7.20 and greater than 7.60 the criti
cal values for
pH. 5. C When the ratio of HCO 3
2 is 20:1, the log of salt/acid becomes 1.3. Substituting this in the He
equation and solving for pH gives pH = 6.1 + log 20; pH = 6.1 + 1.3 = 7.4. Acido
sis results when
this ratio is decreased, and alkalosis when it is increased. 2828_Ch05_171-326
06/08/12 5:14 PM
Page 190 6. What is the PCO 2 if the dCO 2 is 1.8 mmol/L? A. 24 mm Hg B. 35 mm
Hg C. 60 mm Hg D.
72 mm Hg Chemistry/Calculate/Blood gas/2 7. In the HendersonHasselbalch expressio
n pH = 6.1 +
log HCO 3
2 , the 6.1 represents: A. Te combined hydration and dissociation consta
nts for CO 2 in blood
at 37C B. Te solubility constant for CO 2 gas C. Te dissociation constant of H 2
O D. Te
ionization constant of sodium bicarbonate (NaHCO 3 ) Chemistry/Apply knowledge o
f fundamental
biological characteristics/Acidbase/1 8. Which of the following contributes the m
ost to the
serum total CO 2 ? A. PCO 2 B. dCO 2 C. HCO 3 D. Carbonium ion Chemistry/Apply k
nowledge of
fundamental biological characteristics/Acidbase/2 9. In addition to sodium bicarb
onate, what
other substance contributes most to the amount of base in the blood? A. Hemoglob
in concentration
B. Dissolved O 2 concentration C. Inorganic phosphorus D. Organic phosphate Chem
knowledge of fundamental biological characteristics/Acidbase/2 10. Which of the f
ollowing e ects
results from exposure of a normal arterial blood sample to room air? A. PO 2 inc
reased PCO 2
decreased pH increased B. PO 2 decreased PCO 2 increased pH decreased C. PO 2 in
creased PCO 2
decreased pH decreased D. PO 2 decreased PCO 2 decreased pH decreased Chemistry/
laboratory data to recognize problems/Blood gas/3 5.2 | Blood Gases, pH, and Ele
ctrolytes 191
Answers to Questions 610 6. C Dissolved CO 2 is calculated from the measured PCO

2 0.0306, the
solubility coe cient for CO 2 gas in blood at 37C. dCO 2 = PCO 2 0.03 Therefore, PC
O 2 = dCO 2
PCO 2 = 1.8 mmol/L 0.03 mmol/ L per mm Hg = 60 mm Hg 7. A The equilibriu
m constant, K h ,
for the hydration of CO 2 (dCO 2 + H 2 O H 2 CO 3 ) is only about 2.3 10 3 M, maki
ng dCO 2
far more prevalent than carbonic acid. The dissociation constant, K d , for the
reaction H 2 CO 3
H + + HCO 3 is about 2 10 4 M. The product of these constants is the combined equi
constant, K. The negative logarithm of K is the pK, which is 6.103 in blood at 37C.
8. C The
total CO 2 is the sum of the dCO 2 , H 2 CO 3 (carbonic acid or hydrated CO 2 ),
and bicarbonate
(as mainly NaHCO 3 ). When serum is used to measure total CO 2 , the dCO 2 is in
signi cant
because all the CO 2 gas has escaped into the air. Therefore, serum total CO 2 i
s equivalent to
the bicarbonate concentration. Total CO 2 is commonly measured by potentiometry.
An organic acid
is used to release CO 2 gas from bicarbonate and pCO 2 is measured with a Severi
nghaus electrode.
Alternately, bicarbonate can be measured by an enzymatic reaction using phosphoe
nol pyruvate
carboxylase. The enzyme forms oxaloacetate and phosphate from phosphoenol pyruva
te and
bicarbonate. The oxaloacetate is reduced to malate by malate dehydrogenase and N
ADH is oxidized
to NAD + . The negative reaction rate is proportional to plasma bicarbonate conc
entration. 9. A
The primary blood bu er bases preventing acidosis in order of concentration are bi
deoxyhemoglobin, albumin, and monohydrogen phosphate. At physiological pH, there
is signi cantly
more H 2 PO 4 1 than HPO 4 2 , and phosphate is a more e cient bu er system at prevent
alkalosis than acidosis. Since all of the blood bu er systems are in equilibrium,
the pH can be
calculated accurately from the concentration of bicarbonate and dissolved CO 2 u
sing the
HendersonHasselbalch equation. 10. A The PO 2 of air at sea level (21% O 2 ) is a
bout 150 mm Hg.
The PCO 2 of air is only about 0.3 mm Hg. Consequently, blood releases CO 2 gas
and gains O 2
when exposed to air. Loss of CO 2 shifts the equilibrium of the bicarbonate bu er
system to the
right, decreasing hydrogen ion concentration and blood becomes more alkaline. 28
06/08/12 5:14 PM Page 191 11. Which of the following formulas for O 2 content
is correct? A. O
2 content = %O 2 saturation/100 Hgb g/dL 1.39 mL/g + (0.0031 PO 2 ) B. O 2 conte
nt = PO 2
0.0306 mmol/L/mm C. O 2 content = O 2 saturation Hgb g/dL 0.003 mL/g D. O 2 cont
ent = O 2
capacity 0.003 mL/g Chemistry/Calculate/Blood gas/1 12. Te normal di erence betwee
n alveolar
and arterial PO 2 (PAO 2 PaO 2 di erence) is: A. 3 mm Hg B. 10 mm Hg C. 40 mm Hg D.
50 mm Hg

Chemistry/Apply knowledge of fundamental biological characteristics/Blood gas/2

13. A decreased
PAO 2 PaO 2 di erence is found in: A. A/V (arteriovenous) shunting B. V/Q
(ventilation/perfusion) inequality C. Ventilation defects D. All of these option
Chemistry/Evaluate laboratory data to recognize health and disease states/Blood
gas/2 14. Te
determination of the oxygen saturation of hemoglobin is best accomplished by: A.
absorbance measurements of a whole-blood hemolysate B. Near infrared transcutane
ous absorbance
measurement C. Treatment of whole blood with alkaline dithionite prior to measur
ing absorbance D.
Calculation using PO 2 and total hemoglobin by direct spectrophotometry Chemistr
principles of special procedures/ Oxyhemoglobin/1 15. Correction of pH for a pat
ient with a body
temperature of 38C would require: A. Subtraction of 0.015 B. Subtraction of 0.01%
C. Addition of
0.020 D. Subtraction of 0.020 Chemistry/Calculate/Acidbase/2 16. Select the antic
oagulant of
choice for blood gas studies. A. Sodium citrate 3.2% B. Lithium heparin 100 U/mL
blood C. Sodium
citrate 3.8% D. Ammonium oxalate 5.0% Chemistry/Apply knowledge of standard oper
procedures/Specimen collection and handling/1 192 Chapter 5 | Clinical Chemistry
Answers to
Questions 1116 11. A Oxygen content is the sum of O 2 bound to Hgb and O 2 dissol
ved in the
plasma. It is dependent upon the Hgb concentration and the percentage of Hgb bou
nd to O 2 (O 2
saturation). Each gram of Hgb binds 1.39 mL of O 2 . The dissolved O 2 is determ
ined from the
solubility coe cient of O 2 (0.0031 mL per dL/mm Hg) and the PO 2 . O 2 content =
% Sat/100 Hgb
in g/dL 1.39 mL/g + (0.0031 PO 2 ). 12. B The PAO 2 PaO 2 di erence results from th
e low
ratio of ventilation to perfusion in the base of the lungs. The hemoglobin in th
e blood coming
from the base of the lung has a lower O 2 saturation. This blood will take up O
2 from the plasma
of blood leaving well-ventilated areas of the lung, thus lowering the mixed arte
rial PO 2 . 13. C
Patients with A/V shunts, V/Q inequalities, and cardiac failure will have an inc
reased PAO 2 PaO
2 di erence. However, patients with ventilation problems have low alveolar PO 2 ow
ing to
retention of CO 2 in the airway. This reduces the PAO 2 PaO 2 di erence. 14. A Meas
urement of
oxyhemoglobin, deoxyhemoglobin (reduced hemoglobin), carboxyhemoglobin, methemog
lobin, and
sulfhemoglobin can be accomplished by direct spectrophotometry at multiple wavel
engths and
analysis of the absorptivity coe cients of each pigment at various wavelengths. Th
e O 2
saturation is determined by dividing the fraction of oxyhemoglobin by the sum of
all pigments.
This eliminates much of the error that occurs in the other methods when the quan
tity of an
abnormal hemoglobin pigment is increased. 15. A The pH decreases by 0.015 for ea

ch degree Celsius
above the 37C. Because the blood gas analyzer measures pH at 37C, the in vivo pH w
ould be 0.015
pH units below the measured pH. 16. B Heparin is the only anticoagulant that doe
s not alter the
pH of blood; heparin salts must be used for pH and blood gases. Solutions of hep
arin are air
equilibrated and must be used sparingly to prevent contamination of the sample b
y gas in the
solution. 2828_Ch05_171-326 06/08/12 5:14 PM Page 192 17. What is the maximum
storage time and temperature for an arterial blood gas sample drawn in a plastic
syringe? A. B.
C. D. Chemistry/Apply knowledge of standard operating procedures/Specimen collec
tion and
handling/Blood gas/1 18. A patients blood gas results are as follows: pH = 7.26 d
CO 2 = 2.0
mmol/L HCO 3 = 29 mmol/L Tese results would be classi ed as: A. Metabolic acidosis
B. Metabolic
alkalosis C. Respiratory acidosis D. Respiratory alkalosis Chemistry/Evaluate la
boratory data to
recognize health and disease states/Acidbase/3 19. A patients blood gas results ar
e: pH = 7.50
PCO 2 = 55 mm Hg HCO 3 = 40 mmol/L Tese results indicate: A. Respiratory acidosi
s B. Metabolic
alkalosis C. Respiratory alkalosis D. Metabolic acidosis Chemistry/Evaluate labo
ratory data to
recognize health and disease states/Acidbase/3 20. Which set of results is consis
tent with
uncompensated respiratory alkalosis? A. pH 7.70 HCO 3 30 mmol/L PCO 2 25 mm Hg B
. pH 7.66 HCO 3
22 mmol/L PCO 2 20 mm Hg C. pH 7.46 HCO 3 38 mmol/L PCO 2 55 mm Hg D. pH 7.36 HC
O 3 22 mmol/L PCO
2 38 mm Hg Chemistry/Evaluate laboratory data to recognize health and disease st
21. Which of the following will shift the O 2 dissociation curve to the left? A.
Anemia B.
Hyperthermia C. Hypercapnia D. Alkalosis Chemistry/Calculate clinical and labora
tory data/ Blood
gas/2 5.2 | Blood Gases, pH, and Electrolytes 193 Answers to Questions 1721 17.
D Arterial
blood gas samples collected in plastic syringes should be stored at room tempera
ture because
cooling the sample allows oxygen to enter the syringe. Storage time should be no
more than 30
minutes because longer storage results in a signi cant drop in pH and PO 2 and inc
reased PCO 2 .
18. C Imbalances are classi ed as respiratory when the primary disturbance is with
PCO 2 because
PCO 2 is regulated by ventilation. PCO 2 = dCO 2
0.03 or
60 mm Hg (normal 3545 mm Hg). Increased dCO 2 will increase hydrogen ion
causing acidosis. Bicarbonate is moderately increased, but a primary increase in
NaHCO 3 causes
alkalosis. Thus, the cause of this acidosis is CO 2 retention (respiratory acido
sis), and it is
partially compensated by renal retention of bicarbonate. 19. B A pH above 7.45 c
orresponds with
alkalosis. Both bicarbonate and PCO 2 are elevated. Bicarbonate is the conjugate

base and is
under metabolic (renal) control, while PCO 2 is an acid and is under respiratory
Increased bicarbonate (but not increased CO 2 ) results in alkalosis; therefore,
classi cation is metabolic alkalosis, partially compensated by increased PCO 2 . 2
0. B
Respiratory alkalosis is caused by hyperventilation, inducing low PCO 2 . Very o
ften, in the
early phase of an acute respiratory disturbance, the kidneys have not had time t
o compensate, and
the bicarbonate is within normal limits. In answer A, the bicarbonate is high an
d PCO 2 low;
thus, both are contributing to alkalosis and this would be classi ed as a combined
disturbance. In answer C, the pH is almost normal, and both bicarbonate and PCO
2 are increased.
This can occur in the early stage of a metabolic acid base disturbance when full
compensation occurs or in a combined acidbase disorder. In answer D, both bicarbo
nate and PCO 2
are within normal limits (2226 mmol/L, 3545 mm Hg, respectively) as is the pH. 21.
D A left
shift in the oxyhemoglobin dissociation curve signi es an increase in the a nity of
Hgb for O 2 .
This occurs in alkalosis, hypothermia, and in those hemoglobinopathies such as H
gb Chesapeake
that increase the binding of O 2 to heme. A right shift in the oxyhemoglobin dis
sociation curve
lowers the a nity of Hgb for O 2 . This occurs in anemia due to increased 2,3-diph
(2,3-DPG), with increased body temperature, increased hydrogen ion concentration
, hypercapnia
(increased PCO 2 ), and in some hemoglobinopathies, such as Hgb Kansas. Storage
Temperature 10 min 2C8C 20 min 2C8C 30 min 2C8C 30 min 22C 2828_Ch05_171-326 06/08
5:14 PM Page 193 22. In which circumstance will the reporting of calculated oxy
gen saturation of
hemoglobin based on PO 2 , PCO 2 , pH, temperature, and hemoglobin be in error?
A. Carbon
monoxide poisoning B. Diabetic ketoacidosis C. Patient receiving oxygen therapy
D. Assisted
ventilation for respiratory failure Chemistry/Identify sources of error/Blood ga
s/3 23. Which
would be consistent with partially compensated respiratory acidosis? A. pH PCO
2 Bicarbonate
increased increased increased B. pH PCO 2 Bicarbonate increased decreased decre
ased C. pH PCO 2
Bicarbonate decreased decreased decreased D. pH PCO 2 Bicarbonate decreased inc
reased increased
Chemistry/Evaluate laboratory data to recognize health and disease states/3 24.
Which condition
results in metabolic acidosis with severe hypokalemia and chronic alkaline urine
? A. Diabetic
ketoacidosis B. Phenformin-induced acidosis C. Renal tubular acidosis D. Acidosi
s caused by
starvation Chemistry/Correlate clinical and laboratory data/ Acidbase and electro
lytes/2 25.
Which of the following mechanisms is responsible for metabolic acidosis? A. Bica
rbonate de ciency

B. Excessive retention of dissolved CO 2 C. Accumulation of volatile acids D. Hy

Chemistry/Apply knowledge of fundamental biological characteristics/Acidbase/1 26
. Which of the
following disorders is associated with lactate acidosis? A. Diarrhea B. Renal tu
bular acidosis C.
Hypoaldosteronism D. Alcoholism Chemistry/Correlate clinical and laboratory data
/ Acidbase/2 27.
Which of the following is the primary mechanism of compensation for metabolic ac
idosis? A.
Hyperventilation B. Release of epinephrine C. Aldosterone release D. Bicarbonate
Chemistry/Apply knowledge of fundamental biological characteristics/Acidbase/2 19
4 Chapter 5 |
Clinical Chemistry Answers to Questions 2227 22. A CO has about 200 times the a nit
y as O 2 for
hemoglobin and will displace O 2 from hemoglobin at concentrations that have no
signi cant e ect
on the PAO 2 . Consequently, calculated oxygen saturation will be erroneously hi
gh. Other cases
in which the calculated O 2 Sat should not be used include any hemoglobinopathy
that a ects
oxygen a nity and methemoglobinemia. The other situations above a ect the O 2 satura
tion of
hemoglobin in a manner that can be predicted by the e ect of pH, PO 2 , and PCO 2
on the
oxyhemoglobin dissociation curve. 23. D Acidosis = low pH; respiratory = disturb
ance of PCO 2 ; a
low pH is caused by increased PCO 2 . In partially compensated respiratory acido
sis, the
metabolic component of the bu er system, bicarbonate, is retained. This helps to c
ompensate for
retention of PCO 2 by titrating hydrogen ions. The compensatory component always
moves in the
same direction as the cause of the acidbase disturbance. 24. C Metabolic acidosis
can be caused
by any condition that lowers bicarbonate. In nonrenal causes, the kidneys will a
ttempt to
compensate by increased acid excretion. However, in renal tubular acidosis (RTA)
, an intrinsic
defect in the tubules prevents bicarbonate reabsorption. This causes alkaline in
stead of acidic
urine. Excretion of bicarbonate as potassium bicarbonate (KHCO 3 ) results in se
vere hypokalemia.
25. A Metabolic acidosis is caused by bicarbonate de ciency and metabolic alkalosi
s by
bicarbonate excess. Respiratory acidosis is caused by PCO 2 retention (defective
and respiratory alkalosis is caused by PCO 2 loss (hyperventilation). Important
causes of
metabolic acidosis include renal failure, diabetic ketoacidosis, lactate acidosi
s, and diarrhea.
26. D Lactate acidosis often results from hypoxia, which causes a de cit of nicoti
namide adenine
dinucleotide, the oxidized form (NAD + ). This promotes the reduction of pyruvat
e to lactate,
regenerating NAD + needed for glycolysis. In alcoholic acidosis, oxidation of et
hanol to
acetaldehyde consumes the NAD + . In diabetes, lactate acidosis can result from
depletion of

Krebs cycle intermediates. Diarrhea and renal tubular acidosis result in metabol
ic acidosis via
bicarbonate loss. Hypoaldosteronism causes metabolic acidosis via hydrogen and p
otassium ion
retention. 27. A In metabolic acidosis, the respiratory center is stimulated by
chemoreceptors in
the carotid sinus, causing hyperventilation. This results in increased release o
f CO 2 .
Respiratory compensation begins almost immediately unless blocked by pulmonary d
isease or
respiratory therapy. Hyperventilation can bring the PCO 2 down to approximately
1015 mm Hg.
2828_Ch05_171-326 06/08/12 5:14 PM Page 194 28. Te following conditions are a
ll causes of
alkalosis. Which condition is associated with respiratory (rather than metabolic
) alkalosis? A.
Anxiety B. Hypovolemia C. Hyperaldosteronism D. Hypoparathyroidism Chemistry/Cor
relate clinical
and laboratory data/ Acidbase/2 29. Which of the following conditions is associat
ed with both
metabolic and respiratory alkalosis? A. Hyperchloremia B. Hypernatremia C. Hyper
phosphatemia D.
Hypokalemia Chemistry/Correlate clinical and laboratory data/ Acidbase/2 30. In u
metabolic acidosis, which of the following will be normal? A. Plasma bicarbonate
B. PCO 2 C. p50
D. Total CO 2 Chemistry/Correlate clinical and laboratory data/ Acidbase/2 31. Wh
ich of the
following conditions is classi ed as normochloremic acidosis? A. Diabetic ketoacid
osis B. Chronic
pulmonary obstruction C. Uremic acidosis D. Diarrhea Chemistry/Correlate clinica
l and laboratory
data/ Acidbase/2 32. Which PCO 2 value would be seen in maximally compensated met
acidosis? A. 15 mm Hg B. 30 mm Hg C. 40 mm Hg D. 60 mm Hg Chemistry/Evaluate lab
oratory data to
recognize health and disease states/Blood gas/3 33. A patient has the following
arterial blood
gas results: pH = 7.56 PCO 2 = 25 mm Hg PO 2 = 100 mm Hg HCO 3 = 22 mmol/L Tese
results are
most likely the result of which condition? A. Improper specimen collection B. Pr
olonged storage
C. Hyperventilation D. Hypokalemia Chemistry/Evaluate laboratory data to recogni
ze health and
disease states/Acidbase/3 5.2 | Blood Gases, pH, and Electrolytes 195 Answers t
o Questions
2833 28. A Respiratory alkalosis is caused by hyperventilation, which leads to de
creased PCO 2 .
Anxiety and drugs such as epinephrine that stimulate the respiratory center are
common causes of
respiratory alkalosis. Excess aldosterone increases net acid excretion by the ki
dneys. Low
parathyroid hormone causes increased bicarbonate reabsorption, resulting in alka
Hypovolemia increases the relative concentration of bicarbonate. This is common
and is called
dehydrational alkalosis, chloride responsive alkalosis, or alkalosis of sodium d
e cit. 29. D
Hypokalemia is both a cause and result of alkalosis. In alkalosis, hydrogen ions
may move from

the cells into the extracellular uid and potassium into the cells. In hypokalemia
caused by
overproduction of aldosterone, hydrogen ions are secreted by the renal tubules.
This increase in
net acid excretion results in metabolic alkalosis. 30. B The normal compensatory
mechanism for
metabolic acidosis is respiratory hyperventilation. In uncompensated cases, the
PCO 2 is not
reduced, indicating a concomitant problem in respiratory control. 31. A Bicarbon
ate de cit will
lead to hyperchloremia unless the bicarbonate is replaced by an unmeasured anion
. In diabetic
ketoacidosis, acetoacetate and other ketoacids replace bicarbonate. The chloride
remains normal
or low and there is an increased anion gap. 32. A In metabolic acidosis, hyperve
increases the ratio of bicarbonate to dissolved CO 2 . The extent of compensatio
n is limited by
the rate of both gas di usion and diaphragm contraction. The lower limit is betwee
n 10 and 15 mm
Hg PCO 2 , which is the maximum compensatory e ect. 33. C The pH is alkaline (refe
rence range
7.357.45) and this can be caused by either low PCO 2 or increased bicarbonate. Th
is patient has
a normal bicarbonate (reference range 2226 mmol/L) and a low PCO 2 (reference ran
ge 3545 mm
Hg). Low PCO 2 is always caused by hyperventilation, and therefore, this is a ca
se of
uncompensated respiratory alkalosis. The acute stages of respiratory disorders a
re often
uncompensated. Prolonged storage would cause the pH and PO 2 to fall, and the PC
O 2 to rise.
Hypokalemia causes alkalosis, but usually is associated with the retention of CO
2 as
compensation. 2828_Ch05_171-326 06/08/12 5:14 PM Page 195 34. Why are three l
evels used for
quality control of pH and blood gases? A. Systematic errors can be detected earl
ier than with two
controls B. Analytical accuracy needs to be greater than for other analytes C. H
igh, normal, and
low ranges must always be evaluated D. A di erent level is needed for pH, PCO 2 ,
and PO 2
Chemistry/Select appropriate controls/Acidbase/2 35. A single-point calibration i
s performed
between each blood gas sample in order to: A. Correct the electrode slope B. Cor
rect electrode
and instrument drift C. Compensate for temperature variance D. Prevent contamina
tion by the
previous sample Chemistry/Apply knowledge of standard operating procedures/Blood
gas/2 36. In
which condition would hypochloremia be expected? A. Respiratory alkalosis B. Met
abolic acidosis
C. Metabolic alkalosis D. All of these options Chemistry/Correlate clinical and
laboratory data/
Blood gas electrolytes/2 37. Given the following serum electrolyte data, determi
ne the anion gap.
Na = 132 mmol/L Cl = 90 mmol/L HCO 3 = 22 mmol/L A. 12 mmol/L B. 20 mmol/L C. 64
mmol/L D.
Cannot be determined from the information provided Chemistry/Calculate/Electroly
tes/2 38. Which

of the following conditions will cause an increased anion gap? A. Diarrhea B. Hy

C. Hyperkalemia D. Renal failure Chemistry/Correlate clinical and laboratory dat
a/ Electrolytes/2
39. Alcoholism, liver failure, and hypoxia induce acidosis by causing: A. Deplet
ion of cellular
NAD + B. Increased excretion of bicarbonate C. Increased retention of PCO 2 D. L
oss of carbonic
anhydrase Chemistry/Apply knowledge of fundamental biological characteristics/Ac
idbase/2 196
Chapter 5 | Clinical Chemistry Answers to Questions 3439 34. A Error detection oc
curs sooner
when more controls are used. Some errors, such as those resulting from temperatu
re error and
protein coating of electrodes, are not as pronounced near the calibration point,
as in the
acidosis and alkalosis range. The minimum requirement for blood gas QC is one sa
mple every 8
hours and three levels (acidosis, normal, alkalosis) every 24 hours. Three level
s of control are
also used commonly for therapeutic drug monitoring and hormone assays because pr
ecision di ers
signi cantly in the high and low ranges. 35. B Calibration using a single standard
corrects the
instrument for error at the labeled value of the calibrator but does not correct
for analytic
errors away from the set point. A two-point calibration adjusts the slope respon
se of the
electrode, eliminating proportional error caused by poor electrode performance.
36. C Chloride is
the major extracellular anion and is retained or lost to preserve electroneutral
ity. Low chloride
will occur in metabolic alkalosis because excess bicarbonate is present. Low chl
oride also will
occur in partially compensated respiratory acidosis because the kidneys compensa
te by increased
retention of bicarbonate. 37. B The anion gap is de ned as unmeasured anions minus
cations. It is calculated by subtracting the measured anions (bicarbonate and ch
loride) from the
serum sodium (or sodium plus potassium). A normal anion gap is approximately 816
mmol/L (1220
mmol/L when potassium is used). Anion gap = Na (HCO3 + Cl) Anion gap = 132 (90 +
22) = 20
mmol/L 38. D An increased anion gap occurs when there is production or retention
of anions other
than bicarbonate or chloride (measured anions). For example, in renal failure, r
etention of
phosphates and sulfates (as sodium salts) increases the anion gap. Other common
causes of
metabolic acidosis with an increased anion gap are diabetic ketoacidosis and lac
tate acidosis.
The anion gap may also be increased in the absence of an acidbase disorder. Commo
n causes
include hypocalcemia, drug overdose, and laboratory error when measuring electro
lytes. 39. A
Oxygen debt and liver failure block oxidative phosphorylation, preventing NADH
from being
oxidized back to NAD + . Oxidation of ethanol to acetate results in accumulation
of NADH. When

NAD + is depleted, glycolysis cannot proceed. It is regenerated by reduction of

pyruvate to
lactate, causing lactate acidosis. 2828_Ch05_171-326 06/08/12 5:14 PM Page 19
6 40. Which of
the following is the primary mechanism causing respiratory alkalosis? A. Hyperve
ntilation B.
De cient alveolar di usion C. De cient pulmonary perfusion D. Parasympathetic inhibiti
Chemistry/Apply knowledge of fundamental biological characteristics/Acidbase/2 41
. Which
condition can result in acidosis? A. Cystic brosis B. Vomiting C. Hyperaldosteron
ism D.
Excessive O 2 therapy Chemistry/Correlate clinical and laboratory data/ Blood ga
s/2 42. Which of
the following conditions is associated with an increase in ionized calcium (Ca i
) in the blood?
A. Alkalosis B. Hypoparathyroidism C. Hyperalbuminemia D. Malignancy Chemistry/C
orrelate clinical
and laboratory data/ Electrolytes/2 43. Which of the following laboratory result
s is consistent
with primary hypoparathyroidism? A. Low calcium; high inorganic phosphorus P i B
. Low calcium;
low P i C. High calcium; high P i D. High calcium; low P i Chemistry/Correlate c
linical and
laboratory data/ Electrolytes/2 44. Which of the following conditions is associa
ted with
hypophosphatemia? A. Rickets B. Multiple myeloma C. Renal failure D. Hypervitami
nosis D
Chemistry/Correlate laboratory data with physiological processes/Electrolytes/2
5.2 | Blood
Gases, pH, and Electrolytes 197 Answers to Questions 4044 40. A Hyperventilatio
n via
stimulation of the respiratory center (or induced by a respirator) is the mechan
ism of
respiratory alkalosis. Causes include low PO 2 , anxiety, fever, and drugs that
stimulate the
respiratory center. Acute respiratory alkalosis is often uncompensated because r
enal compensation
is not rapid. Uncompensated respiratory alkalosis is characterized by an elevate
d pH and a low
PCO 2 with normal bicarbonate. 41. D When O 2 saturation of venous blood is grea
tly elevated, Hgb
cannot release O 2 . Oxyhemoglobin cannot bind CO 2 or hydrogen ions and acidosi
s results. Pure O
2 may cause neurological damage, leading to convulsion and blindness, especially
in infants. It
can induce respiratory failure by causing pulmonary hemorrhage, edema, and hyali
nization. The
other three conditions cause alkalosis. Vomiting and cystic brosis cause loss of
resulting in hypovolemia and intestinal bicarbonate absorption. Hyperaldosteroni
sm causes
hypokalemia; this results in increased renal H + excretion and a shift of H + in
to cells in
exchange for K + . 42. D Increased Ca i occurs in hyperparathyroidism, malignanc
y, and acidosis.
Ca i is elevated in primary hyperparathyroidism due to resorption of calcium fro
m bone. Many
nonparathyroid malignancies create products called parathyroid hormone-related p
roteins that

stimulate the parathyroid receptors of cells. Acidosis alters the equilibrium be

tween bound and
free calcium, favoring ionization. Hyperalbuminemia increases the total calcium
by increasing the
protein- bound fraction, but does not a ect the Ca i . 43. A Parathyroid hormone d
e ciency causes
reduced resorption of calcium from bone, increased renal excretion of calcium, a
nd decreased
renal excretion of phosphorus. It is distinguished from other causes of hypocalc
emia by Ca i ,
which is reduced only by primary hypoparathyroidism and alkalosis. 44. A Rickets
can result from
dietary phosphate de ciency, vitamin D de ciency, or an inherited disorder of either
vitamin D or
phosphorus metabolism. Vitamin Ddependent rickets (VDDR) can be reversed by megad
oses of vitamin
D. Type 1 is caused by a de ciency in renal cells of 1--hydroxylse, n enzyme tht
converts 25
hydroxyvitmin D to the ctive form, 1,25 hydroxyvitmin D. Type 2 is cused y
 de ciency in
the vitmin D receptor of one tissue. Vitmin Dresistnt rickets (VDRR) is cuse
d y 
de ciency in the renl re sorption of phosphte. Consequently,  ected persons (usu
lly men
ecuse it is most commonly X-linked) hve  norml serum clcium nd  low P i
2828_Ch05_171-326 06/08/12 5:14 PM Pe 197 45. Which of the followin tests
is consistently
 norml in osteoporosis? A. Hih urinry clcium B. Hih serum P i C. Low serum
clcium D. Hih
urine or serum N-telopeptide of type 1 collen Chemistry/Correlte l ortory d
t with
physioloicl processes/Electrolytes/2 46. Which of the followin is  mrker fo
r one formtion?
A. Osteoclcin B. Trtrte resistnt cid phosphtse (TRAP) C. Urinry pyridino
line nd
deoxypyridinoline D. Urinry C-telopeptide nd N-telopeptide crosslinks (CTx nd
Chemistry/Select tests/Bone disorders/2 47. Wht role do CTx nd NTx ply in the
mnement of
osteoporosis? A. Incresed urinry excretion is dinostic of erly ste dises
e B. Incresed
levels indicte  low risk of developin osteoporosis C. Decresed urinry excre
tion indictes 
positive response to tretment D. Te rte of urinry excretion correltes with t
he ste of the
disese Chemistry/Apply knowlede of fundmentl ioloicl chrcteristics/Bone
disorders/2 198
Chpter 5 | Clinicl Chemistry Answers to Questions 4547 45. D Commonly used mrk
ers for other
one diseses such s serum or urinry clcium, inornic phosphorus, totl lk
line phosphtse
(ALP), nd vitmin D re neither sensitive nor specific for osteoporosis. Clciu
m nd phosphorus
re usully within norml limits. Althouh estroen deficiency reduces formtion
of 1,25
hydroxyvitmin D (1,25 hydroxycholeclciferol), promotin postmenopusl osteopo
rosis, the 1,25
hydroxyvitmin D is low in only 30%35% of cses, nd low levels my e cused y
other one

disorders. Serum mrkers for osteoporosis include oth N-telopeptide of type 1 c

ollen (NTx) nd
C-telopeptide of type 1 collen (CTx). These cn e used to follow tretment wi
th resorption
ntonists ( isphosphontes) ecuse they decrese sinificntly when therpy i
s successful. 46.
A Biochemicl mrkers for osteoporosis re clssi ed s either mrkers for one fo
rmtion or
resorption. Osteoclcin is  protein hormone tht stimultes osteo lsts nd inc
reses one
minerliztion. Pyridinoline is formed when hydroxylysine roups on djcent ril
s re joined
toether, nd deoxypyridinoline when hydroxylysine nd lysine roups re joined.
These form
crosslinks etween the C nd N terminl ends of one ril (which re nonhelicl) 
nd the helicl
portion of n djcent ril. The resultin products re clled C- nd N-telopepti
de crosslinks
of type 1 collen. Osteoclsts cuse cleve of these onds, resultin in loss
of oth
telopeptidesdeoxypyridinoline nd pyridinolinein the urine. TRAP is n enzyme (pro
duced y
osteoclsts) tht hydrolyzes phosphte in the hydroxyptite mtrix of the one.
47. C Mrkers
for oth one formtion nd resorption re used to monitor tretment for osteopo
rosis. Serum nd
urinry mesurements of CTx nd NTx nd urinry deoxypyridinoline re used to mo
nitor medictions
such s iphosphontes tht inhi it one resorption. Levels fll with successful
tretment. DEXA
scn, n x-ry procedure sed on su trction of surroundin tissue, is the most
dinostic test for osteoporosis nd cn show one loss s smll s 1%. However,
it tkes months
efore  DEXA scn shows incresed one remodelin followin tretment. 2828_Ch0
06/08/12 5:14 PM Pe 198 48. Wht role does vitmin D mesurement ply in the
mnement of
osteoporosis? A. Vitmin D de ciency must e demonstrted to est lish the dinos
is B. Vitmin D
is consistently elevted in osteoporosis C. A norml vitmin D level rules out o
steoporosis D.
Vitmin D de ciency is  risk fctor for developin osteoporosis Chemistry/Apply k
nowlede of
fundmentl ioloicl chrcteristics/Bone disorders/2 49. Which sttement est
descri es
testin recommendtions for vitmin D? A. Vitmin D testin should e reserved o
nly for those
persons who demonstrte hyperclcemi of n undetermined cuse B. Vitmin D test
in should e
speci c for the 1,25(OH)D3 form C. Testin should e for totl vitmin D when scre
enin for
de ciency D. Vitmin D testin should not e performed if the ptient is receivin
 vitmin D
supplement Chemistry/Correlte l ortory dt with physioloicl processes/Elec
trolytes/2 50. Te
serum level of which of the followin l ortory tests is decresed in oth VDDR
nd VDRR? A.
Vitmin D B. Clcium C. P i D. Prthyroid hormone Chemistry/Correlte l ortor
y dt with

physioloicl processes/Bone disese/2 5.2 | Blood Gses, pH, nd Electrolytes

199 Answers to
Questions 4850 48. D Vitmin D ssy is not used to dinose osteoporosis. Vitmi
n D de ciency
is  cuse of secondry osteoporosis, nd toether with low PTH, clcium, nd es
troen re
importnt risk fctors. If one or more of these is  norml, then one resorptio
n or remodelin
my e  norml, predisposin one to osteoporosis. De ciency of vitmin D lso cu
ses rickets
(clled osteomlci in dults),  condition in which ones ecome soft owin to
deposition of hydroxyptite. 49. C Vitmin D de ciency is fr more common thn vi
tmin D excess,
nd screenin for vitmin D de ciency is dvocted especilly for drk-skinned per
sons nd people
who do not et dequte sunliht. Provitmin D is  steroid, nd vitmin D is no
w considered 
hormone rther thn  vitmin. The hormone reultes trnscription of over 200 
enes nd hs
pronounced e ects on oth dendritic cells nd T lymphocytes. De ciency is ssocited
with mny
chronic diseses includin utoimmune diseses, cncers, hypertension, nd hert
disese. There
re two forms of the vitmin, eroclciferol (D 2 ) nd choleclciferol (D 3 ).
Active D 2 nd D
3 re formed when two hydroxyl roups re dded, the rst ein t the 25 position
y the liver
nd the second t the -1 position y the kidney. The mjority of the circultin
vitmin D is in
the 25-hydroxylted form of D 2 nd D 3 , clled 25(OH)D. The plsm 25(OH)D con
centrtion is n
expression of oth dietry nd endoenous vitmin D nd is the most pproprite
test for
detectin nutritionl vitmin D de ciency. Since the e ect on clcium is derived fro
m the ctive
1,25 form of the vitmin, plsm 1,25(OH)D concentrtion is  more speci c test fo
hypervitminosis D. 50. C Persons with VDDR nd VDRR hve  low P i . However, p
ersons with VDDR
hve decresed serum clcium, s well. Prthyroid hormone (PTH) is incresed in
persons with
VDDR ecuse clcium is the primry stimulus for PTH relese, ut not in persons
with VDRR.
Vitmin D levels vry dependin upon the type of rickets nd the vitmin D met
olite tht is
mesured. 1,25(OH)D, the ctive form of vitmin D, is low in type 1 ut hih in
type 2 VDDR. It
my e either norml or low in VDRR. 2828_Ch05_171-326 06/08/12 5:14 PM Pe
199 51. Which of
the followin is the most ccurte mesurement of P i in serum? A. Rte of unred
phosphomoly dte formtion t 340 nm B. Mesurement of phosphomoly denum lue t
680 nm C. Use of
minonptholsulfonic cid to reduce phosphomoly dte D. Formtion of  complex w
ith mlchite
reen dye Chemistry/Apply principles of sic l ortory procedures/Biochemicl/
2 52. Wht is the
percente of serum clcium tht is ionized (C i )? A. 30% B. 45% C. 60% D. 80%

knowlede of fundmentl ioloicl chrcteristics/Electrolytes/1 53. Which of

the followin
conditions will cuse erroneous C i results? Assume tht the smples re collec
ted nd stored
nero iclly, kept t 4C until mesurement, nd stored for no loner thn 1 hour
. A. Sliht
hemolysis durin venipuncture B. Assy of whole lood collected in sodium oxlt
e C. Anlysis of
serum in  rrier el tu e stored t 4C until the clot hs formed D. Anlysis of
whole lood
collected in sodium heprin, 20 U/mL (low-heprin tu e) Chemistry/Apply knowled
e to reconize
sources of error/Specimen collection nd hndlin/3 54. Which of the followin c
onditions is
ssocited with  low serum mnesium? A. Addisons disese B. Hemolytic nemi C.
Hyperprthyroidism D. Pncretitis Chemistry/Correlte clinicl nd l ortory
Electrolytes/2 55. When mesurin clcium with the complexometric dye o-cresolph
complexone, mnesium is kept from interferin y: A. Usin n lkline pH B. Ad
8-hydroxyquinoline C. Mesurin t 450 nm D. Complexin to EDTA Chemistry/Apply
principles of
sic l ortory procedures/Biochemicl/1 200 Chpter 5 | Clinicl Chemistry Ans
wers to Questions
5155 51. A The colorimetric method (Fiske nd Su Row) used previously for P i r
ected mmonium
moly dte with P i , formin mmonium phosphomoly dte (NH 4 ) 3 [PO 4 (MoO 3 )
. A
reducin ent, minonptholsulfonic cid (ANS), ws dded, formin phos
phomoly denum lue.
The product ws unst le nd required sulfuric cid, mkin precipittion of pro
tein  potentil
source of error. These pro lems re voided y mesurin the rte of formtion o
f unreduced
phosphomoly dte t 340 nm. 52. B Clcium exists in serum in three forms: protei
n ound, ionized,
nd complexed (s undissocited slts). Only C i is physioloiclly ctive. Pro
tein ound nd C
i ech ccount for pproximtely 45% of totl clcium, nd the reminin 10% is
complexed. 53. B
Unlike P i , the intrcellulr clcium level is not sini cntly di erent from plsm
nd clcium is not retly  ected y diet. Whole lood collected with 520 U/mL hep
rin nd
stored on ice no loner thn 2 hours is the smple of choice for C i . Blood 
s syrines
pre lled with 100 U/mL heprin should not e used ecuse the hih heprin concent
rtion will
cuse low results. Citrte, oxlte, nd ethylenediminetetrcetic cid (EDTA)
must not e used
ecuse they chelte clcium. Serum my e used provided tht the smple is iced
, kept cpped
while clottin, nd ssyed within 2 hours ( rrier el tu es my e stored lon
er). 54. D Low
mnesium cn e cused y strointestinl loss, s occurs in dirrhe nd pnc
retitis (loss of
M nd C s sops). Hyperprthyroidism cuses incresed relese of oth clciu
m nd mnesium

from one. Addisons disese (drenocorticosteroid de ciency) my e ssocited with

mnesium ccompnyin hyperklemi. Hemolytic nemi cuses incresed relese o
f mnesium s
well s potssium from dmed red lood cells (RBCs). 55. B o-Cresolphthlein c
omplexone cn e
used to mesure either mnesium or clcium. Interference in clcium ssys is p
revented y
ddition of 8-hydroxyquinoline, which cheltes mnesium. When mnesium is mes
ethylenelycol istetrcetic cid (EGTA) or EDTA is used to chelte clcium. Tw
o other dyes tht
cn e used for oth mnesium nd clcium ssys re clmite nd methylthymol
lue. Arsenzo
III dye is commonly used to mesure clcium. It is more speci c for C +2 thn the
others, nd
does not require ddition of  M +2 cheltor. 2828_Ch05_171-326 06/08/12 5:14
PM Pe 200 56.
Which electrolyte mesurement is lest  ected y hemolysis? A. Potssium B. Clci
um C. P i D.
Mnesium Chemistry/Apply knowlede to reconize sources of error/Specimen colle
ction nd
hndlin/2 57. Which of the followin conditions is ssocited with hypoklemi?
A. Addisons
disese B. Hemolytic nemi C. Dioxin intoxiction D. Alklosis Chemistry/Corre
lte clinicl nd
l ortory dt/ Electrolytes/2 58. Which of the followin conditions is most li
kely to produce
n elevted plsm potssium? A. Hypoprthyroidism B. Cushins syndrome C. Dirr
he D.
Diitlis overdose Chemistry/Correlte clinicl nd l ortory dt/Electrolytes
/2 59. Which of
the followin vlues is the threshold criticl vlue (lert or ction level) for
low plsm
potssium? A. 1.5 mmol/L B. 2.0 mmol/L C. 2.5 mmol/L D. 3.5 mmol/L Chemistry/App
ly knowlede of
fundmentl ioloicl chrcteristics/Electrolytes/1 60. Which electrolyte is l
est likely to e
elevted in renl filure? A. Potssium B. Mnesium C. Inornic phosphorus D.
Chemistry/Correlte clinicl nd l ortory dt/ Electrolytes/2 5.2 | Blood Gs
es, pH, nd
Electrolytes 201 Answers to Questions 5660 56. B Potssium, phosphorus, nd m
nesium re the
mjor intrcellulr ions, nd even sliht hemolysis will cuse flsely elevted
results. Serum
smples with visi le hemolysis (20 m/dL free H ) should e redrwn. 57. D Addi
sons disese
(drenocorticl insu ciency) results in low levels of drenl corticosteroid hormo
nes, includin
ldosterone nd cortisol. Becuse these hormones promote re sorption of sodium
nd secretion of
potssium y the collectin tu ules, ptients with Addisons disese disply hyper
klemi nd
hypontremi. Hemolytic nemi nd dioxin intoxiction cuse relese of intrce
llulr potssium.
Alklosis cuses potssium to move from the extrcellulr uid into the cells s h
ydroen ions
move from the cells into the extrcellulr uid to compenste for lklosis. 58. D

toxicity cuses potssium to leve the cells nd enter the extrcellulr uid, res
ultin in
hyperklemi. Renl filure, hemolytic nemi nd Addisons disese re other freq
uent cuses of
hyperklemi. Hypoprthyroidism indirectly cuses hypoklemi y inducin lkl
osis vi
incresed renl retention of phosphte nd icr onte. Cushins syndrome (dren
l corticl
hyperfunction) results in low potssium nd elevted sodium. Dirrhe cuses los
s of sodium nd
potssium. 59. C The reference rne for potssium is 3.65.4 mmol/L. However, vl
ues elow 2.5
mmol/L require immedite intervention ecuse elow tht level there is  rve
risk of crdic
rrhythmi, which cn led to crdic rrest. The upper lert level for potssiu
m is usully 6.5
mmol/L, except for neontl nd hemolyzed smples. A ove this level, there is d
ner of crdic
filure. 60. D Reduced lomerulr ltrtion coupled with decresed tu ulr secreti
on cuses
ccumultion of potssium, mnesium, nd inornic phosphorus. Poor tu ulr re
sorption of
sodium o sets reduced lomerulr ltrtion. Un ltered sodium drws oth chloride nd w
cusin osmotic equili rtion etween ltrte, serum, nd the tissues. In renl di
sese, serum
sodium is often norml, lthouh totl ody sodium is incresed owin to uid nd
slt retention.
2828_Ch05_171-326 06/08/12 5:14 PM Pe 201 61. Which of the followin is the
mechnism for vsopressin (ADH) relese? A. Hypovolemi B. Hyperosmolr plsm C
. Renin relese
D. Reduced renl lood ow Chemistry/Apply knowlede of fundmentl ioloicl
chrcteristics/Osmollity/2 62. Which of the followin conditions is ssocited
hyperntremi? A. Di etes insipidus B. Hypoldosteronism C. Burns D. Dirrhe
Chemistry/Correlte clinicl nd l ortory dt/ Electrolytes/2 63. Which of th
e followin
vlues is the threshold criticl vlue (lert or ction level) for hih plsm s
odium? A. 150
mmol/L B. 160 mmol/L C. 170 mmol/L D. 180 mmol/L Chemistry/Apply knowlede of fu
ioloicl chrcteristics/Electrolytes/1 64. Which of the followin conditions
is ssocited
with totl ody sodium excess? A. Renl filure B. Hyperthyroidism C. Hypoprth
yroidism D.
Di etic ketocidosis Chemistry/Correlte clinicl nd l ortory dt/ Electrol
ytes/2 202
Chpter 5 | Clinicl Chemistry Answers to Questions 6164 61. B ADH is relesed y
the posterior
pituitry in response to incresed plsm osmollity. Normlly, this is triere
d y relese of
ldosterone cused y ine ective rteril pressure in the kidney. Aldosterone cus
es sodium
re sorption, which rises plsm osmollity; relese of ADH cuses re sorption
of wter, which
increses lood volume nd restores norml osmollity. A de ciency of ADH (di ete
s insipidus)
results in dehydrtion nd hyperntremi. An excess of ADH (syndrome of inpprop
rite ADH relese

[SIADH]) results in dilutionl hypontremi. This my e cused y reionl hypo

hypothyroidism, centrl nervous system injury, drus, nd mlinncy. 62. A Di
etes insipidus
results from filure to produce ADH. Becuse the collectin tu ules re imperme
le to wter in
the  sence of ADH, severe hypovolemi nd dehydrtion result. Hypovolemi stimu
ltes ldosterone
relese, cusin sodium re sorption, which worsens the hyperntremi. Burns, hy
dirrhe, nd diuretic therpy re common cuses of hypontremi. 63. B The dul
t reference rne
for plsm sodium is pproximtely 135145 mmol/L. Levels in excess of 160 mmol/L
re ssocited
with severe dehydrtion, hypovolemi, nd circultory nd hert filure. The thr
eshold for the
low criticl vlue for sodium is 120 mmol/L. This is ssocited with edem, hype
rvolemi, nd
circultory overlod. Alert levels must lso e est lished for potssium, icr
onte, clcium,
pH, PO 2 , lucose, iliru in, hemolo in, pltelet count, nd prothrom in time.
When  smple
result is elow or  ove the low or hih lert level, respectively, the physici
n must e noti ed
immeditely. 64. A Totl ody sodium excess often occurs in persons with renl f
conestive hert filure, nd cirrhosis of the liver. When wter is retined lo
n with sodium,
totl ody sodium excess results rther thn hyperntremi. Hert filure cuses
sodium nd wter
retention y reducin lood ow to the kidneys. Cirrhosis cuses o struction of he
lymphtics nd portl veins, ledin to locl hypertension nd ccumultion of 
scites uid.
Renl filure results in poor lomerulr ltrtion nd isosmotic equili rtion of
slt nd wter.
2828_Ch05_171-326 06/08/12 5:14 PM Pe 202 65. Which of the followin condit
ions is
ssocited with hypontremi? A. Diuretic therpy B. Cushins syndrome C. Di ete
s insipidus D.
Nephrotic syndrome Chemistry/Correlte clinicl nd l ortory dt/ Electrolyte
s/2 66. Which of
the followin conditions involvin electrolytes is descri ed correctly? A. Pseud
occurs only when undiluted smples re mesured B. Potssium levels re slihtly
hiher in
heprinized plsm thn in serum C. Hypol uminemi cuses low totl clcium ut
does not  ect
C i D. Hyperclcemi my e induced y low serum mnesium Chemistry/Correlte
clinicl nd
l ortory dt/ Electrolytes/2 67. Which of the followin l ortory results is
ssocited with cystic rosis? A. Swet chloride reter thn 60 mmol/L B. Elevt
ed serum sodium
nd chloride C. Elevted fecl trypsin ctivity D. Low lucose Chemistry/Evlut
e l ortory dt
to reconize helth nd disese sttes/Electrolytes/2 5.2 | Blood Gses, pH, nd
203 Answers to Questions 6567 65. A Diuretics lower lood pressure y promotin w
ter loss. This

is ccomplished y cusin sodium loss from the proximl tu ule nd/or loop. Add
isons disese,
syndrome of inpproprite ADH relese, urns, di etic ketocidosis, hypopituit
rism, vomitin,
dirrhe, nd cystic
rosis lso cuse hypontremi. Cushins syndrome cuses hype
rntremi y
promotin sodium re sorption in the collectin tu ule in exchne for potssium
. Di etes
insipidus nd nephrotic syndrome promote hyperntremi y cusin wter loss. 66
. C When serum
l umin is low, the equili rium etween ound nd C i is shifted, producin inc
resed C i .
This inhi its relese of PTH y netive feed ck until the C i level returns t
o norml.
Potssium is relesed from pltelets nd leukocytes durin coultion, cusin
serum levels to
e hiher thn plsm. Pseudohypontremi is  mesurement error cused y dilut
in smples
continin excessive ft or protein. The colloids displce plsm wter, resulti
n in less
electrolytes ein delivered into the diluent. Only ion-selective electrodes th
t mesure whole
lood or undiluted serum re un ected. Mnesium is needed for relese of PTH, n
d PTH cuses
relese of clcium nd mnesium from one. Therefore, hypoclcemi cn e ssoc
ited with either
mnesium de ciency or mnesium excess. 67. A Cystic
rosis cuses o struction of
the exocrine
lnds includin the swet lnds, mucus lnds, nd pncres. New orns with pn
involvement demonstrte fecl trypsin de ciency, which my e detected y  low fe
chymotrypsin or immunorective trypsin result. However, these tests require con rm
tion. Serum
sodium nd chloride levels re low. More thn 98% of  ected infnts hve elevted
swet sodium
nd chloride nd low serum levels. Swet chloride in excess of 60 mmol/L con rms t
he clinicl
dinosis. Some persons with the disese hve insulin de ciency nd elevted lood
Genetic tests re vil le to detect severl muttions tht occur t the cystic
trnsmem rne conductnce reultor (CFTR) locus on chromosome 7. 2828_Ch05_171326 06/08/12
5:14 PM Pe 203 68. When performin  swet chloride collection, which of the
followin steps
will result in nlyticl error? A. Usin unweihed uze soked in pilocrpine
nitrte on the
inner surfce of the forerm to stimulte swetin B. Collectin more thn 75 m
of swet in 30
minutes C. Levin the preweihed uze on the inside of the rm exposed to ir
durin collection
D. Rinsin the collected swet from the uze pd usin chloride titrtin solut
Chemistry/Apply knowlede to reconize sources of error/Specimen collection nd
hndlin/3 69.
Which electrolyte level est correltes with plsm osmollity? A. Sodium B. Chl
oride C.
Bicr onte D. Clcium Chemistry/Apply knowlede of fundmentl ioloicl
chrcteristics/Electrolytes/2 70. Which formul is most ccurte in predictin

osmollity? A. N + 2(Cl) + BUN + lucose B. 2(N) + 2(Cl) + lucose + ure C. 2
(N) + (lucose
18) + (BUN 2.8) D. N + Cl + K + HCO 3 Chemistry/Clculte/Osmollity/2 204 Chp
ter 5 |
Clinicl Chemistry Answers to Questions 6870 68. C The swet chloride procedure r
equires the
ppliction of pilocrpine to stimulte swetin, nd the use of iontophoresis (
ppliction of
0.16-mA current for 5 minutes) to rin the swet to the surfce. After iontopho
resis, the skin
on the inner surfce of the forerm is wshed with deionized wter nd dried, n
d  preweihed
pir of 2-in. 2 pds is tped to the skin. Durin the 30-minute collection of sw
et, the uze
must e completely covered to prevent contmintion nd loss of swet y evpor
tion. The
Gi sonCooke reference method for swet chloride uses the Schles nd Schles meth
od (titrtion
y H[NO 3
2 with diphenylcr zone indictor) to ssy 1.0 mL of swet eluted from
the uze with 5 mL
of wter. A Cotlove chloridometer is often used to mesure swet chloride. The s
wet is eluted
from the uze with the titrtin solution to fcilitte mesurement. Alterntiv
ely,  mcroduct
collection system my e used tht does not require weihin. A minimum mss of
75 m swet is
required for collection in uze nd 15 L sweat for collection in macroduct tubin
g. 69. A Sodium
and chloride are the major extracellular ions. Chloride passively follows sodium
, making sodium
the principal determinant of plasma osmolality. 70. C Calculated plasma osmolali
ty is based upon
measurement of sodium, glucose, and urea. Because sodium associates with a count
er ion, two times
the sodium estimates the millimoles per liter of electrolytes. Some laboratories
multiply by 1.86
instead of 2 to correct for undissociated salts. Dividing glucose by 18 converts
from milligrams
per deciliter to millimoles per liter. Dividing blood urea nitrogen (BUN) by 2.8
converts from
milligrams per deciliter BUN to millimoles per liter urea. 2828_Ch05_171-326 06
/08/12 5:14 PM
Page 204 205 5.3 Glucose, Hemoglobin, Iron, and Bilirubin 1. Which of the follow
ing biochemical
processes is promoted by insulin? A. Glycogenolysis B. Gluconeogenesis C. Lipoly
sis D. Uptake of
glucose by cells Chemistry/Apply knowledge of fundamental biological
characteristics/Carbohydrates/1 2. Which of the following hormones promotes hype
rglycemia? A.
Calcitonin B. Growth hormone C. Aldosterone D. Renin Chemistry/Apply knowledge o
f fundamental
biological characteristics/Carbohydrates/1 3. Which of the following is characte
ristic of type 1
diabetes mellitus? A. Requires an oral glucose tolerance test for diagnosis B. I
s the most common
form of diabetes mellitus C. Usually occurs after age 40 D. Requires insulin rep
lacement to

prevent ketosis Chemistry/Correlate clinical and laboratory data/ Biological man

ifestation of
disease/2 Answers to Questions 13 1. D Insulin reduces blood glucose levels by in
glucose uptake by cells. It promotes lipid and glycogen production, induces synt
hesis of
glycolytic enzymes, and inhibits formation of glucose from pyruvate and Krebs cy
intermediates. 2. B Growth hormone and cortisol promote gluconeogenesis and epin
stimulates glycogenolysis. Excess thyroid hormone causes hyperglycemia by increa
sing glucagon and
inactivation of insulin, thereby promoting both gluconeogenesis and glycogenolys
is. An increase
in any of these hormones can cause hyperglycemia. Calcitonin opposes the action
of parathyroid
hormone. Aldosterone is the primary mineralocorticoid hormone and stimulates sod
ium reabsorption
and potassium secretion by the kidneys. Renin is released from the kidney due to
ine ective
arterial pressure and promotes activation of angiotensinogen and aldosterone sec
retion. 3. D Type
1, or juvenile, diabetes is also called insulin- dependent diabetes because pati
ents must be
given insulin to prevent ketosis. Type 1 accounts for only about 10%20% of cases
of diabetes
mellitus, and is usually diagnosed by a fasting plasma glucose. Two consecutive
results 126
mg/dL is diagnostic. Approximately 95% of patients produce autoantibodies agains
t the beta cells
of the pancreatic islets. Other autoantibodies may be produced against insulin,
decarboxylase, and tyrosine phosphorylase IA2. There is genetic association betw
een type 1
diabetes and human leukocyte antigens (HLA) DR3 and DR4. 2828_Ch05_171-326 06/0
8/12 5:14 PM
Page 205 4. Which of the following is characteristic of type 2 diabetes mellitus
? A. Insulin
levels are consistently low B. Most cases require a 3-hour oral glucose toleranc
e test to
diagnose C. Hyperglycemia is often controlled without insulin replacement D. Te
condition is
associated with unexplained weight loss Chemistry/Correlate clinical and laborat
ory data/
Biological manifestation of disease/2 5. Which of the following results falls wi
thin the
diagnostic criteria for diabetes mellitus? A. Fasting plasma glucose of 120 mg/d
L B. Two-hour
postprandial plasma glucose of 160 mg/dL C. Two-hour plasma glucose of 180 mg/dL
following a 75 g
oral glucose challenge D. Random plasma glucose of 250 mg/dL and presence of sym
Chemistry/Evaluate laboratory data to recognize health and disease states/Carboh
ydrates/2 6.
Select the most appropriate adult reference range for fasting blood glucose. A.
40105 mg/dL
(2.225.82 mmol/L) B. 60140 mg/dL (3.337.77 mmol/L) C. 6599 mg/dL (3.615.50 mmol/L) D.
mg/dL (4.168.32 mmol/L) Chemistry/Apply knowledge of fundamental biological
characteristics/Carbohydrates/1 7. When preparing a patient for an oral glucose

tolerance test
(OGTT), which of the following conditions will lead to erroneous results? A. Te
patient remains
ambulatory for 3 days prior to the test B. Carbohydrate intake is restricted to
below 150 g/day
for 3 days prior to test C. No food, co ee, tea, or smoking is allowed 8 hours bef
ore and during
the test D. Administration of 75 g of glucose is given to an adult patient follo
wing a 1012-hour
fast Chemistry/Apply knowledge to recognize sources of error/Glucose tolerance t
est/3 206 Chapter
5 | Clinical Chemistry Answers to Questions 47 4. C Type 2, or late-onset diabete
s, is
associated with a defect in the receptor site for insulin. Insulin levels may be
low, normal, or
high. Patients are usually obese and over 40 years of age, although the incidenc
e is increasing
in both children and young adults. The American Diabetes Association (ADA) recom
mends screening
all adults for diabetes who are overweight and have one additional risk factor a
nd all adults
over age 45, and to retest them every 3 years, if negative. Patients do not requ
ire insulin to
prevent ketosis and hyperglycemia can be controlled in most patients by diet and
drugs that
promote insulin release. Type 2 accounts for 80%90% of all diabetes mellitus. 5.
D The American
Diabetes Association recommends the following criteria for diagnosing diabetes m
ellitus: fasting
glucose 126 mg/dL, casual (random) glucose 200 mg/dL in the presence of symptoms
increased thirst, weight loss), glucose 200 mg/dL at 2 hours after an oral dose
of 75 g of
glucose, and hemoglobin A 1c 6.5%. A diagnosis of diabetes mellitus is indicated
if any one or
combination of these four criteria is met on more than a single testing event. T
he fasting plasma
glucose test requires at least 8 hours with no food or drink except water. The 2
-hour postloading
test should be conducted according to the oral glucose tolerance guidelines curr
ently recommended
by the World Health Organization. 6. C Reference ranges vary slightly depending
upon method and
specimen type. Enzymatic methods speci c for glucose have an upper limit of normal
no greater
than 99 mg/dL. This is the cuto value for impaired fasting plasma glucose (predia
recommended by the American Diabetes Association. Although 65 mg/dL is considere
d the 2.5
percentile, a fasting level below 50 mg/dL is often seen without associated clin
hypoglycemia, and neonates have a lower limit of approximately 40 mg/dL owing to
insulin. 7. B Standardized OGTTs require that patients receive at least 150 gram
s of carbohydrate
per day for 3 days prior to the test in order to stabilize the synthesis of indu
cible glycolytic
enzymes. The 2-hour OGTT test is no longer recommended for screening and should
be reserved for
con rmation of diabetes in cases that are di cult to diagnose, such as persons who l

ack symptoms
and signs of fasting hyperglycemia. 2828_Ch05_171-326 06/08/12 5:14 PM Page 2
06 8. Which of
the following 2-hour glucose challenge results would be classi ed as impaired gluc
ose tolerance
(IGT)? Two-hour serum glucose: A. 130 mg/dL B. 135 mg/dL C. 150 mg/dL D. 204 mg/
Chemistry/Evaluate laboratory data to recognize health and disease states/Glucos
e tolerance/2 9.
Which statement regarding gestational diabetes mellitus (GDM) is correct? A. Is
diagnosed using
the same oral glucose tolerance criteria as in nonpregnancy B. Converts to diabe
tes mellitus
after pregnancy in 60%75% of cases C. Presents no increased health risk to the fe
tus D. Is
de ned as glucose intolerance originating during pregnancy Chemistry/Evaluate labo
ratory data to
recognize health and disease states/Glucose tolerance test/2 10. Which of the fo
llowing ndings
is characteristic of all forms of clinical hypoglycemia? A. A fasting blood gluc
ose value below
55 mg/dL B. High fasting insulin levels C. Neuroglycopenic symptoms at the time
of low blood
sugar D. Decreased serum C peptide Chemistry/Correlate clinical and laboratory d
Carbohydrates/2 5.3 | Glucose, Hemoglobin, Iron, and Bilirubin 207 Answers to
Questions 810 8.
C With the exception of pregnant females, impaired glucose tolerance is de ned by
the ADA as a
serum or plasma glucose at 2 hours following a 75-g oral glucose load of 140 mg/d
L and < 200
mg/dL. Persons who have a fasting plasma glucose of 100 but < 126 mg/dL are class
i ed as having
impaired fasting glucose (IFG). Both IGT and IFG are risk factors for developing
diabetes later
in life. Such persons are classi ed as having prediabetes and should be tested ann
ually. 9. D
Control of GDM reduces perinatal complications such as respiratory distress synd
rome, high birth
weight, and neonatal jaundice. Women at risk are usually screened between 24 and
28 weeks
gestation. The screening test can be performed nonfasting and consists of an ora
l 50-g glucose
challenge followed by serum or plasma glucose measurement at 1 hour. A result 14
0 mg/dL is
followed by a 2-hour or 3-hour oral glucose tolerance test to confirm gestationa
l diabetes. For
the 3-hour test, a 100-g dose of glucose is used and at least two of the followi
ng cutoffs must
be exceeded: fasting, 95 mg/dL or higher; 1 hour, 180 mg/dL or higher; 2 hour 15
5 mg/dL or
higher; 3 hour, 140 mg/dL or higher. The same cutpoints are used for the 2-hour
test except
that a 75-g dose is used. GDM converts to diabetes mellitus within 10 years in 3
0%40% of cases.
ADA recommends testing persons with GDM for diabetes 612 weeks after delivery. 10
. C Clinical
hypoglycemia can be caused by insulinoma, drugs, alcoholism, and reactive hypogl
ycemia. Reactive
hypoglycemia is characterized by delayed or excessive insulin output after eatin

g and is very
rare. Fasting insulin is normal but postprandial levels are increased. High fast
ing insulin
levels (usually > 6 g/L) are seen in insulinoma, and patients with insulinoma alm
ost always
display fasting hypoglycemia, especially when the fast is extended to 4872 hours.
C peptide is a
subunit of proinsulin that is hydrolyzed when insulin is released. In hypoglycem
ia, low levels
indicate an exogenous insulin source, whereas high levels indicate overproductio
n of insulin.
2828_Ch05_171-326 06/08/12 5:14 PM Page 207 11. Which statement regarding gly
(glycosylated) Hgb (G-Hgb) is true? A. Has a sugar attached to the C-terminal en
d of the chin
B. Is  hihly reversi le minolycn C. Re ects the extent of lucose reultion
in the 8- to
12-week intervl prior to smplin D. Will e  norml within 4 dys followin 
n episode of
hyperlycemi Chemistry/Correlte l ortory dt with physioloicl processes/G
hemolo in/2 12. Wht is the Americn Di etes Assocition recommended cuto vlue
for dequte
control of lood lucose in di etics s mesured y lycted hemolo in? A. 5%
B. 6.5% C. 9.5%
D. 11% Chemistry/Evlute l ortory dt to reconize helth nd disese sttes
/Glucose/2 13.
Which sttement rerdin mesurement of H A 1c is true? A. Levels do not need
to e done
fstin B. Both the l ile nd st le H A 1c frctions re mesured C. Smples
should e
mesured within 2 hours of collection D. Te ssy must e done y chromtorphy
knowlede to reconize sources of error/Glycted hemolo in/2 14. Which sttion
ry phse is used
for the mesurement of hemolo in A 1c y hih performnce liquid chromtorphy
? A.
Octdecylsilne (C18) B. Ction exchner C. Anion exchner D. Polystyrene divi
nyl enzene
Chemistry/Apply principles of specil procedures/ Glycted hemolo in/2 208 Chp
ter 5 | Clinicl
Chemistry Answers to Questions 1114 11. C G-H results from the nonenzymtic tt
chment of 
sur such s lucose to the N-terminl vline of the chin. The rection is non
reversi le nd
is relted to the time-vered lood lucose concentrtion over the life spn o
f the RBCs. There
re three G-H frctions desinted A 1 , A 1 , nd A lc . Hemolo in A 1c m
kes up  out 80%
of lycted hemolo in, nd is used to determine the dequcy of insulin therpy
. The
time-vered lood lucose is pproximted y the formul (G-H 33.3) 86 m/dL
, nd insulin
djustments cn e mde to rin this level to within reference limits. Also, l
ycted protein
ssy (clled fructosmine) provides similr dt for the period etween 2 nd 4
weeks efore
smplin. 12. B The ADA recommends tht 6.5% e used s the cuto for determinin
the dequcy of
tretment for di etes. A lycted hemolo in test should e performed t the ti

me of dinosis
nd every 6 months therefter if the result is < 6.5%. If the result is 6.5% or
more, the
tretment pln should e djusted to chieve  lower level, nd the test perform
ed every 3 months
until control is improved. 13. A Since H A 1C represents the vere lood lu
cose 23 months
prior to lood collection, the dietry sttus of the ptient on the dy of the t
est hs no e ect
upon the results. Refrierted whole- lood smples re st le for up to 1 week.
H A 1C is
ssyed y ction exchne hih-performnce liquid chromtorphy or immunossy
(immunotur idimetric inhi ition) ecuse oth methods re speci c for st le H A
1C , nd do
not demonstrte errors cused y  norml hemolo ins, temperture of reents,
or frctions
other thn A 1c . 14. B HPLC methods for mesurin H A 1c re performed y dil
utin whole lood
with n cid u er tht hemolyzes the smple. Norml hemolo in A hs  wek posit
ive chre t
n cidic pH nd inds wekly to the resin. Glycted hemolo in hs n even wek
er positive
chre nd is eluted efore hemolo in A. A norml hemolo in molecules S, D, E,
nd C hve 
hiher positive chre thn hemolo in A nd re retined loner on the column.
Elution is
ccomplished y incresin the ionic strenth of the mo ile phse. Ctions in th
e u er displce
the hemolo in piments from the column. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 208 15.
Evlute the followin chromtorm of  whole- lood hemolyste, nd identify th
e cuse nd est
course of ction. A. Result is not report le ecuse hemolo in F is present n
d interferes B.
Te result is not report le ecuse hemolo in C is present nd interferes C. Te
result is not
report le ecuse l ile hemolo in A 1c is present D. Te result is report le;
hemolo in F or C interfere Chemistry/Evlute l ortory dt to reconize pro
hemolo in/3 16. Which sttement est descri es the use of the H A 1C test? 5.
3 | Glucose,
Hemolo in, Iron, nd Biliru in 209 Answers to Questions 1517 15. D The chromt
orm is from 
person with hemolo in AC; however, hemolo in C is completely seprted from H
A 1c nd does
not interfere. H F is lso present, ut does not interfere unless its concentr
tion is > 30%.
L ile hemolo in is formed initilly when the ldehyde of lucose rects with t
he N-terminl
vline of the lo in chin. This Shi se is reversi le ut is converted to H A
1c y
rerrnement to  ketomine. It is clled l ile A 1c nd produces  pek (LA 1
c ) fter HF nd
efore H A 1c . Therefore, it does not interfere. 16. B The ADA now recommends
tht the
hemolo in A 1c test e used for oth dinosis nd monitorin lood lucose lev
els. The cutpoint
for di etes is n A 1c of 6.5. Persons with n A 1c of 5.7%6.4% re clssi ed s
ein t hih

risk for di etes within 5 yers. An A 1c etween 4.0%5.5% is de ned s within norm
l limits.
17. B Impired fstin lucose is de ned s  plsm lucose 100 ut <126 m/dL. A
lucose of 126 or hiher on two consecutive occsions indictes di etes. A fst
in lucose of 99
m/dL is considered norml. Pek Cli rted Retention Pek
% Are Time Are
Al 0.60 0.25 12500 F 0.50 0.50 11300 LA 1c 0.75 0.70 15545 A 1c 6.2 0.9
0 45112 P 3 2.6 1.60
57489 Ao 48.0 1.8 994813 C 43.0 2.00 926745 17. Accordin to Americn Di etes A
criteri, which result is consistent with  dinosis of impired fstin lucos
e? A. 99 m/dL B.
117 m/dL C. 126 m/dL D. 135 m/dL Chemistry/Evlute l ortory dt to recon
ize helth nd
disese sttes/Glucose/2 A. Should e used for monitorin lucose control only B
. My e used for
oth dinosis nd monitorin C. Should e used only to monitor persons with typ
e 1 di etes D.
My e used only to monitor persons with type 2 di etes Chemistry/Correlte cli
nicl nd
l ortory dt/ Glycted hemolo in/2 2828_Ch05_171-326 06/08/12 5:14 PM P
e 209 18. Wht is
the recommended cuto for the erly detection of chronic kidney disese in di eti
cs usin the
test for microl uminuri? A. >30 m/ cretinine B. >80 m/ cretinine C. >200
m/ cretinine
D. >80 m/L Chemistry/Evlute l ortory dt to reconize helth nd disese s
19. In ddition to mesurin lood lucose, H A 1c , nd microl umin, which t
est should e
done on di etic persons once per yer? A. Urine lucose B. Urine ketones C. Pl
sm fructosmines
D. Estimted lomerulr ltrtion rte Chemistry/Select method/Cr ohydrtes/2 20.
Which testin
sitution is pproprite for the use of point-of-cre whole- lood lucose method
s? A. Screenin
for type 2 di etes mellitus B. Dinosis of di etes mellitus C. Monitorin of
lood lucose
control in type 1 nd type 2 di etics D. Monitorin di etics for hyperlycemic
episodes only
Chemistry/Select method/Cr ohydrtes/2 21. Which of the followin is the refere
nce method for
mesurin serum lucose? A. SomoyiNelson B. Hexokinse C. Glucose oxidse D. Glu
dehydroense Chemistry/Select method/Cr ohydrtes/2 210 Chpter 5 | Clinicl C
hemistry Answers
to Questions 1821 18. A Microl uminuri is the excretion of smll quntities of
l umin in the
urine. In di etics, excretion of l umin tht is within llow le limits for he
lthy persons my
sinl the onset of chronic kidney disese. The term microl uminuri is defined
s l umin
excretion 30 m/ cretinine ut 300 m/ cretinine. The use of the l umin to
rtio is preferred to mesures of l umin excretory rte (g/min) because the latt
er is subject
to error associated with timed specimen collection. ADA recommends the test be d
one annually for

all type 2 diabetics and type 1 diabetics who have had the disease for > 5 years
. 19. D While
urinary glucose can identify persons who may have diabetes, it is not sensitive
enough to manage
glucose control on a daily basis, and has been replaced by whole-blood glucose m
onitoring or
continuous glucose monitoring. While the urinary ketone test is a useful screeni
ng test for
diabetic and other forms of ketosis, the plasma hydroxy utyrte test should e u
sed to identify
nd monitor ketosis in di etic persons. Fructosmine is  useful djunct to H
A 1c to identify
poor control of lood lucose in the pst 24 weeks, ut hs not een recommended
for routine use
in ll di etic ptients. 20. C The ADA does not recommend the use of whole- loo
d lucose
monitors for est lishin  dinosis of di etes or screenin persons for di e
tes. The
nlyticl mesurement rne of these devices vries retly, nd whole lood l
ucose is
pproximtely 10% lower thn serum or plsm lucose. In ddition, nlyticl v
rince is reter
nd ccurcy less thn for l ortory instruments. Whole lood lucose meters sh
ould e used y
di etics nd creivers to monitor lucose control nd cn detect oth hyper- 
nd hypolycemic
sttes tht result from too little or too much insulin replcement. Therefore, p
monitorin with such  device is recommended for ll persons who receive insulin
therpy. 21. B
The hexokinse method is considered more ccurte thn lucose oxidse methods
ecuse the
couplin rection usin lucose-6-phosphte dehydroense (G-6-PD) is hihly spe
ci c. The
hexokinse method my e done on serum or plsm collected usin heprin, EDTA, u
oride, oxlte,
or citrte. The method cn lso e used for urine, cere rospinl uid, nd serous u
2828_Ch05_171-326 06/08/12 5:14 PM Pe 210 22. Polrorphic methods for lu
cose nlysis re
sed upon which principle of mesurement? A. Nonenzymtic oxidtion of lucose
B. Te rte of O 2
depletion C. Chemiluminescence cused y formtion of denosine triphosphte (AT
P) D. Te chne
in electricl potentil s lucose is oxidized Chemistry/Apply principles of s
ic l ortory
procedures/Cr ohydrtes/2 23. In ddition to polrorphy, wht other electroch
emicl method cn
e used to mesure lucose in plsm? A. Conductivity B. Potentiometry C. Anodic
voltmmetry D. Amperometry Chemistry/Apply principles of sic l ortory
procedures/Cr ohydrtes/2 24. Select the enzyme tht is most speci c for -D-lucos
e. A.
Hexokinse B. G-6-PD C. Phosphohexisomerse D. Glucose oxidse Chemistry/Apply k
nowlede of
fundmentl ioloicl chrcteristics/Biochemicl/1 25. Select the couplin enz
yme used in the
hexokinse method for lucose. A. Glucose-6-phosphte dehydroense B. Peroxids
e C. Glucose
dehydroense D. Glucose-6-phosphtse Chemistry/Apply knowlede of sic l or

procedures/Cr ohydrtes/1 26. Which lucose method is su ject to flsely low re
sults cused y
scor te? A. Hexokinse B. Glucose dehydroense C. Trinder lucose oxidse D.
Chemistry/Apply knowlede to reconize sources of error/Cr ohydrtes/2 5.3 | Gl
Hemolo in, Iron, nd Biliru in 211 Answers to Questions 2226 22. B Polrorph
ic lucose
electrodes mesure the consumption of O 2 s lucose is oxidized. Glucose oxids
e in the reent
ctlyzes the oxidtion of lucose y O 2 under rst-order conditions, formin hyd
roen peroxide
(H 2 O 2 ). As the dissolved O 2 decreses, less is reduced t the cthode, resu
ltin in 
decrese in current proportionl to lucose concentrtion. It is importnt tht
the H 2 O 2 not
rekdown to re-form O 2 . This is prevented y ddin moly dte nd iodide tht
rect with H 2 O
2 , formin iodine nd wter, nd y ddin ctlse nd ethnol tht rect with
H 2 O 2 ,
formin cetldehyde nd wter. 23. D In some criticl cre nlyzers, mperomet
ric mesurement
of lucose is used. The lucose oxidse is imprented into the mem rne coverin
 the electrode.
It rects with lucose in the smple, formin H 2 O 2. This di uses cross the mem
rne to the
node of the electrode, where it is oxidized to O 2 . The electrons produced re
used to reduce
oxyen t the cthode, completin the current pth. At the node (usully pltin
um), 2H 2 O 2 4e
+ 2O 2 + 4H + . At the cthode(usully silver), O 2 + 4H + + 4e 2H 2 O. The net e
qution is
2H 2 O 2 O 2 + 2H 2 O. 24. D Glucose oxidse is the most speci c enzyme rectin wi
th only
-D-lucose. However, the peroxidse couplin rection used in the lucose oxidse
method is
su ject to positive nd netive interference. Therefore, hexokinse is used in
the reference
method. 25. A The hexokinse reference method uses  protein-free ltrte prepred
with rium
hydroxide (BOH) nd zinc sulfte (ZnSO 4 ). Hexokinse ctlyzes the phosphoryl
tion of lucose
in the ltrte usin ATP s the phosphte donor. Glucose-6-phosphte (lucose-6-PO
4 ) is
oxidized to 6-phospholuconte nd NAD + is reduced to NADH usin G-6-PD. The in
crese in
 sor nce t 340 nm is proportionl to lucose concentrtion. Althouh hexokin
se will
phosphorylte some other hexoses includin mnnose, fructose, nd lucosmine, t
he couplin
rection is entirely speci c for lucose-6-PO 4 elimintin interference from othe
r surs. 26. C
Althouh lucose oxidse is speci c for -D-lucose, the couplin (indictor) recti
on is prone
to netive interference from scor te, uric cid, cetocetic cid, nd other
reducin ents.
These compete with the chromoen (e.., o-dinisidine) for peroxide, resultin i
n less dye ein
oxidized to chromophore. The choice of chromoen determines the speci city nd lin

4-minophenzone nd phenol is more resistnt to interference from zo compounds
nd proteins
thn is o-dinisidine. 2828_Ch05_171-326 06/08/12 5:14 PM Pe 211 27. Which
of the followin
is  potentil source of error in the hexokinse method? A. Glctosemi B. Hemo
lysis C. Smple
collected in uoride D. Ascor ic cid Chemistry/Apply knowlede to reconize sourc
es of
error/Cr ohydrtes/2 28. Which sttement  out lucose in cere rospinl uid (CSF
) is correct?
A. Levels elow 40 m/dL occur in septic meninitis, cncer, nd multiple sclero
sis B. CSF
lucose is normlly the sme s the plsm lucose level C. Hyperlycorrhchi i
s cused y
dehydrtion D. In some clinicl conditions, the CSF lucose cn e reter thn
the plsm
lucose Chemistry/Correlte l ortory dt with physioloicl processes/Cere ro
spinl uid/2 29.
In peroxidse-coupled lucose methods, which reent complexes with the chromoe
n? A.
Nitroprusside B. Phenol C. Trtrte D. Hydroxide Chemistry/Apply knowlede of 
sic l ortory
procedures/Cr ohydrtes/1 30. Point-of-cre-tests (POCTs) for whole- lood luco
se monitorin re
sed minly on the use of: A. Glucose oxidse s the enzyme B. Amperometric det
ection C.
Immunochromtorphy D. Peroxidse couplin rections Chemistry/Apply knowlede
of sic
l ortory procedures/Cr ohydrtes/1 31. Wht e ect does hemtocrit hve on POCT
tests for
whole- lood lucose monitorin? A. Low hemtocrit decreses lucose redins on
ll devices B.
Hih hemtocrit rises lucose redins on ll devices C. Te e ect is vri le nd
dependent on
the enzyme/coenzyme system D. Low hemtocrit rises redins nd hih hemtocrit
lowers redins
unless corrected Chemistry/Apply knowlede to reconize sources of error/Cr ohy
drtes/3 212
Chpter 5 | Clinicl Chemistry Answers to Questions 2731 27. B The hexokinse met
hod cn e
performed on serum or plsm usin heprin, EDTA, citrte, or oxlte. RBCs cont
in lucose-6-PO
4 nd intrcellulr enzymes tht enerte NADH, cusin positive interference. T
hemolyzed smples require  serum lnk correction (su trction of the rection
rte with
hexokinse omitted from the reent). 28. A Hih lucose in CSF is  re ection of
nd not centrl nervous system disese. The CSF lucose is usully 50%65% of the
plsm lucose.
Low levels re sini cnt nd re most often ssocited with cteril or funl m
mlinncy in the centrl nervous system, nd some cses of su rchnoid hemorrh
e, rheumtoid
rthritis, nd multiple sclerosis. 29. B The couplin step in the Trinder lucos
e oxidse method
uses peroxidse to ctlyze the oxidtion of  dye y H 2 O 2 . Dyes such s 4-
minophenozone or
4-minontipyrine re coupled to phenol to form  quinoneimine dye tht is red 

nd is mesured t
 out 500 nm. 30. B All POCT devices for monitorin lood lucose use either lu
dehydroense (GDH) or lucose oxidse nd re mperometric. For lucose oxidse
methods, the
electrons derive from the oxidtion of hydroen peroxide. For GDH, the electrons
re trnsferred
from one of severl coenzymes tht re reduced when lucose is oxidized, FAD + ,
NAD + , or PQQ
(pyrroloquinoline quinone). Interferences depend upon which enzyme/coenzyme pir
re used. For
exmple, mltose nd xylose interference cn e pronounced with GDH/PQQ- sed st
rips, ut not
with other GDH or lucose oxidse strips. Uric cid depresses lucose oxidse re
ctions ut hs
no e ect on GDH rections. 31. D Hemtocrit  ects POCT lucose mesurements. Hih h
lowers the lucose ecuse RBC lucose concentrtion is lower thn plsm concen
trtion. Other
fctors include indin of oxyen to hemolo in nd the slower di usion of lucose
onto the solid
phse oth of which occur when the hemtocrit is hih. Bis due to n  norml hem
tocrit cn e
voided y simultneously mesurin the conductivity of the smple. The hemtocr
it is clculted
nd used to mthemticlly correct the lucose mesurement. 2828_Ch05_171-326 0
6/08/12 5:14 PM
Pe 212 32. Which of the followin is clssi ed s  mucopolyscchride store d
isese? A.
Pompes disese B. von Gierke disese C. Hers disese D. Hurlers syndrome Chemistry/
clinicl nd l ortory dt/ Cr ohydrtes/1 33. Identify the enzyme de ciency re
sponsi le for
type 1 lycoen store disese (von Gierkes disese). A. Glucose-6-phosphtse B
. Glycoen
phosphorylse C. Glycoen synthetse D. -Glucosidse Chemistry/Correlte clinicl
nd l ortory
dt/ Cr ohydrtes/2 34. Which of the followin  norml l ortory results is
found in von
Gierkes disese? A. Hyperlycemi B. Incresed lucose response to epinephrine d
ministrtion C.
Met olic lklosis D. Hyperlipidemi Chemistry/Correlte clinicl nd l ortor
y dt/
Cr ohydrtes/2 35. Te D-xylose  sorption test is used for the di erentil dino
sis of which
two diseses? A. Pncretic insu ciency from ml sorption B. Primry from second
ry disorders of
lycoen synthesis C. Type 1 nd type 2 di etes mellitus D. Generlized from sp
eci c
cr ohydrte intolernce Chemistry/Correlte clinicl nd l ortory dt/ D-xyl
ose  sorption/2
5.3 | Glucose, Hemolo in, Iron, nd Biliru in 213 Answers to Questions 3235 32
. D Hurlers
syndrome is n utosoml recessive disese resultin from  de ciency of iduronid
Glycosminolycns (mucopolyscchrides) ccumulte in the lysosomes. Multiple o
rn filure nd
mentl retrdtion occur, resultin in erly mortlity. Excess dermtn nd hep
rin sulfte re
excreted in urine. Other mucopolyscchridoses (MPS store diseses) re Hunters

, Scheies,
Sn lippos, nd Morquios syndromes. 33. A Type 1 lycoen store disese (von Gierk
disese) is n utosoml recessive de ciency of lucose-6-phosphtse. Glycoen c
cumultes in
tissues, cusin hypolycemi, ketosis, nd ftty liver. There re seven types o
f lycoen
store disese, desinted type 1 throuh type 7, involvin de ciency of n enzym
e tht cts on
lycoen. Types 1, 4, nd 6 cuse de cient lycoen rekdown in the liver. Types
2, 5, nd 7
involve skeletl muscle nd re less severe. Type 3 usully involves oth liver
nd muscle,
lthouh n uncommon su type (3B) involves only the liver. 34. D Von Gierkes dise
se (type 1
lycoen store disese) results from  de ciency of lucose-6-phosphtse. This
locks the
hydrolysis of lucose-6-PO 4 to lucose nd P i , preventin derdtion of lyc
oen to lucose.
The disese is ssocited with incresed trilyceride levels ecuse fts re mo
ilized for
enery nd lctte cidosis cused y incresed lycolysis. A presumptive dino
sis is mde when
intrvenous lctose dministrtion fils to increse serum lucose, nd cn e
con rmed y
demonstrtin lucose-6-phosphtse de ciency or decresed lucose production in r
esponse to
epinephrine. 35. A Xylose is  pentose tht is  sor ed without the help of pnc
retic enzymes
nd is not met olized. In norml dults, more thn 25% of the dose is excreted
into the urine
fter 5 hours. Low lood or urine levels re seen in ml sorption syndrome, spr
ue, Crohns
disese, nd other intestinl disorders, ut not pncretitis. 2828_Ch05_171-326
06/08/12 5:14
PM Pe 213 36. Which of the followin sttements  out cr ohydrte intolernc
e is true? A.
Glctosemi results from de ciency of lctose-1-phosphte (lctose-1-PO 4 ) u
diphosphte trnsferse B. Glctosemi results in  positive lucose oxidse te
st for lucose in
urine C. Urinry lctose is seen in oth lctosemi nd lctse de ciency D. A
tolernce test is used to con rm  dinosis of lctosemi Chemistry/Correlte c
linicl nd
l ortory dt/ Cr ohydrtes/2 37. Which of the followin sttements rerdin
iron met olism
is correct? A. Iron  sorption is decresed y lcohol inestion B. Normlly, 40
%50% of inested
iron is  sor ed C. Te dily requirement is hiher for prennt nd menstrutin
women D.
A sorption increses with the mount of iron in the ody stores Chemistry/Apply
knowlede of
fundmentl ioloicl chrcteristics/Iron/1 38. Which of the followin process
es occurs when
iron is in the oxidized (Fe 3+ ) stte? A. A sorption y intestinl epithelium B
. Bindin to
trnsferrin nd incorportion into ferritin C. Incorportion into protoporphyrin
IX to form
functionl heme D. Rection with chromoens in colorimetric ssys Chemistry/App

ly knowlede of
fundmentl ioloicl chrcteristics/Iron/1 39. Which of the followin is sso
cited with low
serum iron nd hih totl iron- indin cpcity (TIBC)? A. Iron de ciency nemi B
. Heptitis C.
Nephrosis D. Noniron de ciency nemis Chemistry/Correlte clinicl nd l ortory
dt/ Iron/2
214 Chpter 5 | Clinicl Chemistry Answers to Questions 3639 36. A Glctose is m
et olized to
lctose-1-PO 4 y the ction of lctokinse. Glctose-1-PO 4 uridine diphos
phte (UDP)
trnsferse converts lctose-1-PO 4 to lucose. De ciency of either enzyme cuse
s elevted
lood nd urine lctose. Lctse de ciency results in the presence of urinry l
ctose ecuse
it is not roken down to lucose nd lctose. Tests for reducin surs employ
in copper
sulfte re used to screen for lctose, lctose, nd fructose in urine. Nonlu
surs re not detected y the lucose oxidse rection. A positive test is foll
owed y TLC to
identify the sur, nd demonstrtion of the enzyme de ciency in RBCs. The lcto
se tolernce
test is used (rrely) to evlute the extent of liver filure since the liver is
the site of
lctose met olism. 37. C For dult men nd nonmenstrutin women, pproximte
ly 12 m/dy of
iron is needed to replce the smll mount lost minly y exfolition of cells.
Becuse 5%10% of
dietry iron is  sor ed normlly, the dily dietry requirement in this roup i
s 1020 m/dy.
Menstrutin women hve n dditionl requirement of 1 m/dy nd prennt women
2 m/dy.
A sorption e ciency will increse in iron de ciency nd decrese in iron overlod. I
 sorption is enhnced y low stric pH nd is incresed y lcohol inestion.
38. B Intestinl
 sorption occurs only if the iron is in the reduced (Fe +2 ) stte. After  sor
ption, Fe +2 is
oxidized to Fe +3 y ut mucosl cells. Trnsferrin nd ferritin ind iron e cient
ly only when in
the oxidized stte. Iron within H
inds to O 2 y coordinte ondin, which oc
curs only if the
iron is in the reduced stte. Likewise, in colorimetric methods, Fe +2 forms coo
rdinte onds
with cr on nd nitroen toms of the chromoen. 39. A Iron-de ciency nemi is th
e principl
cuse of low serum iron nd hih TIBC ecuse it promotes incresed trnsferrin.
without iron supplementtion depletes mternl iron stores nd lso results in l
ow serum iron nd
hih TIBC. Iron-supplemented prenncy nd use of contrceptives increse oth i
ron nd TIBC.
Nephrosis cuses low iron nd TIBC due to loss of oth iron nd trnsferrin y t
he kidneys.
Heptitis cuses incresed relese of store iron, resultin in hih levels of
iron nd
trnsferrin. Noniron de ciency nemis my cuse hih iron nd usully show low TI
BC nd norml
or hih ferritin. 2828_Ch05_171-326 06/08/12 5:14 PM Pe 214 40. Which condi

tion is
ssocited with the lowest percent sturtion of trnsferrin? A. Hemochromtosis
B. Anemi of
chronic infection C. Iron de ciency nemi D. Noniron de ciency nemi Chemistry/Cor
clinicl nd l ortory dt/ Iron/2 41. Which condition is most often ssocite
d with  hih
serum iron level? A. Nephrosis B. Chronic infection or in mmtion C. Polycythemi
ver D.
Noniron de ciency nemis Chemistry/Correlte clinicl nd l ortory dt/Iron/2
42. Which of
the followin is likely to occur rst in iron de ciency nemi? A. Decresed serum i
ron B.
Incresed TIBC C. Decresed serum ferritin D. Incresed trnsferrin Chemistry/Co
rrelte clinicl
nd l ortory dt/ Iron/2 43. Which formul provides the est estimte of seru
m TIBC? A. Serum
trnsferrin in m/dL 0.70 = TIBC (/dL) B. Serum trnsferrin in m/dL 1.43 = TIBC
(/dL) C.
Serum iron (/dL)/1.2 + 0.06 = TIBC (/dL) D. Serum Fe (/dL) 1.25 = TIBC (/dL)
Chemistry/Clculte/Iron/2 44. Which sttement rerdin the dinosis of iron d
e ciency is
correct? A. Serum iron levels re lwys hiher t niht thn durin the dy B.
Serum iron levels
ein to fll efore the ody stores ecome depleted C. A norml level of serum
ferritin rules
out iron de ciency D. A low serum ferritin is dinostic of iron de ciency Chemistry
clinicl nd l ortory dt/ Iron/2 5.3 | Glucose, Hemolo in, Iron, nd Biliru
in 215 Answers
to Questions 4044 40. C Percent sturtion = Serum Fe 100/TIBC. Normlly, trnsfe
rrin is
one-third sturted with iron. In iron de ciency sttes, the serum iron flls ut
rises. This cuses the numertor nd denomintor to move in opposite directions,
resultin in
very low percent sturtion ( out 10%). The opposite occurs in hemochromtosis
nd sidero lstic
nemi, resultin in n incresed percent sturtion. 41. D Anemi ssocited wi
th chronic
infection cuses  low serum iron, ut unlike iron de ciency, cuses  low (or nor
ml) TIBC nd
does not cuse low ferritin. Noniron de ciency nemis such s pernicious nemi 
sidero lstic nemi produce hih serum iron nd low TIBC. Nephrosis cuses iron
loss y the
kidneys. Polycythemi is ssocited with incresed iron within the RBCs nd depl
etion of iron
stores. 42. C Body stores must e depleted of iron efore serum iron flls. Thus
, serum ferritin
flls in the erly stes of iron de ciency, mkin it  more sensitive test thn
serum iron in
uncomplicted cses. Ferritin levels re low only in iron de ciency. However, conc
urrent illness
such s mlinncy, infection, nd in mmtion my promote ferritin relese from t
he tissues,
cusin the serum ferritin to e norml in iron de ciency. 43. B Trnsferrin,  -l
o ulin, hs 
moleculr size of  out 77,000. Trnsferrin is the principl iron trnsport prot
ein, nd TIBC is

determined y the serum trnsferrin concentrtion. One mole of trnsferrin inds

two moles of Fe
+3 , so the trnsferrin concentrtion cn e used to predict the TIBC. Since the
mesurement of TIBC requires mnul pretretment to remove the excess iron dded
nd is prone to
overestimtion if ll of the un ound iron is not removed, some l s prefer to me
sure trnsferrin
immunochemiclly nd clculte TIBC. This formul my underestimte TIBC ecuse
l umin nd
other proteins will ind iron when the percent iron sturtion of trnsferrin is
 normlly hih.
44. D Serum iron levels re flsely elevted y hemolysis nd su ject to diurnl
Levels re hihest in the mornin nd lowest t niht, ut this pttern is rever
sed in persons
who work t niht. A low ferritin is speci c for iron de ciency. However, only  out
1% of
ferritin is in the vsculr system. Any disese tht increses ferritin relese
my msk iron
de ciency. 2828_Ch05_171-326 06/08/12 5:14 PM Pe 215 45. Which sttement  ou
t iron methods
is true? A. Interference from H cn e corrected y  serum lnk B. Colorimet
ric methods
mesure indin of Fe 2+ to  lind such s ferrozine C. Atomic  sorption is t
he method of
choice for mesurement of serum iron D. Serum iron cn e mesured y potentiome
Chemistry/Apply principles of specil procedures/Iron/2 46. Which of the followi
n sttements
rerdin the TIBC ssy is correct? A. All TIBC methods require ddition of exc
ess iron to
sturte trnsferrin B. All methods require the removl of un ound iron C. Mesu
rement of TIBC is
speci c for trnsferrin- ound iron D. Te chromoen used must e di erent from the o
ne used for
mesurin serum iron Chemistry/Apply principles of specil procedures/Iron/2 47.
Which of the
followin sttements rerdin the met olism of iliru in is true? A. It is for
med y hydrolysis
of the methene ride of uro ilinoen B. It is reduced to iliverdin prior to ex
cretion C. It
is  y-product of porphyrin production D. It is produced from the destruction o
f RBCs
Chemistry/Apply knowlede of fundmentl ioloicl chrcteristics/Biliru in/1
48. Biliru in is
trnsported from reticuloendothelil cells to the liver y: A. Al umin B. Biliru
in- indin
lo ulin C. Hptolo in D. Trnsferrin Chemistry/Apply knowlede of fundmentl
chrcteristics/Biliru in/1 49. In the liver, iliru in is conjuted y dditio
n of: A. Vinyl
roups B. Methyl roups C. Hydroxyl roups D. Glucuronyl roups Chemistry/Apply
knowlede of
fundmentl ioloicl chrcteristics/Biliru in/1 50. Which enzyme is responsi
le for the
conjution of iliru in? A. -Glucuronidse B. UDP-lucuronyl trnsferse C. Bili
ru in oxidse
D. Biliverdin reductse Chemistry/Apply knowlede of fundmentl ioloicl
chrcteristics/Biliru in/1 216 Chpter 5 | Clinicl Chemistry Answers to Questi

ons 4550 45. B

Atomic  sorption is not the method of choice for serum iron ecuse mtrix erro
r nd vrition
of iron recovered y extrction cuse is nd poor precision. Most methods use
HCl to
deconjute Fe 3+ from trnsferrin followed y reduction to Fe 2+ . This rects
with  neutrl
lind such s ferrozine, tripyridyltrizine (TPTZ), or thophennthroline to 
ive  lue
complex. Anodic strippin voltmmetry cn lso e used to mesure serum iron. He
molysis must e
voided ecuse RBCs contin  much hiher concentrtion of iron thn does plsm
. 46. A All TIBC
methods require ddition of excess iron to sturte trnsferrin. Excess iron is
removed y ion
exchne or lumin el columns or precipittion with MCO 3 nd the ound iron
is mesured y
the sme procedure s is used for serum iron. Alterntively, excess iron in the
reduced stte cn
e dded t n lkline pH. Under these conditions, trnsferrin will ind Fe 2+
nd the un ound
Fe 2+ cn e mesured directly. 47. D Synthesis of porphyrins results in product
ion of heme nd
met olism of porphyrins other thn protoporphyrin IX yields uroporphyrins nd c
not iliru in. Reticuloendothelil cells in the spleen diest H nd relese th
e iron from heme.
The tetrpyrrole rin is opened t the methene ride y heme oxyense, formin
Biliru in is formed y reduction of iliverdin t the methene ride. It is comp
lexed to
l umin nd trnsported to the liver. 48. A Al umin trnsports iliru in, hpto
lo in trnsports
free H , nd trnsferrin trnsports ferric iron. When l umin indin is exceed
ed, un ound
iliru in, clled free iliru in, increses. This my cross the lood rin rrie
r, resultin in
kernicterus. 49. D The esteri ction of lucuronic cid to the propionyl side chi
ns of the inner
pyrrole rins (I nd II) mkes iliru in wter solu le. Conjution is required
efore iliru in
cn e excreted vi the ile. 50. B UDP-lucuronyl trnsferse esteri es lucuroni
c cid to
unconjuted iliru in, mkin it wter solu le. Most conjuted iliru in is di
however, the liver mkes  smll mount of monolucuronide nd other lycosides.
hydrolyzes lucuronide from iliru in, hormones, or drus. It is used prior to o
rnic extrction
to deconjute urinry met olites (e.., totl cortisol). Biliverdin reductse
forms iliru in
from iliverdin (nd heme oxyense forms iliverdin from heme). Biliru in oxid
se is used in n
enzymtic iliru in ssy in which iliru in is oxidized ck to iliverdin nd
the rte of
iliverdin formtion is mesured t 410 nm. 2828_Ch05_171-326 06/08/12 5:14 PM
Pe 216 51. Te
term -biirubin refers to: A. Water-soube biirubin B. Free unconjuate biiru
bin C.
Biirubin tihty boun to abumin D. Direct-reactin biirubin Chemistry/Appy

knowee of
funamenta biooica characteristics/Biirubin/1 52. Which of the foowin pr
ocesses is part
of the norma metaboism of biirubin? A. Both conjuate an unconjuate biir
ubin are excrete
into the bie B. Methene bries of biirubin are reuce by intestina bacteria
urobiinoens C. Most of the biirubin eivere into the intestine is reabsorbe
 D. Biirubin
an urobiinoen reabsorbe from the intestine are mainy excrete by the kiney
s Chemistry/Appy
knowee of funamenta biooica characteristics/Biirubin/1 53. Which of the
foowin is a
characteristic of conjuate biirubin? A. It is water soube B. It reacts more
sowy than
unconjuate biirubin C. It is more stabe than unconjuate biirubin D. It ha
s the same
absorbance properties as unconjuate biirubin Chemistry/Appy knowee of fun
biooica characteristics/Biirubin/1 54. Which of the foowin statements re
urobiinoen is true? A. It is forme in the intestines by bacteria reuction o
f biirubin B. It
consists of a sine water-soube bie piment C. It is measure by its reactio
n with
p-aminosaicyate D. In hemoytic anemia, it is ecrease in urine an feces Che
knowee of funamenta biooica characteristics/Biirubin/1 55. Which statem
ent rearin
biirubin metaboism is true? A. Biirubin uneroes rapi photo-oxiation when
expose to
ayiht B. Biirubin excretion is inhibite by barbiturates C. Biirubin excret
ion is increase
by chorpromazine D. Biirubin is excrete ony as the iucuronie Chemistry/E
aboratory ata to reconize probems/Biirubin/2 5.3 | Gucose, Hemoobin, Iro
n, an Biirubin
217 Answers to Questions 5155 51. C HPLC separates biirubin into four fractions
: =
unconjuted, = monolucuronide, = dilucuronide, nd = irreversiby abumin bou
Biirubin is a separate fraction from the unconjuate biirubin, which is boun
oosey to
abumin. Biirubin an conjuate biirubin react with iazo reaent in the ire
ct biirubin
assay. 52. B Most of the conjuate biirubin eivere into the intestine is e
conjuate by
-lucuronidse nd then reduced y intestinl or to form three di erent reduction p
collectively clled uro ilinoens. The mjority of iliru in nd uro ilinoen in
the intestine
re not re sor ed. Most of tht which is re sor ed is re-excreted y the liver
. The portl vein
delivers lood from the owel to the sinusoids. Heptocytes tke up  out 90% of
the returned
ile piments nd secrete them in into the ile. This process is clled the e
circultion. 53. A Conjuted iliru in refers to iliru in mono- nd dilucuron
ides. Conjuted
iliru in rects lmost immeditely with the queous dizo reent without need

for  nonpolr
solvent. Historiclly, conjuted iliru in hs een used synonymously with dire
iliru in, lthouh the ltter includes the -biirubin fraction when measure by
JenrassikGrof metho. Conjuate biirubin is excrete in both bie an urine. I
t is easiy
photo-oxiize an has very imite stabiity. For this reason, biirubin stana
rs are usuay
prepare from unconjuate biirubin stabiize by the aition of akai an a
bumin. 54. A
Urobiinoen is a coective term iven to the reuction proucts of biirubin f
orme by the
action of enteric bacteria. Urobiinoen excretion is increase in extravascuar
anemias an ecrease in obstructive jaunice (choestatic isease). Urobiinoe
n is measure
usin Ehrichs reaent, an aci soution of p-imethyaminobenzaehye. 55. A Sa
mpes for
biirubin anaysis must be protecte from irect suniht. Drus may have a sin
i cant in vivo
e ect on biirubin eves. Barbiturates ower serum biirubin by increasin excret
ion. Other
rus that cause choestasis, such as chorpromazine, increase the serum biirub
in. Athouh most
conjuate biirubin is in the form of iucuronie, some monoucuronie an o
ther ycosies
are excrete. In ucurony transferase e ciency, some biirubin is excrete as s
2828_Ch05_171-326 06/08/12 5:14 PM Pae 217 56. Which conition is cause by
e cient
secretion of biirubin into the bie canaicui? A. Giberts isease B. Neonata
hyperbiirubinemia C. DubinJohnson synrome D. CrierNajjar synrome Chemistry/Co
aboratory ata with physiooica processes/Biirubin/2 57. In hepatitis, the r
ise in serum
conjuate biirubin can be cause by: A. Seconary rena insu ciency B. Faiure o
f the
enterohepatic circuation C. Enzymatic conversion of urobiinoen to biirubin D
. Extrahepatic
conjuation Chemistry/Correate aboratory ata with physiooica processes/Bi
irubin/2 58.
Which of the foowin is a characteristic of obstructive jaunice? A. Te ratio
of irect to
tota biirubin is reater than 1:2 B. Conjuate biirubin is eevate, but unc
biirubin is norma C. Urinary urobiinoen is increase D. Urinary biirubin is
Chemistry/Correate cinica an aboratory ata/ Biirubin/2 59. Which of the f
oowin wou
cause an increase in ony the unconjuate biirubin? A. Hemoytic anemia B. Obs
tructive jaunice
C. Hepatitis D. Hepatic cirrhosis Chemistry/Correate cinica an aboratory a
ta/ Biirubin/2
218 Chapter 5 | Cinica Chemistry Answers to Questions 5659 56. C DubinJohnson sy
nrome is an
autosoma recessive conition arisin from mutation of an ABC transporter ene.
It prouces mi
jaunice from accumuation of conjuate biirubin that is not secrete into the
bie canaicui.

Tota an irect biirubin are eevate, but other iver function is norma. Rot
or synrome is an
autosoma recessive conition that aso resuts in retention of conjuate biir
ubin. The
mechanism in Rotor synrome is unknown, an ike DubinJohnson synrome it is comm
asymptomatic. It can be i erentiate from DubinJohnson synrome by the pattern of
coproporphyrin excretion an because it prouces no back pimentation in the i
ver. 57. B
Conjuate biirubin is increase in hepatitis an other causes of hepatic necro
sis ue to
faiure to re-excrete conjuate biirubin reabsorbe from the intestine. Increa
se irect
biirubin can aso be attribute to accompanyin intrahepatic obstruction, which
bocks the ow
of bie. 58. A Obstruction prevents conjuate biirubin from reachin the intes
tine, resutin
in ecrease prouction, excretion, an absorption of urobiinoen. Conjuate b
reuritates into sinusoia boo an enters the enera circuation via the he
patic vein. The
eve of serum irect (conjuate) biirubin becomes reater than unconjuate b
iirubin. The
unconjuate form is aso increase because of accompanyin necrosis, econjuat
ion, an
inhibition of UDP-ucurony transferase 59. A Conjuate biirubin increases as
a resut of
obstructive processes within the iver or biiary system or from faiure of the
circuation. Hemoytic anemia (prehepatic jaunice) presents a reater biirubin
oa to a norma
iver, resutin in increase biirubin excretion. When the rate of biirubin fo
rmation excees
the rate of excretion, the unconjuate biirubin rises. 2828_Ch05_171-326 06/0
8/12 5:14 PM
Pae 218 60. Which form of hyperbiirubinemia is cause by an inherite absence
of UDP-ucurony
transferase? A. Giberts synrome B. Rotor synrome C. CrierNajjar synrome D. D
synrome Chemistry/Appy knowee of funamenta biooica characteristics/Bi
irubin/1 61.
Which statement rearin tota an irect biirubin eves is true? A. Tota bi
irubin eve is
a ess sensitive an speci c marker of iver isease than the irect eve B. Dire
ct biirubin
excees 3.5 m/L in most cases of hemoytic anemia C. Direct biirubin is norma
 in choestatic
iver isease D. Te ratio of irect to tota biirubin excees 0.40 in hemoytic
Chemistry/Correate cinica an aboratory ata/Biirubin/2 62. Which statement
characterizes serum biirubin eves in the rst week foowin eivery? A. Serum
biirubin 24
hours after eivery shou not excee the upper reference imit for auts B. J
aunice is
usuay rst seen 4872 hours postpartum in neonata hyperbiirubinemia C. Serum bi
irubin above
5.0 m/L occurrin 25 ays after eivery inicates hemoytic or hepatic isease
D. Conjuate

biirubin accounts for about 50% of the tota biirubin in neonates Chemistry/Co
rreate cinica
an aboratory ata/ Biirubin/2 63. Which form of jaunice occurs within ays o
f eivery an
usuay asts 13 weeks, but is not ue to norma neonata hyperbiirubinemia or h
isease of the newborn? A. Gibert synrome B. Lucey Drisco synrome C. Rotor s
ynrome D.
DubinJohnson synrome Chemistry/Correate cinica an aboratory ata/ Biirubin
/2 5.3 |
Gucose, Hemoobin, Iron, an Biirubin 219 Answers to Questions 6063 60. C Cr
synrome is a rare conition that occurs in two forms. Type 1 is inherite as an
recessive trait an causes a tota e ciency of UDP-ucurony transferase. Life e
xpectancy is
ess than 1 year. Type 2 is an autosoma ominant trait an is characterize by
esser jaunice
an usuay the absence of kernicterus. Biirubin eves can be controe with
which promotes biirubin excretion. Giberts synrome is an autosoma recessive c
characterize by ecrease biirubin uptake an ecrease formation of biirubin
It is the most common form of inherite jaunice. UDP ucurony transferase act
ivity is reuce
owin to an increase in the number of AT repeats in the promoter reion of the 
DubinJohnson an Rotor synromes are autosoma recessive isorers associate wit
h efective
eivery of biirubin into the biiary system. 61. A Direct biirubin measuremen
t is a sensitive
an speci c marker for hepatic an posthepatic jaunice because it is not eevate
by hemoytic
anemia. In hemoytic anemia, the tota biirubin oes not excee 3.5 m/L, an
the ratio of
irect to tota is ess than 0.20. Unconjuate biirubin is the major fraction
in necrotic iver
isease because microsoma enzymes are ost. Unconjuate biirubin is eevate
aon with irect
biirubin in choestasis because some necrosis takes pace an some conjuate b
iirubin is
hyroyze back to unconjuate biirubin. 62. B Biirubin eves may reach as h
ih as 23 m/L
in the rst 24 hours after birth owin to the trauma of eivery, such as resorpti
on of a
subura hematoma. Neonata hyperbiirubinemia occurs 23 ays after birth ue to
hemoysis at birth an transient e ciency of the microsoma enzyme, UDP-ucurony
Normay, eves rise to about 510 m/L but may be reater than 15 m/L, requir
in therapy
with UV iht to photo-oxiize the biirubin. Neonata jaunice can ast up to 1
week in a mature
neonate an up to 2 weeks in prematures babies. Neonata biirubin is amost exc
unconjuate. 63. B LuceyDrisco synrome is a rare form of jaunice cause by u
biirubin that presents within 24 ays of birth an can ast severa weeks. It is
cause by an

inhibitor of UDP-ucurony transferase in materna pasma that crosses the pac

enta. Jaunice is
usuay severe enouh to require treatment. 2828_Ch05_171-326 06/08/12 5:14 PM
Pae 219 64. A
ab measures tota biirubin by the JenrassikGrof biirubin metho with sampe b
ankin. What
wou be the e ect of moerate hemoysis on the test resut? A. Fasey increase
ue to optica
interference B. Fasey increase ue to reease of biirubin from RBCs C. Fase
y ow ue to
inhibition of the iazo reaction by hemoobin D. No e ect ue to correction of po
interference by sampe bankin Chemistry/Appy knowee to reconize sources o
error/Biirubin/2 65. Which reaent is use in the JenrassikGrof metho to soub
unconjuate biirubin? A. 50% methano B. N-butano C. Ca eine D. Acetic aci Che
principes of basic aboratory proceures/Biirubin/1 66. Which statement about
biirubin methos is true? A. Direct biirubin must react with iazo reaent un
er akaine
conitions B. Most methos are base upon reaction with iazotize sufaniic ac
i C. Ascorbic
aci can be use to eiminate interference cause by Hb D. Te coor of the azob
iirubin prouct
is inepenent of pH Chemistry/Appy principes of basic aboratory proceures/B
iirubin/1 67.
Which statement rearin the measurement of biirubin by the JenrassikGrof meth
o is correct?
A. Te same iuent is use for both tota an irect assays to minimize i erences
in reactivity
B. Positive interference by Hb is prevente by the aition of HC after the i
azo reaction C.
Te coor of the azobiirubin prouct is intensi e by the aition of ascorbic aci
 D. Fehins
reaent is ae after the iazo reaction to reuce optica interference by hemo
Chemistry/Appy principes of basic aboratory proceures/Biirubin/2 220 Chapte
r 5 | Cinica
Chemistry Answers to Questions 6467 64. C The sampe bank measures the absorbanc
e of the sampe
an reaent in the absence of azobiirubin formation an corrects the measuremen
t for optica
interference cause by hemoobin absorbin the waveenth of measurement. Howev
er, hemoobin is
an inhibitor of the iazo reaction an wi cause fasey ow resuts in a bank
sampe. For this reason, irect bichromatic spectrophotometric methos are prefe
rre when
measurin biirubin in neonata sampes, which are often hemoyze. 65. C A poa
rity moi er is
require to make unconjuate biirubin soube in iazo reaent. The MaoyEvey
n metho uses
50% methano to reuce the poarity of the iazo reaent. Ca eine is use in the J
metho. This metho is recommene because it is not fasey eevate by hemoys
is an ives
quantitative recovery of both conjuate an unconjuate biirubin. 66. B Uncon
juate biirubin

is poory soube in aci, an therefore, irect biirubin is assaye usin iaz
otize sufaniic
aci iute in weak HC. The irect iazo reaction shou be measure after no
oner than 3
minutes to prevent reaction of unconjuate biirubin, or the iazo roup can be
reuce usin
ascorbate or hyroxyamine preventin any further reaction. 67. D The JenrassikG
rof metho uses
HC as the iuent for the measurement of irect biirubin because unconjuate
biirubin is
poory soube at ow pH. Tota biirubin is measure usin an acetate bu er with
ca eine ae
to increase the soubiity of the unconjuate biirubin. After aition of iaz
otize sufaniic
aci an incubatiion, the iazo roup is reuce by ascorbic aci, an Fehins r
eaent is ae
to akainize the iuent. At an akaine pH the prouct chanes from pink to b
ue, shiftin the
absorbance maximum to 600 nm where Hb oes not contribute sini canty to absorba
2828_Ch05_171-326 06/08/12 5:14 PM Pae 220 68. A neonata biirubin assay pe
rforme at the
nursery by bichromatic irect spectrophotometry is 4.0 m/L. Four hours ater,
a secon sampe
assaye for tota biirubin by the JenrassikGrof metho ives a resut of 3.0 m
/L. Both
sampes are reporte to be hemoyze. What is the most ikey expanation of the
se resuts? A.
Hb interference in the secon assay B. -Biirubin contributin to the resut of
the rst assay
C. Fasey hih resuts from the rst assay cause by irect biirubin D. Physioo
ica variation
owin to premature hepatic microsoma enzymes Chemistry/Appy knowee to reco
nize sources of
error/Biirubin/3 69. In the enzymatic assay of biirubin, how is measurement of
both tota an
irect biirubin accompishe? A. Usin i erent pH for tota an irect assays B.
Usin UDP
ucurony transferase an biirubin reuctase C. Usin i erent poarity moi ers D
. Measurin
the rate of absorbance ecrease at i erent time intervas Chemistry/Appy princip
es of basic
aboratory proceures/Biirubin/2 70. What is the principe of the transcutaneou
s biirubin
assay? A. Conuctivity B. Amperometric inhibition C. Mutiwaveenth re ectance ph
otometry D.
Infrare spectroscopy Chemistry/Appy principes of specia proceures/ Biirubi
n/1 5.3 |
Gucose, Hemoobin, Iron, an Biirubin 221 Answers to Questions 6870 68. A Th
JenrassikGrof metho is base upon a iazo reaction that may be suppresse by H
b. Because
serum bankin an measurement at 600 nm correct for positive interference from
Hb, the resuts
may be fasey ow when sini cant hemoysis is present. Direct spectrophometric b
methos empoyin bichromatic optics correct for the presence of Hb. These are
often cae
neonata biirubin tests. A commony use approach is to measure absorbance at 454
nm an 540

nm. The absorbance contribute by Hb at 540 nm is equa to the absorbance contr
ibute by Hb at
454 nm. Therefore, the absorbance i erence wi correct for free Hb. Neonata sa
mpes contain
itte or no irect -biirubin. They aso ack carotene piments that cou inter
fere with the
irect spectrophotometric measurement of biirubin. 69. A Enzymatic methos use
biirubin oxiase
to convert biirubin back to biiverin, an measure the ecrease in absorbance
that resuts. At
pH 8, both conjuate, unconjuate, an eta biirubin react with the enzyme,
but at pH 4 ony
the conjuate form reacts. 70. C Measurement of biirubin concentration throuh
the skin
requires the use of mutipe waveenths to correct for absorbance by meanin an
iht-absorbin constituents of skin an boo. More than 100 waveenths an mu
tipe re ectance
measurements at various sites may be use to erive the venous biirubin concent
ration in m/L.
Such evices have been shown to have a hih speci city. They can be use to ienti
fy neonates
with hyperbiirubinemia, an to monitor treatment. 2828_Ch05_171-326 06/08/12
5:14 PM Pae 221
222 5.4 Cacuations, Quaity Contro, an Statistics 1. How many rams of soiu
m hyroxie
(NaOH) are require to prepare 150.0 mL of a 5.0% w/v soution? A. 1.5  B. 4.0
 C. 7.5  D.
15.0  Cinica chemistry/Cacuate/Soutions/2 2. How many miiiters of aci
a acetic aci
are neee to prepare 2.0 L of 10.0% v/v acetic aci? A. 10.0 mL B. 20.0 mL C. 1
00.0 mL D. 200.0
mL Cinica chemistry/Cacuate/Soutions/2 3. A biuret reaent requires prepara
tion of a stock
soution containin 9.6  of copper II sufate (CuSO 4 ) per iter. How many ra
ms of CuSO 4 5H
2 O are neee to prepare 1.0 L of the stock soution? Atomic weihts: H = 1.0;
Cu = 63.6; O =
16.0; S = 32.1 A. 5.4  B. 6.1  C. 15.0  D. 17.0  Cinica chemistry/Cacuat
preparation/2 Answers to Questions 13 1. C A percent soution expresse in w/v (w
refers to rams of soute per 100.0 mL of soution. To cacuate, mutipy the p
ercentae (as
rams) by the voume neee (mL), then ivie by 100.0 (mL). (5.0  150.0 mL) 10
0.0 mL = 7.5
 To prepare the soution, weih 7.5  of NaOH peets an a to a 150.0-mL vo
umetric ask. A
su cient eionize H 2 O to issove the NaOH. After the soution coos, a eion
ize H 2 O to
the 150.0-mL ine on the ask an mix aain. 2. D The expression percent v/v refer
s to the voume
of one iqui in mL present in 100.0 mL of soution. To cacuate, mutipy the
percentae (as
mL) by the voume require (mL), then ivie by 100 (mL). (10.0 mL 2000.0 mL) 10
0.0 mL =
200.0 mL To prepare 2.0 L of a 10.0% v/v soution of acetic aci, a approximat
ey 1.0 L of
eionize H 2 O to a 2.0-L voumetric ask. A 200.0 mL of acia acetic aci an
 mix. Then,

a su cient eionize H 2 O to brin the meniscus to the 2.0-L ine an mix aain
. 3. C
Determine the mass of CuSO 4 5H 2 O containin 9.6  of anhyrous CuSO 4 . First
, cacuate the
percentae of CuSO 4 in the hyrate, then ivie the amount neee (9.6 ) by th
e percentae.
4 = moecuar weiht CuSO 4 moecuar weiht CuSO 4 5H 2 O 100 = (159.7
249.7) 100
= 63.96% Grams CuSO 4 5H 2 O = 9.6  0.6396 = 15.0  A convenient formua to use
hyrate = (MW hyrate MW anhyrous sat)  anhyrous sat 2828_Ch05_171-326 06/
08/12 5:14
PM Pae 222 4. How many miiiters of HNO 3 (purity 68.0%, speci c ravity 1.42)
are neee to
prepare 1.0 L of a 2.0 N soution? Atomic weihts: H = 1.0; N = 14.0; O = 16.0 A
. 89.5 mL B.
126.0 mL C. 130.5 mL D. 180.0 mL Cinica chemistry/Cacuate/Reaent preparatio
n/2 5. Convert
10.0 m/L cacium (atomic weiht = 40.1) to Internationa System of Units (SI).
A. 0.25 B. 0.40
C. 2.5 D. 0.4 Cinica chemistry/Cacuate/SI unit conversion/2 6. Convert 2.0 m
Eq/L manesium
(atomic weiht = 24.3) to miirams per eciiter. A. 0.8 m/L B. 1.2 m/L C.
2.4 m/L D. 4.9
m/L Cinica chemistry/Cacuate/Unit conversion/2 7. How many miiiters of
a 2,000.0 m/L
ucose stock soution are neee to prepare 100.0 mL of a 150.0 m/L ucose w
orkin stanar?
A. 1.5 mL B. 7.5 mL C. 15.0 mL D. 25.0 mL Cinica chemistry/Cacuate/Soutions
/2 5.4 |
Cacuations, Quaity Contro, an Statistics 223 Answers to Questions 47 4. C
The moecuar
weiht of HNO 3 is 63.0 . Because the vaance of the aci is 1 (1 mo of hyro
en is prouce
per moe of aci), the equivaent weiht is aso 63.0 . The mass is cacuate
by mutipyin
the normaity (2.0 N) by the equivaent weiht (63.0 ) an voume (1.0 L); ther
efore, 126.0  of
aci are require. Because the purity is 68.0% an the speci c ravity 1.42, the a
mount of HNO 3
in rams per miiiter is 0.68 1.42 /mL or 0.9656 /mL. The voume require to
ive 126.0 
is cacuate by iviin the mass neee (rams) by the rams per miiiter. m
L HNO 3 = 126.0 
0.9656 /mL = 126.0  1.0 mL/0.9656  = 130.5 mL 5. C The SI unit is the recomme
ne metho
of reportin cinica aboratory resuts. The SI unit for a eectroytes is mi
imoe per
iter. To convert from miirams per eciiter to miimoes per iter, mutip
y by 10 to
convert to miirams per iter, then ivie by the atomic mass expresse in mi
irams. 10.0
m/L 10.0 L/1.0 L = 100.0 m/L 100.0 m/L 1.0 mmo/40.1 m = 2.5 mmo/L 6. C T
o convert
from miiequivaent per iter to miirams per eciiter, rst cacuate the mi
weiht (equivaent weiht expresse in miirams), which is the atomic mass iv
ie by the
vaence. Because manesium is ivaent, each moe has the chare equivaent of 2

mo of hyroen.
Then, mutipy the miiequivaent per iter by the miiequivaent weiht to co
nvert to
miirams per iter. Next, ivie by 10 to convert miirams per iter to mi
irams per
eciiter. Miiequivaent weiht M = 24.3 2 = 12.15 m/mEq 2.0 mEq/L 12.15 m/
mEq = 24.3
m/L 24.3 m/L 1.0 L/10.0 L = 2.4 m/L 7. B To cacuate the voume of stock s
oution neee,
ivie the concentration of workin stanar by the concentration of stock stan
ar, then
mutipy by the voume of workin stanar that is neee. C 1 V 1 = C 2 V 2 , w
here C 1 =
concentration of stock stanar V 1 = voume of stock stanar C 2 = concentrati
on of workin
stanar V 2 = voume of workin stanar 2000.0 m/L V 1 = 150.0 m/L 100.0 m
L V 1 =
(150.0 2000.0) 100.0 mL V 1 = 7.5 mL 2828_Ch05_171-326 06/08/12 5:14 PM Pae
223 8. What
is the pH of a soution of HNO 3 , if the hyroen ion concentration is 2.5 10 2
M? A. 1.0 B.
1.6 C. 2.5 D. 2.8 Cinica chemistry/Cacuate/pH/2 9. Cacuate the pH of a so
ution of 1.5 10
5 M NH 4 OH. A. 4.2 B. 7.2 C. 9.2 D. 11.2 Cinica chemistry/Cacuate/pH/2 10. H
ow many
sini cant ures shou be reporte when the pH of a 0.060 M soution of nitric aci
cacuate? A. 1 B. 2 C. 3 D. 4 Cinica chemistry/Cacuate/Sini cant ures/2 11.
What is the
pH of a 0.05 M soution of acetic aci? K a = 1.75 10 5 , pK a = 4.76 A. 1.7 B. 3
.0 C. 4.3 D.
4.6 Cinica chemistry/Cacuate/pH/2 12. What is the pH of a bu er containin 40.
0 mmo/L NaHC 2
O 4 an 4.0 mmo/L H 2 C 2 O 4 ? (pK a = 1.25) A. 1.35 B. 2.25 C. 5.75 D. 6.12 C
chemistry/Cacuate/pH/2 224 Chapter 5 | Cinica Chemistry Answers to Questions
812 8. B For a
stron aci, the pH is equa to the neative oarithm of the hyroen ion conce
ntration. pH =
-Lo H + pH = -Lo 0.025 pH = 1.6 9. C First, cacuate the pOH of the soution.
pOH = -Lo [OH
pOH = - Lo 1.5 x 10 5 = 4.82 pH = 14 - pOH pH = 14 - 4.8 = 9.2 10. B Whe
n zeros appear by
themseves to the eft of the ecima point, they are not sinificant. When they
are to the eft
of the ecima point an are precee by a number, they are sinificant. Zeros a
fter the ecima
point precein a number are not sinificant. However, they are sinificant if t
hey foow
another number or are between two numbers. Therefore, 0.060 M has ony two sini
ficant fiures
(the unerine iits). In aboratory practice, most anaytes are reporte with
two sinificant
fiures. Routine anaytes that are exceptions are pH, which incues three sini
ficant fiures,
an anaytes with whoe numbers above 100 such as soium, choestero, triycer
ies, an
ucose. 11. B Weak acis are not competey ionize, an pH must be cacuate
from the

issociation constant of the aci (in this case 1.75 10 5 ). K a = [H +


[HAc] 1.75 x 10 5 = [H +

5.0 x 10 2 Since [H +
= [Ac

X 2 = (1.75 10 5 ) (5.0 10 2 ) = 8.75 10 7 x = 8.75 10 7 = [H +
= 9.35 10
4 M pH = Lo 9.35 10 4 M = 3.0 Aternativey, pH = 1
2 (pK
a Lo HA) pH = 1
2 (4.76 Lo 5.0 10
2 ) = 1
2 (4.76 + 1.30)
= 3.0 12. B The HenersonHassebach equation can be use to etermine th
e pH of a bu er
containin a weak aci an a sat of the aci. pH = pK a + o sat Aci = 1.25
+ o 40.0 mmo/L
4.0 mmo/L = 1.25 + o 10 = 2.25 2828_Ch05_171-326 06/08/12 5:14 PM Pae 224
13. A sovent
neee for HPLC requires a 20.0 mmo/L phosphoric aci bu er, pH 3.50, mae by mix
in KH 2 PO 4
an H 3 PO 4 . How many rams of KH 2 PO 4 are require to make 1.0 L of this bu e
r? Formua
weihts: KH 2 PO 4 = 136.1; H 3 PO 4 = 98.0; pK a H 3 PO 4 = 2.12 A. 1.96  B. 2
.61  C. 2.72 
D. 19.2  Cinica chemistry/Cacuate/Bu ers/2 14. A proceure for choestero is
with a serum-base choestero stanar that was etermine by the AbeKena m
etho to be
200.0 m/L. Assumin the same voume of sampe an reaent are use, cacuate
the choestero
concentration in the patients sampe from the foowin resuts. 5.4 | Cacuatio
ns, Quaity
Contro, an Statistics 225 Answers to Questions 1315 13. B The HenersonHasseb
ach equation
is use to cacuate the ratio of sat to aci neee to ive a pH of 3.50. pH =
pK a +
o(sat/aci) 3.50 = 2.12 + o(KH 2 PO 4
3 PO 4 ) 1.38 = o(KH 2 PO 4
3 PO 4 ) antio 1.38 = KH 2 PO 4
3 PO 4 KH 2 PO 4
3 PO 4 = 23.99 Rearranin ives KH 2 PO 4 = 23.99 H 3 PO 4 . Because th
e phosphate in the
bu er is 20.0 mmo/L, then H 3 PO 4 + KH 2 PO 4 must equa 20. Because KH 2 PO 4 =
23.99 H 3 PO
4 then: H 3 PO 4 + (23.99 H 3 PO 4 ) = 20.0 mmo/L 24.99 H 3 PO 4 = 20.0 mmo/L
H 3 PO 4 =
20.0/24.99 = 0.800 mmo/L KH 2 PO 4 = 20.00.800 = 19.2 mmo/L (0.0192 M) To eter
mine the rams

require, mutipy the moes of KH 2 PO 4 by the formua weiht. 0.0192 mo/L 13

6.1 /mo =
2.613  14. B C u = A u
s C s where C u = concentration of unknown, A u = absorbance of unknown,
A s = absorbance
of stanar, an C s = concentration of stanar. C u = 0.740/0.860 200 m/L =
172 m/L 15. B
The serum bank absorbance is subtracte from the resut for the patients serum b
efore appyin
the ratiometric formua to cacuate concentration. C u = [(A u A SB )/A s
s where A SB = absorbance of serum bank = (0.7500.100)/0.620 125 m/L =
131 m/L
Stanar Absorbance Absorbance Concen- of Reaent Absorbance of Patient
tration Bank
of Stanar
Serum 200 m/L 0.00 0.860 0.740 Stanar Absorbance of Absorba
nce of
Absorbance of Absorbance of Concentration Reaent Bank Stanar
Serum Serum
Bank 125 m/L 0.000 0.62 0.750 0.100 A. 123 m/L B. 172 m/L C. 232 m/L D.
314 m/L
Cinica chemistry/Cacuate/Beers aw/2 15. A ycero kinase metho for triyc
erie cas for
a serum bank in which norma saine is substitute for ipase in orer to measu
re enoenous
ycero. Given the foowin resuts, an assumin the same voume of sampe an
 reaent are
use for each test, cacuate the triycerie concentration in the patients samp
e. A. 119
m/L B. 131 m/L C. 156 m/L D. 180 m/L Cinica chemistry/Cacuate/Beers 
2828_Ch05_171-326 06/08/12 5:14 PM Pae 225 16. A proceure for aspartate ami
(AST) is performe manuay because of a repeatin error coe for noninearity o
btaine on the
aboratorys automate chemistry anayzer; 0.05 mL of serum an 1.0 mL of substrat
e are use. Te
reaction rate is measure at 30C at 340 nm usin a 1.0 cM iht path, an the e
ta absorbance
(-A) per minute is etermine to be 0.382. Base upon a moar absorptivity coe cien
t for NADH at
340 nm of 6.22 X 10 3 M 1 cM 1 L 1 , cacuate the enzyme activity in internationa
(IUs) per iter. A. 26 IU/L B. 326 IU/L C. 1228 IU/L D. 1290 IU/L Cinica
chemistry/Cacuate/Internationa units/2 17. When referrin to quaity contro
(QC) resuts,
what parameter usuay etermines the acceptabe rane? A. Te 95% con ence interv
a for the mean
B. Te rane that incues 50% of the resuts C. Te centra 68% of resuts D. Te
rane encompasse
by 2.5 stanar eviations Chemistry/Evauate aboratory ata to assess vaiity/
Accuracy of
proceures/Quaity contro/1 18. Which of the foowin quaity contro (QC) ru
es wou be
broken 1 out of 20 times by chance aone? A. 1 2s B. 2 2s C. 1 3s D. 1 4s Chemis
aboratory ata to assess vaiity/ Accuracy of proceures/Quaity contro/1 19.
Which of the
foowin conitions is cause for rejectin an anaytica run? A. Two consecutiv

e contros
reater than 2 s above or beow the mean B. Tree consecutive contros reater th
an 1 s above the
mean C. Four contros steaiy increasin in vaue but ess than 1 s from the mea
n D. One
contro above +1 s an the other beow 1 s from the mean Chemistry/Seect course
action/Quaity contro/3 226 Chapter 5 | Cinica Chemistry Answers to Questions
1619 16. D An
IU is e ne as 1 mol of substrate consumed or product produced per minute. The mic
romoles of
NADH consumed in this reaction are determined by dividing the change in absorban
ce per minute by
the absorbance of 1 mol of NADH. Because 1 mol/L/cm would have an absorbance of 6
.22 X 10 3
absorbance units, then 1 mol/mL/cm would produce an absorbance of 6.22. Therefore
, dividing the
A per minute by 6.22 ives the micromoes of NADH consume in the reaction. This
is mutipie
by the iution of serum to etermine the micromoes per miiiter, an mutip
ie by 1,000 to
convert to micromoes per iter. IU/L = A/min x TV(mL) 1,000 mL/L 6.22(A/mol/mL/cM
) x 1 cm x
SV(mL) = A/min 1.05 x 1,000 6.22 X 0.05 = A/min 1,050 0.311 = A/min 3,376 = 0.382
= 1,290 IU/L 17. A The acceptabe rane for quaity contro resuts is usuay s
et at the 95%
con ence interva. This is e ne as the rane between 1.96s an +1.96s. This means
that we can
expect a QC resut to fa within this rane 95 out of 100 times. For practica
purposes, this is
the same as 2 s (95.4 out of 100 resuts shou fa within 2 s of the mean on the
basis of
chance). 18. A The notation 1 2S means that one contro is outsie 2 stanar ev
iation units.
QC resuts foow the be- shape curve cae the Gaussian (norma) istributi
on. If a contro
is assaye 100 times, 68 out of 100 resuts wou fa within +1 s an 1 s of the
mean. Ninetyve (95.4) out of 100 resuts wou fa within +2 s an 2 s. This eaves ony 5 ou
t of 100
resuts (1:20) that fa outsie the 2 s imit. Aso, 99.7 out of 100 resuts fa
 within 3 s
of the mean. 19. A Rejectin a run when three consecutive contros fa between
1 an 2 s or when
a tren of four increasin or ecreasin contro resuts occurs wou ea to fr
equent rejection
of vai anaytica runs. Appropriate contro imits are four consecutive contro
s above or beow
1 s (4 1s ) to etect a sini cant shift, an a cusum resut exceein the 2.7 s i
mit to etect
a sini cant shift or tren. When contros eviate in opposite irections, the i er
ence shou
excee 4s before the run is rejecte. 2828_Ch05_171-326 06/08/12 5:14 PM Pae
226 20. One of
two contros within a run is above +2s an the other contro is beow 2s from the
mean. What o
these resuts inicate? A. Poor precision has e to ranom error (RE) B. A syst
ematic error (SE)
is present C. Proportiona error is present D. QC materia is contaminate Chemi

aboratory ata to reconize probems/Quaity contro/2 21. Two consecutive cont
ros are both
beyon 2s from the mean. How frequenty wou this occur on the basis of chance a
one? A. 1:100
B. 5:100 C. 1:400 D. 1:1,600 Chemistry/Evauate aboratory ata to assess vaii
ty/ Accuracy of
proceures/Quaity contro/2 22. Te term R 4S means that: A. Four consecutive co
ntros are
reater than 1 stanar eviation from the mean B. Two contros in the same run a
re reater than
4s units apart C. Two consecutive contros in the same run are each reater than
4s from the
mean D. Tere is a shift above the mean for four consecutive contros Chemistry/E
aboratory ata to assess vaiity/Accuracy of proceures/Quaity contro/2 23.
A tren in QC
resuts is most ikey cause by: A. Deterioration of the reaent B. Miscaibrat
ion of the
instrument C. Improper iution of stanars D. Eectronic noise Chemistry/Evau
ate aboratory
ata to assess vaiity/ Accuracy of proceures/Quaity contro/2 24. In most ci
rcumstances, when
two contros within a run are both reater than 2s from the mean, what action sho
u be taken
rst? A. Recaibrate, then repeat contros foowe by seecte patient sampes if
contro is acceptabe B. Repeat the contros before takin any corrective action
C. Chane the
reaent ot, then recaibrate D. Prepare fresh stanars an recaibrate Chemist
aboratory ata to take corrective action accorin to preetermine criteria/Qu
aity contro/3
5.4 | Cacuations, Quaity Contro, an Statistics 227 Answers to Questions 2
024 20. A When
contro resuts eviate from the mean in opposite irections, the run is a ecte b
y RE, which
resuts from imprecision. An anaytica run is rejecte when two contros within
the same run
have an aebraic i erence in excess of 4s (R 4s ). The R 4S rue is appie ony
to contros
within a run (Leve 1 Leve 2), never across runs or ays. 21. D QC resuts fo
ow a Gaussian
or norma istribution. Ninety- ve percent of the resuts fa within 2s of the mea
n; therefore,
2.5 out of 100 (1:40) are above +2s an 2.5 out of 100 are beow 2s. The probabi
ity of two
consecutive contros bein beyon 2s is the prouct of their iniviua probabii
ties. 1/40
1/40 = 1/1,600 trias by chance. 22. B The R 4s rue is appie to two contro 
eves within the
same run. The rue is vioate when the aebraic ifference between them (eve
1 eve 2)
excees 4s. The rue is never appie across ifferent runs. The R 4s rue etec
ts ranom error
(error ue to poor precision). 23. A A tren occurs when six or more consecutive
quaity contro
resuts either increase or ecrease in the same irection; however, this is not
cause for
rejection unti a mutirue is broken. Trens are systematic errors (a ectin accu

racy) inke to
an unstabe reaent, caibrator, or instrument conition. For exampe, oss of v
oatie aci from
a reaent causes a steay pH increase, preventin separation of anayte from pro
tein. This
resuts in ower QC resuts each ay. 24. A When a 2 2s rue is broken an SE is
present an
corrective action is require (repeatin just the QC wi not correct the probe
m). If
recaibration yies acceptabe QC resuts, both sets of QC resuts an the corr
ective action
taken are ocumente in the QC o. If the manitue of the error is are enou
h to be meicay
sini cant, then a patient sampes since the ast previousy acceptabe QC shou
 be repeate.
If in question, the manitue of the error can be evauate by repeatin abnorma
sampes. If the averae i erence between resuts before an after recaibration i
s > 2s, then
a sampes shou be repeate since the ast acceptabe QC. 2828_Ch05_171-326
06/08/12 5:14 PM
Pae 227 25. When estabishin QC imits, which of the foowin practices is i
nappropriate? A.
Usin ast months QC ata to etermine current taret imits B. Excusion of any
QC resuts
reater than 2s from the mean C. Usin contro resuts from a shifts on which t
he assay is
performe D. Usin imits etermine by reference aboratories usin the same me
Chemistry/Appy principes of aboratory operations/Quaity contro/2 26. Which
of the foowin
assays has the poorest precision? A. B. C. D. Chemistry/Cacuate/Coe cient of var
iation/3 27.
Given the foowin ata, cacuate the coe cient of variation for ucose. A. 3.0
% B. 4.6% C.
7.6% D. 33.0% Cinica chemistry/Cacuate/Statistics/2 28. Which of the foowi
n pots is best
for etectin a types of QC errors? A. LevyJennins B. TonksYouen C. Cusum D. L
reression Chemistry/Evauate aboratory ata to reconize probems/Quaity cont
ro/2 29. Which
of the foowin pots is best for comparison of precision an accuracy amon a
boratories? A.
LevyJennins B. TonksYouen C. Cusum D. Linear reression Chemistry/Evauate abor
atory ata to
reconize probems/Quaity contro/2 228 Chapter 5 | Cinica Chemistry Answers
to Questions
2529 25. B Data between 2 an 3s must be incue in cacuations of the next months
acceptabe rane. Eimination of these vaues wou continuousy reuce the ist
ribution of QC
resuts, makin out-of-contro situations a frequent occurrence. Generay, QC res
uts reater
than 3s are not use to cacuate next months mean. 26. A Athouh cacium has th
e owest s, it
represents the assay with poorest precision. Reative precision between i erent a
naytes or
i erent eves of the same anayte must be evauate by the coe cient of variation
(CV) because
stanar eviation is epenent upon the mean. CV = s 100/Mean. This normaizes

eviation to a mean of 100. The CV for cacium in the exampe is 12.0%. 27. A Th
e coe cient of
variation is cacuate by iviin the stanar eviation by the mean an muti
pyin by 100.
CV =
s x 100 = 2.3 100 = 3.0% 76 The CV is the most appropriate statistic to
use when
comparin the precision of sampes that have i erent means. For exampe, when com
parin the
precision of the eve 1 contro to the eve 2 contro, the coe cient of variatio
n normaizes
the variance to be inepenent of the mean. The contro with the ower CV is the
one for which
the anaysis is more precise. 28. A The LevyJennins pot is a raph of a QC re
suts with
concentration potte on the y axis an run number on the x axis. The mean is at
the center of
the y axis, an concentrations corresponin to 2 an +2s are hihihte. Resut
s are evauate
for mutirue vioations across both eves an runs. Corrective action for shif
ts an trens can
be taken before QC rues are broken. 29. B The TonksYouen pot is use for inter
comparison of monthy means. The metho mean for eve 1 is at the center of the
y axis an mean
for eve 2 at the center of the x axis. Lines are rawn from the means of both
eves across the
raph, iviin it into four equa quarants. If a aboratorys monthy means both
pot in the
ower eft or upper riht, then systematic error (SE) exists in its metho. Mean
Anayte (mmo/L) Deviation Ca 2.5 0.3 K 4.0 0.4 Na 140 4.0 C 100 2.5 Anayt
e Mean
Stanar Deviation Gucose 76 m/L 2.3 2828_Ch05_171-326 06/08/12 5:14 PM Pa
e 228 30. Which
pot wi ive the eariest inication of a shift or tren? A. LevyJennins B. To
nksYouen C.
Cusum D. Historam Chemistry/Evauate aboratory ata to reconize probems/Qua
ity contro/2 31.
A of the foowin are requirements for a QC materia except: A. Lon-term sta
biity B. Te
matrix is simiar to the specimens bein teste C. Te concentration of anaytes
re ects the
cinica rane D. Anayte concentration must be inepenent of the metho of ass
Chemistry/Appy principes of basic aboratory proceures/Quaity contro/2 5.4
| Cacuations,
Quaity Contro, an Statistics 229 Answers to Questions 3031 30. C Cusum point
s are the
aebraic sum of the i erence between each QC resut an the mean. The y axis is
the sum of
i erences an the x axis is the run number. The center of the y axis is 0. Becaus
e QC resuts
foow a ranom istribution, the points shou istribute about the zero ine.
Resuts are out
of contro when the sope excees 45 or a ecision imit (e.., 2.7s) is exceee.
31. D
Quaity contro materias are stabe, mae of the same components as the specime
n, cover the
ynamic inear rane of the assay, an can be use for mutipe anaytes. The ta

ret mean for QC

sampes is etermine from repicate assays by the users metho, not the true conce
ntration of
the anayte. Out-of-contro resuts are inke to anaytic performance rather th
an to the
inherent accuracy of the metho. 1 2 3 4 5 6 7 8 9 10
11121314151617181920212223242526 2728293031 1 2 3 4 5 6 7 8 9 10
11121314151617181920212223242526 2728293031 8.8 8.5 8.2 7.9 7.6 12.8 12.5 12.2 1
1.9 11.6 Leve 1
Contro: Cacium Mean 8.2 m/L s = 0.31 Leve 2 Contro: Cacium Mean 12.2
m/L s = 0.30
+2s +1s -2s -1s +2s +1s -2s -1s x x 2828_Ch05_171-326 06/08/12 5:14 PM Pae 2
29 Questions
3235 refer to the precein LevyJennins chart. 32. Examine the LevyJennins chart
at the
bottom of the previous pae an ientify the QC probem that occurre urin the
rst haf of the
month. A. Shift B. Tren C. Ranom error D. Kurtosis Chemistry/Evauate aborato
ry ata to
reconize probems/Quaity contro/3 33. Referrin to the LevyJennins chart, wha
t is the rst
ay in the month when the run shou be rejecte an patient resuts shou be r
epeate? A. Day 6
B. Day 7 C. Day 8 D. Day 9 Chemistry/Evauate aboratory ata to reconize prob
contro/3 34. Referrin to the LevyJennins chart, what anaytica error is prese
nt urin the
secon haf of the month? A. Shift B. Tren C. Ranom error D. Kurtosis Chemistr
aboratory ata to reconize probems/Quaity contro/3 35. What is the rst ay i
n the secon
haf of the month that patient resuts wou be rejecte? A. Day 16 B. Day 17 C.
Day 18 D. Day 19
Chemistry/Evauate aboratory ata to reconize probems/Quaity contro/3 230 C
hapter 5 |
Cinica Chemistry Answers to Questions 3235 32. B A tren is characterize by si
x consecutive
ecreasin or increasin contro resuts. The vaue for both contros becomes pr
hiher from ay 4 to ay 9. Trens are cause by chanes to the test system that
increase over
time, such as eterioration of reaents or caibrators, proressive chanes in t
evaporation, iht exposure, an bacteria contamination. A tren is a type of S
E because a
resuts are a ecte. Conversey, RE a ects some resuts (but not others) in an unpre
manner. Contro rues a ecte by RE are 1 3s an R 4s . 33. C Athouh the tren i
s apparent
across QC eves by ay 7, the patient resuts wou not be rejecte unti ay 8
when the 4 1s
rue is broken. An avantae to pottin contro ata is that trens can be ien
ti e before
resuts are out of contro an patient ata must be rejecte. In this case, corr
ective steps
shou have been impemente by ay 7 to avoi the eay an expense associate
with havin to
repeat the anaysis of patient sampes. 34. A A shift is characterize by six co
nsecutive points
yin on the same sie of the mean. This occurs from ay 15 to ay 20. Shifts ar

e cause by a
chane in the assay conitions that a ect the accuracy of a resuts, such as a c
hane in the
concentration of the caibrator; chane in reaent; a new ot of reaent that i e
rs in
composition; or improper temperature settin, waveenth, or sampe voume. The
term kurtosis
refers to the eree of atness or sharpness in the peak of a set of vaues havin
a Gaussian
istribution. 35. B The 4 1s rue is broken across QC eves on ay 17. This mea
ns that four
consecutive contros are reater than 1s from the mean. QC rues that are sensiti
ve to SE are
appie across both runs an eves to increase the probabiity of error etecti
on. These are 2
2s , 4 1s , an 10. 2828_Ch05_171-326 06/08/12 5:14 PM Pae 230 36. Given the
foowin QC
chart, ientify the ay in which a vioation of the R 4s QC rue occurs. 5.4 | C
Quaity Contro, an Statistics 231 Answers to Questions 3638 36. D An R 4s err
or is e ne as
the aebraic i erence between two contros within the same run. In this LevyJenni
ns pot, on
ay 15, Leve 1 is above the +2s imit (approximatey +2.5s) an Leve 2 is beo
w the 2s imit
(approximatey 2.5s). These contros are approximatey 5s apart (+2.5s minus 2.5s
= +5s). 37. C
The minimum requirement for frequency of quaity contro for a enera chemistry
anayte (base
upon the Cinica Laboratory Improvement Act, 1988) is two eves of contro ass
aye every 24
hours. Some aboratories prefer to assay two contro eves every 8 hours to inc
rease the
opportunity for error etection. Two contros every 8 hours are require for bo
o ases,
automate hematooy, an point-of-care ucose testin to compy with Coee o
f American
Pathooy requirements. Anaytes that ispay ifferent CVs at the ow, norma,
an hih ranes
require 3 eves of contro in 24 hours. These incue boo ases, therapeutic
rus, an
hormones. 38. A Stuents t test is the ratio of mean ifference to the stanar e
rror of the
mean ifference (bias/ranom error) an tests for a sinificant ifference in me
ans. The F test
is the ratio of variances an etermines if one metho is sinificanty ess pre
cise. The
correation coefficient is a measure of the association between two variabes an
 shou be hih
in any metho comparison. An r vaue ess than 0.90 in metho comparisons usua
y occurs when the
rane of resuts is too narrow. +2s Mean -2s +2s Mean -2s QC1 QC2 1 16 15 14 1
3 12 11 10 9 8 7
6 5 4 3 2 A. Day 3 B. Day 8 C. Day 10 D. Day 15 Chemistry/Evauate aboratory a
ta to reconize
probems/Quaity contro/ 3 37. What is the minimum requirement for performin Q
C for a tota
protein assay? A. One eve assaye every 8 hours B. Two eves assaye within 8
hours C. Two
eves assaye within 24 hours D. Tree eves assaye within 24 hours Chemistry/

Appy principes
of basic aboratory proceures/Quaity contro/2 38. Which of the foowin stat
istica tests is
use to compare the means of two methos? A. Stuents t test B. F istribution C.
coe cient (r) D. Linear reression anaysis Chemistry/Evauate aboratory ata to
assess the
vaiity/Accuracy of proceures/Statistics/2 2828_Ch05_171-326 06/08/12 5:14 P
M Pae 231 39.
Two freezin point osmometers are compare by runnin 40 paire patient sampes
one time on each
instrument, an the foowin resuts are obtaine: 232 Chapter 5 | Cinica Che
mistry Answers to
Questions 3941 39. A The F test etermines whether there is a statisticay sini c
ant i erence
in the variance of the two sampin istributions. Assumin the sampes are co
ecte an store
in the same way an the anaysis is one by a technooist who is famiiar with
the instrument,
then i erences in variance can be attribute to a i erence in instrument precision
. The F test
is cacuate by iviin the variance (s 1 ) 2 of the instrument havin the hi
her stanar
eviation by the variance (s 2 ) 2 of the instrument havin the smaer stanar
eviation. F =
(s 1 ) 2 (s 2 ) 2 = (3.1) 2 (2.8) 2 = 9.61 7.84 = 1.22 If the vaue of F is sma
er than the
critica vaue at the 0.10 eve of sini cance, then the hypothesis (there is no
sini cant
i erence in the variance of the two instruments) is accepte. 40. D The bias is 
efine as the
ifference between the means of the two methos an is cacuate usin the form
ua: bias = y
. The bias is an estimate of SE. The stuents t test is use to etermine if bias
statisticay sinificant. The t statistic is the ratio of bias to the stanar
error of the mean
ifference. The reater the bias, the hiher the t score. 41. B Proportiona err
or (sope or
percent error) resuts in reater absoute error (eviation from the taret vau
e) at hiher
sampe concentration. Constant error refers to a ifference between the taret v
aue an the
resut, which is inepenent of sampe concentration. For exampe, if both eve
1 an eve 2
contros for aboratory A averae 5 m/L beow the cumuative mean reporte by
a other
aboratories usin the same metho, then aboratory A has a constant error of 5 m
/L for that
metho. Stanar Instrument Mean Deviation Osmometer A 280 mOsm/k 3.1 Osmom
eter B 294
mOsm/k 2.8 Stanar Instrument Mean Deviation Metho x (reference 235 m/
L 3.8 metho)
Metho y (caniate 246 m/L 3.4 metho) If the critica vaue for F = 2.8, th
en what
concusion can be rawn rearin the precision of the two instruments? A. Tere
is no
statisticay sini cant i erence in precision B. Osmometer A emonstrates better p
recision that
is statisticay sini cant C. Osmometer B emonstrates better precision that is s

sini cant D. Precision cannot be evauate statisticay when sine measurements
are mae on
sampes Chemistry/Evauate aboratory ata to assess the vaiity/Accuracy of
proceures/Statistics/3 40. Two methos for tota choestero are compare by ru
nnin 40 paire
patient sampes in upicate on each instrument. Te foowin resuts are obtain
e: Assumin the
sampes are coecte an store in the same way an the anaysis one by a tech
nooist who is
famiiar with both methos, what is the bias of metho y? A. 0.4 B. 7.2 C. 10.6
D. 11.0
Chemistry/Evauate aboratory ata to assess the vaiity/Accuracy of proceures
/Statistics/2 41.
When the manitue of error increases with increasin sampe concentration, it i
s cae: A.
Constant error B. Proportiona error C. Ranom error D. Bias Chemistry/Evauate
aboratory ata
to assess vaiity/ Accuracy of proceures/Statistics/2 2828_Ch05_171-326 06/08
/12 5:14 PM
Pae 232 42. Which expanation is the best interpretation of the foowin BUN b
ias pot? 5.4 |
Cacuations, Quaity Contro, an Statistics 233 Answers to Questions 4243 42.
D A bias pot
compares the bias (caniate metho minus reference metho) to the resut of the
metho. Ieay, points shou be scattere equay on both sies of the zero i
ne. When the
majority of points is beow the zero ine, the caniate metho is neativey bi
ase (ower than
the reference). In this case, the ifference between the methos increases in pr
oportion to the
BUN concentration. This type of pot occurs when the sope of the inear reress
ion ine is ow.
43. A The inear reression anaysis is the most usefu statistic to compare pai
re patient
resuts because it estimates the manitue of specific errors. The y intercept o
f the reression
ine is a measure of constant error, an the sope is a measure of proportiona
error. Toether,
these represent the bias or SE of the new metho. The correation coefficient is
infuence by
the rane of the sampe an the RE. Two methos that measure the same anayte wi
 have a hih
correation coefficient, provie the concentrations are measure over a wie ra
ne, an this
statistic shou not be use to jue the acceptabiity of the new metho. The s
tanar error of
estimate is a measure of the coseness of ata points to the reression ine an
is an expression
of RE. Linear Correation Stanar Error of Reression Coefficient (r) Est
imate (s y/x )
= 2.10 + 1.01x 0.984 0.23 Which statement best characterizes the reationship be
tween the
methos? A. Tere is a sini cant bias cause by constant error B. Tere is a sini ca
proportiona error C. Tere is no isareement between the methos because the co
coe cient approaches 1.0 D. Tere is no systematic error, but the ranom error of t
he new metho

is unacceptabe Chemistry/Evauate aboratory ata to assess the vaiity/Accura

cy of
proceures/Statistics/2 5 0 -5 -10 -15 B i a s
( y x ) BUN (Ref) BUN Bias Pot 0 20 40 60 80 100 120 A. Te
new metho
consistenty overestimates the BUN by a constant concentration B. Te new metho
is reater than
the reference metho but not by a statisticay sini cant marin C. Te new metho
is ower than
the reference metho by 5 m/L D. Te new metho is ower than the reference an
the manitue is
concentration epenent Chemistry/Evauate aboratory ata to assess the vaiit
y/Accuracy of
proceures/Statistics/ 3 43. Serum sampes coecte from hospitaize patients
over a 2-week
perio are spit into two aiquots an anayze for prostate speci c antien (PSA)
by two
methos. Each sampe was assaye by both methos within 30 minutes of coection
by a
technooist famiiar with both methos. Te reference metho is metho (upper re
ference imit =
4.0 /L). Linear reression anaysis was performe by the east-squares metho, a
n resuts are
as foows: 2828_Ch05_171-326 06/08/12 5:14 PM Pae 233 44. Which statement b
est summarizes
the reationship between the new BUN metho an reference metho base upon the
foowin inear
reression scatterpot? 234 Chapter 5 | Cinica Chemistry Answers to Questions
4446 44. B The
scatterpot shows that each sampe prouces a coorinate (x correspons to the r
eference resut
an y to the caniate metho resut) that is very cose to the reression ine.
This means that
the variance of reression is ow an there is a hih eree of certainty that t
he preicte
vaue of y wi be cose to its measure vaue. Near-zero concentration there is
oo areement
between methos; however, the hiher the resut, the reater the i erence between
x an y. The
reression equation for this scatterpot is y = 0.01 + 0.90 x, inicatin a propo
rtiona error
of 10%. 45. C Linear reression anaysis ives an estimate of SE, which is equa
to ( x c )
where x c is the expecte concentration, an is the vaue preicte by the inea
r reression
equation. SE = [0.3 + (0.9 50 m/L)] 50.0 m/L = 44.750.0 = 5.3 m/L The stanar

eviation of the new metho for the hih contro is use to estimate the RE beca
use the mean of
this contro is nearest to the expecte concentration of 50 m/L. RE is estimat
e by 1.96 s.
RE = 1.96 1.12 =  2.2 m/L Tota anaytica error (TE) is equa to the sum of SE
an RE. TE =
SE + RE = 5.3 m/L + (2.2 m/L) = 7.5 m/L 46. D The cinica speci city of a abo
test is e ne as the true neatives ivie by the sum of true neatives an fas
e positives
Speci city =

TN 100 TN + FP Speci city is e ne as the percentae of isease-free peope

who have a
neative test resut. The probabiity of fase positives is cacuate from the
speci city as: 1
speci city
) 100 100 80 60 40 20 0 B U N
C a n  i  a t e BUN Reference BUN Metho Com parison 0 20 40 60
80 100 120 A.
Te methos aree very we but show a hih stanar error of estimate B. Tere is
itte or no
constant error, but some proportiona error C. Tere wi be a sini cant eree of
uncertainty in
the reression equation D. Tere is sini cant constant an proportiona error but
itte ranom
error Chemistry/Evauate aboratory ata to assess the vaiity/Accuracy of
proceures/Statistics/3 45. A new metho for BUN is evauate by comparin the r
esuts of 40
paire patient sampes to the urease-UV metho. Norma an hih contros were ru
n on each shift
for 5 ays, ve times per ay. Te resuts are as foows: Linear Reression Low
Contro = 0.3 + 0.90x x = 14.2 m/L; x = 48.6 m/L; s = 1.24 s = 1.12 What is t
he tota
anaytica error estimate for a sampe havin a concentration of 50 m/L? A. 2.2
m/L B. 2.8
m/L C. 7.5 m/L D. 10.0 m/L Chemistry/Cacuate/Metho comparison statistics/
3 46. In
aition to the number of true neatives (TN), which of the foowin measuremen
ts is neee to
cacuate speci city? A. True positives B. Prevaence C. Fase neatives D. Fase
Chemistry/Cacuation/Speci city/2 2828_Ch05_171-326 06/08/12 5:14 PM Pae 234
47. A new tumor
marker for ovarian cancer is evauate for sensitivity by testin serum sampes
from patients who
have been ianose by stain biopsy as havin mainant or benin esions. Te
foowin resuts
were obtaine: Number of mainant patients who are positive for CA 125 = 21 out
of 24 Number of
benin patients who are neative for CA 125 = 61 out of 62 What is the sensitivi
ty of the new CA
125 test? A. 98.4% B. 95.3% C. 87.5% D. 85.0% Cinica chemistry/Cacuate/Sensi
tivity/2 48. A
new test for prostate cancer is foun to have a sensitivity of 80.0% an a speci c
ity of 84.0%.
If the prevaence of prostate cancer is 4.0% in men over 42 years o, what is t
he preictive
vaue of a positive test resut (PV+) in this roup? A. 96.0% B. 86.0% C. 32.4%
D. 17.2%
Chemistry/Cacuate/Preictive vaue/2 49. What measurement in aition to true
neatives an
prevaence is require to cacuate the preictive vaue of a neative test resu
t (PV)? A.
Fase neatives B. Variance C. True positives D. Fase positives Chemistry/Cacu
vaue/2 50. A aboratory is estabishin a reference rane for a new anayte an
wants the rane
to be etermine by the reiona popuation of auts ae 18 an oer. Te anay

te concentration
is known to be inepenent of race an ener. Which is the most appropriate pro
cess to foow?
A. Determine the mean an stanar eviation of the anayte from 40 heathy au
ts an cacuate
the 2s imit B. Measure the anayte in 120 heathy auts an cacuate the centr
a 95th
percentie C. Measure the anayte in 120 heathy auts an use the owest an h
ihest as the
reference rane imits D. Measure the anayte in 60 heathy auts an 60 auts
with conitions
that a ect the anayte concentration; cacuate the concentration of east overap
Chemistry/Seect methos/Statistics/2 5.4 | Cacuations, Quaity Contro, an S
tatistics 235
Answers to Questions 4750 47. C Sensitivity is e ne as the percentae of persons
with the
isease who have a positive test resut. It is cacuate as true positives (TP)
ivie by the
sum of TP an fase neatives (FN).
Sensitivity =
TP 100 TP + FN Sensitivity = (21 100) (21 + 3) = 87.5% 48. D The preict
ive vaue of a
positive test (PV+) is e ne as the percentae of persons with a positive test re
sut who wi
have the isease or conition. It is epenent upon the sensitivity of the test
an the
prevaence of the isease in the popuation teste. PV+ is cacuate by mutip
yin the true
positives by 100, then iviin by the sum of true positives an fase positives
PV+ =
TP 100 (TP + FP) where TP equas (sensitivity prevaence) an FP equas
(1 speci city)
(1 prevaence) = 0.80 0.04 100 (0.80 0.04) + [(1 0.84) (1 0.04)] = 0.032 10
0.032 + (0.96 0.16) = 17.2% 49. A The PV is e ne as the probabiity that a person
with a
neative test resut is free of isease. A hih PV is a characteristic of a oo
screenin test.
The preictive vaue of a neative test is cacuate by mutipyin the true ne
atives by 100,
then iviin by the sum of the true neatives an fase neatives.
PV =
TN 100 TN + FN 50. B Since the concentration of an anayte may not be no
rmay istribute
in a popuation, the reference rane shou not be etermine from the stanar
eviation. It is
more appropriate to etermine the centra 95th percentie (the rane that encomp
asses 95% of the
resuts). A minimum of 120 sampes is neee for statistica sinificance. Resu
ts are rank
orere from owest to hihest. The 3r resut is the owest vaue an the 118th
is the hihest
vaue in the reference rane. The aboratory can verify a preexistin reference
rane (e.., as
etermine by the manufacturers stuy) by testin 20 heathy persons. If no more
than 10% fa
outsie the rane, it can be consiere vai for the patient popuation. 2828_C
06/08/12 5:14 PM Pae 235 51. When comparin the aboratorys monthy mean to it
s peer roup to

etermine if bias is present, what statistic is most appropriate? A. F test B. L

inear reression
anaysis C. Correation coe cient D. Stanar eviation inex Chemistry/Appy prin
cipes of
aboratory operations/ Quaity manaement/2 52. Which of the foowin methos i
s most usefu in
orer to etect sampe misienti cation? A. Cumuative summation B. Critica imit
C. Deta imit
D. Sini cant chane imit Chemistry/Appy knowee to ientify sources of error/
53. Which of the foowin tota quaity manaement toos can be use to cacua
te the anaytica
error rate for an anayte in the cinica aboratory? A. LEAN B. Six sima C. IS
O 9000 D.
Laboratory information system Chemistry/Appy principes of aboratory operation
s/ Quaity
manaement/2 236 Chapter 5 | Cinica Chemistry Answers to Questions 5153 51. D T
he stanar
eviation inex (SDI) compares the abs mean to the peer roups mean in terms of s
eviations instea of concentration. This normaizes the vaue so that it is in
epenent of mean,
an aows performance comparisons for any anayte. The SDI equas the abs mean
minus the peer
roups mean ivie by the peer roups stanar eviation. It has a simiar probab
istribution to a t test an a vaue reater than 2.0 is consiere sini cant. 52
. C Cumuative
summation is a statistica metho use in quaity assurance to etect a tren in
QC resuts.
Critica imits are use to efine when meica intervention is ikey neee to
prevent injury
or eath. The sinificant chane imit is the ifference in test resuts that is
sinificant, or that which cannot be attribute to the sum of norma physiooic
a an anaytica
variation. The eta imit (eta check) etermines whether the ifference betwe
en two
measurements usuay 2448 hours apart excees the expecte. Athouh this can res
ut from an
abrupt chane in the patients status, other causes are sampe misientification,
an ranom error. Deta imits are expresse in percent an vary epenin on an
ayte stabiity.
53. B A four of the answer choices are tota quaity manaement (TQM) toos us
e in the
cinica aboratory to improve performance. Six sima is a measurement of the fr
equency of
prouct efects. In cinica aboratories, it refers to the frequency of an erro
neous resut. At
the six-sima eve, the anaytica process has such sma variance that an erro
r of six times
the stanar eviation wou sti be within acceptabe imits for tota aowab
e error. For
exampe, a six-sima process for an anayte prouces a sini cant error in test re
sut ony 3.4
out of 1 miion times the test is performe. Conversey, a metho performin at
the three-sima
eve wou ive 66,807 errors per miion. The sima of a metho is cacuate
by subtractin

its bias from the tota metho error an iviin by its stanar eviation. It
is the methos
ranom error ivie by its stanar eviation. 2828_Ch05_171-326 06/08/12 5:1
4 PM Pae 236
54. In which circumstances is a vaiation stuy (versus performin routine qua
ity contro)
require? A. Instrument recaibration B. Source amp or ion seective eectroe
chane C. Chane
in reaent ot D. Chane in caibrator ot Chemistry/Appy principes of aborat
ory operations/
Quaity manaement/2 55. Te foowin pot represents a stuy of a screenin tes
t for mainant
prostate cancer usin pasma PSA (n/mL). Te outcome measure was positive cyto
oy resuts
obtaine by biopsy. What concentration ives the hihest sensitivity with the e
ast number of
unnecessary biopsies? 5.4 | Cacuations, Quaity Contro, an Statistics 237
Answers to
Questions 5455 54. C A of the iste conitions except a chane in the reaent
ot number can
be vaiate by assayin two eves of contro materia foowin the proceure.
A chane in
reaent ot number may ater the test system more ramaticay, especiay when
the reaent was
subjecte to storae an shippin conitions that ater its performance. Therefo
re, both contros
an patient sampes shou be anayze an the resuts compare to the reaent i
n current use
usin criteria etermine by the tota aowabe error for the anayte. 55. B A
operatin characteristic (ROC) curve is use to ientify the test resut, ivin
the hihest
sensitivity with the east number of fase-positive resuts. Sensitivity (true p
ositives) is
potte aainst fase positives. The number in the uppermost eft corner represe
nts the hihest
etection with the owest number of fase positives. In this case, a resut of 3
.6 n/mL etects
72% of mainancies with 1 in 10 (10%) fase positives. 0.0 0.1 0.2
0.5 0.6 0.7 0.8 0.50 0.55 0.60 0.65 0.70 0.75 2.6 2.8 3.0 3.2 3.4 3.6

3.8 4.0 4.2 4.4 4.6 4.8 5.0 5.2 S E N S I T I V I T Y 1-SPECIFICITY Receiver Op
Characteristic Curve:PSA A. 2.6 B. 3.6 C. 3.8 D. 5.2 Chemistry/Evauate aborato
ry ata to assess
vaiity/ Accuracy of proceures/Laboratory operations/3 2828_Ch05_171-326 06/0
8/12 5:14 PM
Pae 237 238 5.5 Creatinine, Uric Aci, BUN, an Ammonia 1. Creatinine is forme
from the: A.
Oxiation of creatine B. Oxiation of protein C. Deamination of ibasic amino ac
is D. Metaboism
of purines Chemistry/Appy knowee of funamenta biooica characteristics/B
iochemica/1 2.
Creatinine is consiere the substance of choice to measure enoenous rena ce
arance because:
A. Te rate of formation per ay is inepenent of boy size B. It is competey 
tere by the
omerui C. Pasma eves are hihy epenent upon iet D. Cearance is the sa
me for both men


an women Chemistry/Appy knowee of funamenta biooica characteristics/Bi

ochemica/1 3.
Which statement rearin creatinine is true? A. Serum eves are eevate in ea
ry rena isease
B. Hih serum eves resut from reuce omeruar tration C. Serum creatine ha
s the same
ianostic utiity as serum creatinine D. Serum creatinine is a more sensitive m
easure of rena
function than creatinine cearance Chemistry/Cacuate aboratory ata with phys
processes/Biochemica/2 4. Which of the foowin formuas is the correct expres
sion for
creatinine cearance? A. Creatinine cearance = U/P X V X 1.73/A B. Creatinine c
earance = P/V X
U X A/1.73 C. Creatinine cearance = P/V X U X 1.73/A D. Creatinine cearance =
U/V X P X 1.73/A
Chemistry/Cacuate/Creatinine cearance/1 Answers to Questions 14 1. A Creatinin
e is prouce
at a rate of approximatey 2% aiy from the oxiation of creatine mainy in ske
eta musce.
Creatine can be converte to creatinine by aition of stron aci or akai or
by the enzyme
creatine hyroxyase. 2. B Creatinine concentration is epenent upon musce mas
s, but varies by
ess than 15% per ay. Creatinine is not metaboize by the iver, or epenent
on iet, an is
100% tere by the omerui. It is not reabsorbe sini canty but is secrete si
especiay when trate ow is sow. Pasma creatinine an cystatin C are the two su
bstances of
choice for evauatin the omeruar tration rate (GFR). 3. B Serum creatinine i
s a specific
but not a sensitive measure of omeruar function. About 60% of the fitration
capacity of the
kineys is ost when serum creatinine becomes eevate. Because urine creatinine
iminishes as
serum creatinine increases in rena isease, the creatinine cearance is more se
nsitive than
serum creatinine in etectin omeruar isease. A creatinine cearance beow 6
0 mL/min
inicates oss of about 50% functiona nephron capacity an is cassifie as mo
erate (stae 3)
chronic kiney isease. 4. A Cearance is the voume of pasma that contains the
same quantity of
substance that is excrete in the urine in 1 minute. Creatinine cearance is ca
cuate as the
ratio of urine creatinine to pasma creatinine in miirams per eciiter. This
is mutipie by
the voume of urine prouce per minute an correcte for ean boy mass by mut
ipyin by
1.73/A, where A is the patients boy surface area in square meters. Separate refe
rence ranes
are neee for maes, femaes, an chiren because each has a i erent percentae
of ean musce
mass. 2828_Ch05_171-326 06/08/12 5:14 PM Pae 238 5. Which of the foowin c
onitions is most
ikey to cause a fasey hih creatinine cearance resut? A. Te patient uses t
he mistream voi
proceure when coectin his or her urine B. Te patient as tap water to the u
rine container

because he or she forets to save one of the urine sampes C. Te patient oes no
t empty his or
her baer at the concusion of the test D. Te patient empties his or her ba
er at the start
of the test an as the urine to the coection Chemistry/Ientify sources of e
cearance/3 6. Te moi cation of iet in rena isease (MDRD) formua for cacuat
in eGFR
requires which four parameters? A. Urine creatinine, serum creatinine, heiht, w
eiht B. Serum
creatinine, ae, ener, race C. Serum creatinine, heiht, weiht, ae D. Urine
ener, weiht, ae Chemistry/Appy principes of specia proceures/Creatinine
cearance/1 7.
What substance may be measure as an aternative to creatinine for evauatin GF
R? A. Pasma urea
B. Cystatin C C. Uric aci D. Potassium Chemistry/Appy knowee of funamenta
characteristics/Biochemica/1 8. Which of the foowin enzymes aows creatinin
e to be measure
by coupin the creatinine amiohyroase (creatininase) reaction to the peroxi
ase reaction? A.
Gucose-6-phosphate ehyroenase B. Creatinine iminohyroase C. Sarcosine oxi
ase D. Creatine
kinase Chemistry/Appy principes of enera aboratory proceures/Biochemica/1
5.5 |
Creatinine, Uric Aci, BUN, an Ammonia 239 Answers to Questions 58 5. D Urine
in the baer
shou be eiminate an not save at the start of the test because it represent
s urine forme
prior to the test perio. The other conitions (choices AC) wi resut in fase
y ow urine
creatinine or voume an, therefore, fasey ower cearance resuts. Error is i
ntrouce by
incompete emptyin of the baer when short times are use to measure cearanc
e. A 24-hour
time urine is the specimen of choice. When trate ow fas beow 2 mL/min, error
is introuce
because tubuar secretion of creatinine occurs. The patient must be kept we hy
rate urin the
test to prevent this. 6. B The Nationa Kiney Founation recommens screenin f
or chronic kiney
isease usin the estimate omeruar tration rate (eGFR) because of the hih f
requency of
sampe coection errors associate with measurin creatinine cearance. The eGF
R shou be
cacuate accorin to the MDRD formua, an reporte aon with the serum or p
asma creatinine.
eGFR (mL/min/1.73m 2 ) = 186 x Pasma Cr 1.154 x Ae 0.203 x 0.742 (if femae) x 1
.21 (if
Back) 7. B Athouh a of the anaytes iste are increase in chronic kiney
isease as a
resut of ow GFR, potassium, urea, an uric aci may be increase by other mech
anisms an
therefore, they are not speci c for omeruar function. Cystatin C is an inhibito
r of cysteine
proteases. Bein ony 13 kioatons, it is competey tere by the omeruus t
hen reabsorbe
by the tubues. The pasma eve is hihy correate to GFR because itte is e
iminate by

nonrena routes. Pasma eves are not in uence by iet, ae, ener, or nutritio
na status. Low
GFR causes retention of cystatin C in pasma an eves become abnormay hih a
t cearance rates
beow 90 mL/min, makin the test more sensitive than creatinine. 8. C The peroxi
enzymatic assay of creatinine is base upon the conversion of creatinine to crea
tine by
creatinine amiohyroase (creatininase). The enzyme creatinine amiinohyroase
then hyroyzes creatine to prouce sarcosine an urea. The enzyme sarcosine oxi
ase converts
sarcosine to ycine proucin formaehye an hyroen peroxie. Peroxiase th
en catayzes the
oxiation of a ye (4-aminophenazone an pheno) by the peroxie formin a re-c
oore prouct.
This metho is more speci c than the Ja e reaction, which tens to overestimate crea
tinine by
about 5% in persons with norma rena function. 2828_Ch05_171-326 06/08/12 5:1
4 PM Pae 239 9.
Seect the primary reaent use in the Ja e metho for creatinine. A. Akaine cop
per II sufate
B. Saturate picric aci an NaOH C. Soium nitroprussie an pheno D. Phosphot
unstic aci
Chemistry/Appy principes of enera aboratory proceures/Biochemica/1 10. In
terference from
other reucin substances can be partiay eiminate in the Ja e reaction by: A.
Measurin the
prouct at 340 nm B. Measurin the prouct with an eectroe C. Measurin the ti
me rate of
prouct formation D. Performin a sampe bank Chemistry/Ientify sources of err
11. Which of the foowin statements is true? A. Cystatin C is measure immunoc
hemicay B. Te
caibrator use for cystatin C is traceabe to the Nationa Bureau of Stanars
caibrator C.
Cystatin C assays have a ower coe cient of variation than pasma creatinine D. En
zymatic an
rate Ja e reactions for creatinine ive comparabe resuts Chemistry/Ientify sour
ces of
error/Biochemica/3 12. In which case wou eGFR erive from the pasma creatin
ine ikey ive a
more accurate measure of GFR than measurement of pasma cystatin C? A. Diabetic
patient B.
Chronic rena faiure C. Postrena transpant D. Chronic hepatitis Chemistry/Ien
tify sources of
error/Biochemica/ 3 240 Chapter 5 | Cinica Chemistry Answers to Questions 912
9. B The Ja e
metho uses saturate picric aci, which oxiizes creatinine in akai, formin
picrate. The reaction is nonspeci c; ketones, ascorbate, proteins, an other reuc
in aents
contribute to the na coor. Akaine CuSO 4 is use in the biuret metho for pro
tein. 10. C The
Ja e reaction is nonspeci c; proteins an other reucin substances such as pyruvate
, protein,
an ascorbate cause positive interference. Much of this interference is reuce
by usin a time
rate reaction. Ketoacis react with akaine picrate amost immeiatey, an pro
teins react

sowy. Therefore, reain the absorbance at 20 an 80 secons an usin the abs
orbance i erence
minimizes the e ects of those compouns. Creatinine can be measure usin an amper
eectroe. However, this requires the enzymes creatininase, creatinase, an sarc
osine oxiase.
The ast enzyme prouces hyroen peroxie from sarcosine, which is oxiize. Th
is prouces
current in proportion to creatinine concentration. Performin a sampe bank oe
s not correct for
interferin substances that react with akaine picrate. 11. A Cystatin C can be
measure by
enzyme immunoassay, immunonepheometry, an immunoturbiimetry. However, there i
s no stanarize
caibrator as for creatinine, an therefore, resuts vary consieraby from ab
to ab. The
coe cient of variation for these methos tens to be sihty hiher than for crea
tinine. Since
the enzymatic methos are speci c, they ive ower pasma creatinine resuts than
the Ja e metho
in persons with norma rena function. However, they ten to ive hiher cearan
ce resuts than
for inuin or iohexo cearance because some creatinine is secrete by the rena
tubues. 12. C
Cystatin C is eiminate amost excusivey by the kineys an pasma eves are
not epenent on
ae, sex, or nutritiona status. However, pasma eves are a ecte by some rus,
those use to prevent rena transpant rejection. Increase pasma eves have b
een reporte in
chronic in ammatory iseases an cancer. Formuas are avaiabe to cacuate eGFR
from pasma
cystatin C, but unike for creatinine, the formuas must be matche to the metho
 of assay. The
eGFR erive from cystatin C can etect a fa in GFR sooner an may be more sen
sitive for
iabetic an other popuations at risk for chronic kiney isease. As a screenin
 test for eGFR,
it has about the same preictive vaue as eGFR erive from creatinine. 2828_Ch0
06/08/12 5:14 PM Pae 240 13. A sampe of amniotic ui coecte for feta un
stuies from a woman with a prenancy compromise by hemoytic isease of the ne
wborn (HDN) has a
creatinine of 88 m/L. What is the most ikey cause of this resut? A. Te spec
imen is
contaminate with boo B. Biirubin has interfere with the measurement of crea
tinine C. A
ranom error occurre when the absorbance sina was bein processe by the ana
yzer D. Te ui
is urine from accienta puncture of the urinary baer Chemistry/Ientify sour
ces of
error/Biochemica/3 14. Which anayte shou be reporte as a ratio usin creati
concentration as a reference? A. Urinary microabumin B. Urinary estrio C. Urin
ary soium D.
Urinary urea Chemistry/Appy principes of enera aboratory proceures/Creatin
ine/1 15. Urea is
prouce from: A. Te cataboism of proteins an amino acis B. Oxiation of puri
nes C. Oxiation

of pyrimiines D. Te breakown of compex carbohyrates Chemistry/Appy knowe

e of funamenta
biooica characteristics/Biochemica/1 16. Urea concentration is cacuate fr
om the BUN by
mutipyin by a factor of: A. 0.5 B. 2.14 C. 6.45 D. 14 Chemistry/Cacuate/Bio
chemica/2 17.
Which of the statements beow about serum urea is true? A. Leves are inepenen
t of iet B. Urea
is not reabsorbe by the rena tubues C. Hih BUN eves can resut from necrot
ic iver isease
D. BUN is eevate in prerena as we as rena faiure Chemistry/Correate abo
ratory ata with
physiooica processes/Biochemica/2 5.5 | Creatinine, Uric Aci, BUN, an Ammo
nia 241 Answers
to Questions 1317 13. D Creatinine eves in this rane are foun ony in urine s
Auts usuay excrete between 1.2 an 1.5  of creatinine per ay. For this rea
son, creatinine
is routiney measure in 24-hour urine sampes to etermine the competeness of
coection. A
24-hour urine with ess than 0.8 /ay inicates that some of the urine was prob
aby iscare.
Creatinine is aso use to evauate feta maturity. As estation proresses, mor
e creatinine is
excrete into the amniotic ui by the fetus. Athouh a eve above 2 m/L is no
t a speci c
inicator of maturity, a eve beow 2 m/L inicates immaturity. 14. A Measure
ment of urinary
microabumin concentration shou be reporte as a ratio of abumin to creatinin
e (e.., m
abumin per  creatinine). This eiminates the nee for 24-hour coection in or
er to avoi
variation cause by i erences in ui intake. A ry reaent strip test for creatini
ne is
avaiabe that measures the abiity of a creatininecopper compex to break own H
2 O 2 ,
formin a coore compex. The strip uses bu ere copper II sufate, tetramethybe
nziine, an
anhyrous peroxie. Binin of creatinine in urine to copper forms a peroxiaseike compex that
resuts in oxiation of the benziine compoun. Aso, 24-hour urinary metanephri
vaniymaneic aci, an homovaniic aci are reporte per ram creatinine wh
en measure in
infants an chiren in orer to compensate for i erences in boy size. 15. A Ure
a is enerate
by eamination of amino acis. Most is erive from the hepatic cataboism of pr
oteins. Uric aci
is prouce by the cataboism of purines. Oxiation of pyrimiines prouces orot
ic aci. 16. B
BUN is mutipie by 2.14 to ive the urea concentration in m/L. BUN (m/L) =
urea (% N in
urea 100) Urea = BUN 1/(% N in urea 100) Urea = BUN (1/0.467) = 2.14 17. D Urea i
competey tere by the omerui but reabsorbe by the rena tubues at a rate
epenent upon
trate ow an tubuar status. Urea eves are a sensitive inicator of rena isea
se, becomin
eevate by omeruar injury, tubuar amae, or poor boo ow to the kineys (p

faiure). Serum urea (an BUN) eves are in uence by iet an are ow in necroti
c iver
isease. 2828_Ch05_171-326 06/08/12 5:14 PM Pae 241 18. A patients BUN is 60
m/L an serum
creatinine is 3.0 m/L. Tese resuts suest: A. Laboratory error measurin BUN
B. Rena faiure
C. Prerena faiure D. Patient was not fastin Chemistry/Evauate aboratory at
a to etermine
possibe inconsistent resuts/Biochemica/3 19. Urinary urea measurements may be
use for
cacuation of: A. Gomeruar tration B. Rena boo ow C. Nitroen baance D. A
 of these
options Chemistry/Correate aboratory ata with physiooica processes/Biochem
ica/2 20. BUN is
etermine eectrochemicay by coupin the urease reaction to measurement of:
A. Potentia with
a urea-seective eectroe B. Te time rate of increase in conuctivity C. Te ox
iation of
ammonia D. Carbon ioxie Chemistry/Appy principes of specia proceures/ Bioc
hemica/1 21. In
the utravioet enzymatic metho for BUN, the urease reaction is coupe to a se
con enzymatic
reaction usin: A. AST B. Gutamate ehyroenase C. Gutamine synthetase D. Aa
aminotransferase (ALT) Chemistry/Appy principes of basic aboratory proceures
22. Which prouct is measure in the coupin step of the urease-UV metho for B
UN? A. CO 2 B.
Dinitrophenyhyrazine C. Diphenycarbazone D. NAD + Chemistry/Appy principes
of basic
aboratory proceures/Biochemica/1 242 Chapter 5 | Cinica Chemistry Answers t
o Questions 1822
18. C BUN is a ecte by rena boo ow as we as by omeruar an tubuar functio
n. When boo
ow to the kineys is iminishe by circuatory insu ciency (prerena faiure), om
tration ecreases an tubuar reabsorption increases ue to sower trate ow. Beca
use urea is
reabsorbe, BUN eves rise hiher than creatinine. This causes the BUN:creatini
ne ratio to be
reater than 10:1 in prerena faiure. 19. C Because BUN is hane by the tubu
es, serum eves
are not speci c for omeruar tration rate. Urea cearance is in uence by iet an
function as we as rena function. Protein intake minus excretion etermines ni
troen baance. A
neative baance (excretion excees intake) occurs in stress, starvation, fever,
cachexia, an
chronic iness. Nitroen baance = (Protein intake in rams per ay 6.25) (Urin
e urea
nitroen in rams per ay + 4), where 4 estimates the protein nitroen ost in t
he feces per ay
an iviin by 6.25 converts protein to protein nitroen. 20. B A conuctivity
eectroe is use
to measure the increase in conuctance of the soution as urea is hyroyze by
urease in the
presence of soium carbonate. Urea + H 2 O 2NH 3 + CO 2 2NH 3 + 2H 2 O + Na 2 CO
3 2NH 4 + +
CO 3 2 + 2NaOH Ammonium ions increase the conuctance of the soution. The time
rate of current

increase is proportiona to the BUN concentration. Aternativey, the ammonium i

ons prouce can
be measure usin an ion-seective eectroe. 21. B BUN is most frequenty measu
re by the
urease-UV metho in which the urease reaction is coupe to the utamate ehyr
oenase reaction,
eneratin NAD + . Urea + H 2 O Urease 2NH 3 + CO 2 2-Oxoutarate + NH 3 + NADH
+ H + GLD
Gutamate + NAD + + H 2 O When the urease reaction is performe uner rst-orer c
onitions, the
ecrease in absorbance at 340 nm is proportiona to the urea concentration. 22.
D In the
urease-UV metho, urease is use to hyroyze urea, formin CO 2 an ammonia. G
ehyroenase catayzes the oxiation of NADH, formin utamate from 2-oxouta
rate an ammonia.
The utamate ehyroenase reaction is use for measurin both BUN an ammonia.
2828_Ch05_171-326 06/08/12 5:14 PM Pae 242 23. Which enzyme e ciency is respo
nsibe for
phenyketonuria (PKU)? A. Phenyaanine hyroxyase B. Tyrosine transaminase C.
p-Hyroxyphenypyruvic aci oxiase D. Homoentisic aci oxiase Chemistry/Appy
knowee of
funamenta biooica characteristics/Aminoaciuria/1 24. Which of the foowin
 conitions is
cassi e as a rena-type aminoaciuria? A. Fanconi synrome B. Wisons isease C.
Hepatitis D.
Homocystinuria Chemistry/Correate cinica an aboratory ata/ Aminoaciuria/2
25. Which
aminoaciuria resuts in the over ow of branche chain amino acis? A. Hartnups is
ease B.
Akaptonuria C. Homocystinuria D. Mape syrup urine isease Chemistry/Appy know
ee of
funamenta biooica characteristics/Aminoaciuria/1 26. In aition to pheny
ketonuria, mape
syrup urine isease, an homocystinuria, what other aminoaciuria can be etecte
 by tanem MS?
A. Akaptonuria B. Hartnup isease C. Citruinemia D. Cystinuria Chemistry/App
y principes of
specia proceures/ Aminoaciuria/2 27. Of the methos use to measure amino aci
s, which is
capabe of measurin fatty acis simutaneousy? A. Tanem-mass spectroscopy B.
iqui chromatoraphy C. Capiary eectrophoresis D. Two-imensiona thin-ayer
Chemistry/Appy principes of specia proceures/Amino acis/1 5.5 | Creatinine,
Uric Aci, BUN,
an Ammonia 243 Answers to Questions 2327 23. A PKU is an over ow aminoaciuria r
esutin from
the accumuation of phenyaanine. It is cause by a e ciency of phenyaanine hy
which converts phenyaanine to tyrosine. Excess phenyaanine accumuates in b
oo. This is
transaminate, formin phenypyruvic aci, which is excrete in the urine. 24. A
synrome is an inherite isorer characterize by anemia, menta retaration, r
ickets, an
aminoaciuria. Because the aminoaciuria resuts from a efect in the rena tubu
e, it is
cassifie as a (seconary-inherite) rena-type aminoaciuria. Wisons isease

ceruopasmin eficiency) causes hepatic faiure. It is cassifie as a seconar