Rodak's Hematology 6th Edition Test Bank

TEST BANK FOR RODAK'S HEMATOLOGY 6TH EDITION BY WALENGA
Nursylab 1# Nursing Materials Seller of 2021
1. Chapter 01-01
Hematology is the study of:
*a. blood cells.

b. serum electrolytes.
c. plasma hormone levels.
d. bacteria in the blood.
General Feedback:
Hematology is the study of blood cells—red blood cells, white
blood cells, and platelets. Plasma and serum electrolytes and hormone
levels are evaluated in various subdivisions of clinical chemistry, and
bacteria are evaluated in clinical microbiology.
2. Chapter 01-02
The morphology of blood cells is important to evaluate:
a. every time a complete blood count (CBC) is requested on a

patient.
b. when an instrument-generated flag is obtained.
*c. when a profiling instrument result is abnormal.
d. when the white count is elevated.
General Feedback:
Every laboratory must determine—based on its instrumentation,
needs of the clinician and other parameter flags that alert the medical
laboratory scientist to the necessity for further evaluation—when it is
necessary to evaluate cell N URSINGTBMany
morphology. .COMinstrument-generated flags,
although useful, may not require review. If an automated CBC does not
suggest the need, no reason exists to evaluate the blood film, even if
the white count is elevated.
3. Chapter 01-03
Who is ultimately responsible for determining the specimen integrity
before analysis?
*a. Medical laboratory professional

b. Nursing staff
c. Phlebotomist
d. Specimen-processing personnel
General Feedback:
The medical laboratory scientist is responsible for ensuring
the integrity of a specimen before analysis. Only he or she can judge
whether the specimen is acceptable so that valid results can be
obtained. Acceptable criteria include such things as type of specimen
for the test ordered (e.g., blood, serum, urine); appropriate additive
present (if needed) and amount of specimen relative to the additive;
time interval since obtained; and presence or absence of hemolysis,
lipemia, and other similar conditions. None of the other personnel
named have the education and understanding to fully make that judgment.
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4. Chapter 01-04
Hematocrit is also called:
a. white cell count.

b. bone marrow examination.
c. red blood cell (RBC) count.
*d. packed red cell volume.
General Feedback:
Historically the hematocrit was determined by centrifuging an
aliquot of anticoagulated whole blood under specified conditions (e.g.,
centrifugal force, capillary tube length, and bore diameter) and then
determining the ratio of the space occupied by the packed red cells
compared with that of the entire blood volume in the capillary tube,
often expressed as a percentage. Hence, it is also called the packed
red cell volume.
5. Chapter 01-05
The primary function of platelets is to:
a. defend the body against bacterial invasion.

b. carry oxygen to tissues.
*c. facilitate blood clotting.
d. regulate acid-base balance.
General Feedback:
Whenever disruption occurs to a blood vessel so that bleeding
results, platelets respond N URSINGTtoB.stop
initially COMthe bleeding in small
vessels; they also play an integral role in facilitating the formation
of a blood clot. White cells defend against bacterial invasion; red
cells (i.e., hemoglobin) carry oxygen to tissues; and a complex
interaction of plasma electrolytes, proteins, and carbon dioxide
participates in acid-base balance.
6. Chapter 01-06
Which of the following can be evaluated only through the microscopic
examination of a stained blood film?
a. White blood cell (WBC) count

b. Reticulocyte count
c. Hemoglobin concentration
*d. Presence or absence of cytoplasmic inclusions
General Feedback:
Making and staining a blood film and then placing it under a
microscope allow the medical laboratory scientist to evaluate the
morphology of blood cells and examine them for the presence or absence
of blood cell inclusions. These inclusions are important for cell
identification and, when abnormal inclusions are present, sometimes
provide “clues” as to the cause of disease. All the other parameters
mentioned are or can be performed using an automated hematology
instrument, including reticulocyte counting.
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7. Chapter 01-07
Upon centrifugation of a blood specimen, the layer between the red
blood cells and plasma is called the:
a. hematocrit.
*b. buffy coat.
c. serum.
d. platelet pellet.
General Feedback:
When blood is centrifuged, the layer between the red cells and
plasma is called the buffy coat. This layer consists of both white
blood cells and platelets. The hematocrit is the packed cell volume
that reflects the number of red blood cells. The serum is the liquid
portion of the blood formed from a clotted blood sample. The platelet
pellet is a special layer of platelets that is required for platelet
function studies. This layer of platelets is prepared from a whole
blood specimen using specific centrifugation time and speed.
8. Chapter 01-08
Select the term that describes a low white blood cell count.
*a. Leukopenia
b. Leukocytosis
c. Neutropenia
d. Leukemia
General Feedback: NURSINGTB.COM

The term leukopenia refers to a low total white blood cell
count. Leukocytosis is a term that describes an increase in white blood
cell count. Neutropenia is a low cell count that is specific to the
neutrophils. Leukemia is cancer of the blood cells, most often white
blood cells.
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2. Chapter 02-02
A patient’s white blood cells (WBCs) are counted on an automated cell
counter 10 times. The mean white count is 8000/mL, and the standard
deviation (SD) is 300. What is the coefficient of variation (CV)?
a. 0.04%
b. 2.6%
*c. 3.8%
d. 26%
General Feedback:
% CV = (SD/mean) × 100 = (300/8000) × 100 = 3.8%.
3. Chapter 02-03
What does the CV calculated in Question 2 describe about the white cell
counts?
a. Accuracy
b. Reliability
c. Proper calibration
*d. Precision
General Feedback:
The CV is a measure of precision, or how well a result can be
reproduced. It allows comparisons of assays with different means and is
a unitless number, although usually expressed as a percentage. Accuracy
is how close a result is to the true value; proper calibration is
NUReliability
required to obtain accuracy. RSINGTB.C isOM
how well a method holds
both accuracy and precision over time.
4. Chapter 02-04
A patient specimen is analyzed on an instrument known to be in control
from previous assays performed on a calibrated instrument and gives a
hemoglobin result of 13.2 g/dL. Two hours later it is evaluated on
another instrument that is being evaluated for purchase by the
laboratory. The result is 11.8 g/dL. This result, when compared with
the first, is:
a. acceptable agreement.
b. reportable.
c. precise agreement.
*d. inaccurate.
General Feedback:
This result is inaccurate compared with the first because it
is significantly different. Precision is not known, because multiple
results are needed to determine precision; in addition, precision must
be determined using the same instrument, not between instruments.
Because it is not accurate, it cannot be reported.
5. Chapter 02-05
Which is true regarding reference ranges?
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a. Should be derived from reference books

b. Need to be determined only for adults
c. Can be established by running the test procedure on 10 healthy
people
*d. Are ranges of values for an analyte in normal healthy people
General Feedback:
Reference ranges should be determined by evaluating a group of
perhaps as many as 120 normal healthy people for the same analyte. If
the analyte differs in different groups, based on data such as age and
sex, it must be determined for each group if at all possible.
6. Chapter 02-06
A test that is positive in all patients who have the disease but also
in some who do not have the disease is:
*a. sensitive.
b. specific.
c. precise.
d. reliable.
General Feedback:
Sensitivity (diagnostic) is defined by the number of people
with the disease who test positive. In this case, all patients with the
disease have a positive result, so the test is very sensitive. The
test, however, is not specific because it is also positive in some
people who do not have the disease. Reliability refers to the
performance stability of a N URSover
test INGTtime.
B.COPrecision
M evaluates
reproducibility of the result if repeated multiple times on a specimen.
7. Chapter 02-07
The antinuclear antibody (ANA) test is positive in almost all people
who have systemic lupus erythematosus (SLE). It is also positive in
some patients who do not have SLE. The antideoxyribonucleic acid (anti-
DNA) test is positive only in people with SLE but not in all who do.
Which of the following is true?
*a. The ANA test is a good screening test, and anti-DNA test is a
good confirmatory test.
b. The anti-DNA test is a good screening test, and the ANA test
is a good confirmatory test.
c. Both are good screening tests for SLE.
d. Neither of these tests is valid.
General Feedback:
Because almost all patients with SLE have a positive ANA test,
it is a good screening test (if the result is negative, it practically
rules out this diagnosis for a patient). However, because the ANA test
is also positive in other patients, the anti-DNA test is a good
confirmatory test, because only patients with SLE have a positive
result. In practice, the ANA test is done first; if it is positive,
then the anti-DNA test is done as follow-up. If a patient is positive
with both tests, then his or her diagnosis is SLE.
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8. Chapter 02-08
A purchased hemoglobin standard is used to adjust a hemoglobinometer.
This standard is being used as a:
a. control.
b. precision check.
c. delta check.
*d. calibrator.
General Feedback:
Standards are used to calibrate instruments. Controls are used
to routinely evaluate the accuracy of a method once it is calibrated.
Precision is a measure of reproducibility, whereas delta checks compare
a patient result with a previous result (same test on the same
patient). This can only be done for a test result that essentially does
not vary significantly from testing time to testing time.
9. Chapter 02-09
The tubing that brings the lyse reagent to the hemoglobin cuvette on an
automated cell counter is pinched and not delivering any reagent. All
hemoglobin values are greater than 20 g/dL. This represents what type
of error?
a. Random
b. Imprecision
*c. Constant systematic
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d. Proportional systematic
General Feedback:
A constant systematic error is one in which the magnitude of
the error remains the same throughout the range of the test
measurement. The error is proportional if the magnitude varies relative
to the result. This is not a random error, which happens only
infrequently and is not predictable. Precision requires multiple
measurements of the same specimen and evaluates the ability to
consistently reproduce the result.
10. Chapter 02-10

One of two controls that have been evaluated over the last 28 days
gives a result on day 29 between 2 and 3 SDs of the mean; the other
control is within 2 SDs of its mean. What is the correct procedure to
follow?
a. Ignore the result unless it happens again the next day.

*b. Rerun the control and, if acceptable, continue with patients.
c. Recalibrate the instrument.
d. Open new vials of controls and repeat both controls.
General Feedback:
One control is acceptable, whereas the other is a warning that
the method may be going out of control. The test option in this case is
to repeat the analysis of the control, and if it is acceptable,
continue with patient analysis, reporting the results. The instrument
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does not appear to need recalibration because one control is acceptable

and the other is within 3 SDs (1 result of 20 can acceptably be within
±3 SDs). If the repeat on the “out of control” vial is still out
between 2 and 3 SDs, then a new vial of that control should be opened
and analyzed. The control that was acceptable does need to be repeated.
11. Chapter 02-11

The control values for both controls for the prothrombin test were
ranging between the mean and ±1 SD for the first 19 days of use.
Starting on day 20, the values for both were consistently between +1
and +2 SDs. This is an example of a:
*a. shift.
b. trend.
c. random error.
d. predictable error.
General Feedback:
If all results are consistently different from the previous in
the same direction, it indicates a shift in the methodology has
occurred. A trend would show a gradual change over time. This is
neither a predictable error nor a random error because it is
consistent.
12. Chapter 02-12

Which would most likely be associated with the situation described in
Question 11?
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a. Operator error
b. Fading light source
c. Miscalibrated instrument
*d. Starting a new lot number of thromboplastin reagent
General Feedback:
Shifts can occur when a new reagent is introduced. A fading
light source would lead to trend error. If the instrument were
calibrated incorrectly, both controls should be out; likewise, operator
error would result in both controls being unacceptable.
13. Chapter 02-13

Which group of patients should not be included in establishing moving
averages using red cell indices?
*a. Chemotherapy patients

b. Female patients
c. Obstetric patients
d. Surgical patients
General Feedback:
The moving average method works well in institutions that
assay specimens from generalized populations that contain minimal
numbers of sickle cell or oncology patients. This method is not
restricted in female, obstetric, or surgical patients.
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14. Chapter 02-14

A laboratory comparing its results to those of other laboratories on
the same specimen is an example of:
a. precision monitoring.
b. internal quality assessment.
*c. external quality assessment.
d. delta checks.
General Feedback:
When results are compared with those of another laboratory,
this is part of external quality assessment. Internal quality
assessment is done totally within one laboratory. Delta checks compare
a patient result with a previous result on the same patient. Precision
is determined by multiple analysis of the same specimen.
15. Chapter 02-15

The best way to prevent errors in the laboratory is to:
a. purchase high-quality instruments from reputable vendors.

*b. hire professionals with integrity.
c. have quality management.
d. perform external quality control procedures.
General Feedback:
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Competent professional staff that act with integrity can
ensure that the best-quality results are routinely obtained for
patients. A high-quality instrument is effective only when it is
correctly calibrated and maintained. Management, although ultimately
responsible, relies on the laboratory personnel to be aware of
potential problems in assays. External quality control programs do not
guarantee the daily validity of patient results.
16. Chapter 02-16

A laboratory gets numerous complaints regarding the length of time it
takes hematology results to get to the emergency department. What would
be an appropriate response?
*a. Make this a quality assurance project.

b. Ignore the complaints.
c. Explain why it takes so long.
d. Tell the employees to work faster.
General Feedback:
Quality assurance evaluates the process from the time a test
is ordered until it is reported to the correct patient chart. One of
the responsibilities of a clinical laboratory is to get results to
physicians and other caretakers in a timely manner; the acceptable
turnaround time for a particular procedure will vary depending on the
reason it is ordered. Obviously, an emergency department has a need for
rapid turnaround time. Complaints from caregivers should never be
ignored; it probably is not reasonable to tell employees to work
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faster, and explaining why it takes so long will not help provide good
patient care.
17. Chapter 02-17

The precision limits of a method are defined by:
a. the mean.
*b. the SD.
c. sensitivity.
d. specificity.
General Feedback:
Evaluating the same specimen multiple times and applying
statistics to the results determine precision or reproducibility. The
SD describes the precision. The mean is the average result (assuming a
gaussian distribution). Sensitivity describes how well a test
identifies positive patients, whereas specificity is how well it
identifies only positive patients.
18. Chapter 02-18

A clinical laboratory scientist performs 30 replicate hemoglobin
determinations on a single blood sample. When statistics are used to
determine the precision of the method, the mean is 13.8 g/dL and 1 SD
is 0.1 g/dL. This means that 95.5% of the results on this specimen lie:
a. between 13.4 and 14.2 g/dL.

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*b. between 13.6 and 14.0 g/dL.
c. between 13.5 and 14.1 g/dL.
d. between 13.7 and 13.9 g/dL.
General Feedback:
Because 1 SD is 0.1 g/dL, 2 SD = 0.2 g/dL. Thus 95.5% of the
results lie between 13.6 (±2 SDs) and 14.0 (+2 SDs).
19. Chapter 02-19

The following hemoglobin results, reported in g/dL, are obtained on a
hospitalized patient on 3 consecutive days:
Day 1 Day 2 Day 3
14.3 11.5 14.4
The SD for this hemoglobin method was calculated in Question 18. A

delta check was obtained on day 2. Controls were run as appropriate
each day and were all within limits for this procedure.
What is the most probable reason for the day 2 result when compared
with those for days 1 and 3?
a. It is within the 95.5% confidence levels for this test.

*b. It may represent an error in patient identification.
c. The patient had a major blood loss between days 1 and 2.
d. It is within the 99% confidence levels for this test.
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General Feedback:
The results for days 1 and 3 are statistically the same result
(i.e., they are within the 95.5% confidence levels for this procedure
and are therefore precise). The result for day 2 is clearly very
significantly different, thus giving a delta check (the only possible
explanation of those given here is that a patient identification error
occurred and the specimen on day 2 is from a different patient). Delta
checks are designed to help pick up this kind of critical error. If it
had been within the 99% confidence limits, it would have been within 3
SDs, or no less than 14.0 g/dL. Because the results from day 1 and day
3 are the same, blood loss with a drop in hemoglobin cannot explain the
day 2 results.
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1. Chapter 03-01
What component of the erythrocyte is most responsible for its
cytoskeleton and cellular integrity?
a. Glycocalyx
*b. Cytoskeletal protein
c. Nucleus
d. Golgi apparatus
General Feedback:
Cytoskeletal proteins are found on the inner cytoplasmic side
of the membrane and form the lattice of the cytoskeleton.
2. Chapter 03-02
What cellular component of the erythrocyte is its control center?
a. Heterochromatin
b. Golgi apparatus
*c. Nucleus
d. Cytoplasm
General Feedback:
The nucleus is the control center of the cell, is responsible
for all its chemical reactions, and is the site of deoxyribonucleic
acid (DNA) replication and transcription.
3. Chapter 03-03
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How does the genetically active portion of the nuclear chromatin look
when stained with Wright stain?
a. Condensed, darkly stained

b. Clumped, dark purple
c. Ropelike, pink or red
*d. Diffuse, uncondensed and pale blue
General Feedback:
The genetically active portion of the nuclear chromatin,
composed of DNA plus supporting proteins, appears diffuse and
uncondensed and stains pale blue with Wright stain. It is also called
euchromatin. Chromatin, which is condensed and stains darkly, is also
called heterochromatin; it is the genetically inactive portion of the
nucleus.
4. Chapter 03-04
What cellular component “directs traffic” for smooth functioning?
a. Mitochondria
b. Ribosomes
*c. Golgi apparatus
d. Nucleoli
General Feedback:
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The Golgi apparatus directs traffic in the cell, where it is

responsible for modifying, sorting, and packaging macromolecules for
secretion or delivery to other organelles within the cell.
5. Chapter 03-05
If the cytoplasm of a cell is very basophilic or dark blue when stained
with Wright stain, it contains:
a. low concentration of lysosomes.

*b. large number of ribosomes.
c. small number of ribosomes.
d. high concentration of lysosomes.
General Feedback:
Ribosomes, which are made up of ribonucleic acid (RNA), stain
dark blue or basophilic with Wright stain. If a cell’s cytoplasm
contains many ribosomes, it will stain very blue.
6. Chapter 03-06
Protein synthesis occurs in what part of a cell?
*a. Ribosomes
b. Nucleus
c. Mitochondria
d. Lysosomes
General Feedback:
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Protein synthesis occurs on ribosomes, found in rough
endoplasmic reticulum.
7. Chapter 03-07
What cellular component is responsible for energy production and
metabolic processes?
a. Ribosomes
b. Nucleus
*c. Mitochondria
d. Lysosomes
General Feedback:
Mitochondria are responsible for energy production and
metabolic processes of a cell.
8. Chapter 03-08
Lysosomes are found in the cytoplasm of many cells and contain:
a. cholesterol.
*b. hydrolytic enzymes.
c. glycoproteins.
d. RNA.
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General Feedback:
Lysosomes contain hydrolytic enzymes.
9. Chapter 03-09
What cellular structures appear as granules with Wright stain?
a. Ribosomes
b. Golgi bodies
c. Mitochondria
*d. Lysosomes
General Feedback:
With Wright stain, lysosomes are visualized as azurophilic
granules.
10. Chapter 03-10

The nucleolus of a cell is composed of:
a. hydrolytic enzymes.
b. glycoproteins.
*c. RNA.
d. lipids.
General Feedback:
The nucleolus is composed of ribosomal RNA, DNA, and proteins
in loose fibrillar form and is found within the nucleus of a cell.
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11. Chapter 03-11

Where are surface markers that help in cell identification found?
*a. Cell membrane

b. Golgi complex
c. Rough endoplasmic reticulum
d. Nucleus
General Feedback:
Surface markers are found on the cell membrane and are
primarily composed of glycoproteins. Cluster differentiation (CD)
numbers are used to identify them.
12. Chapter 03-12

A cell that is actively synthesizing protein has:
*a. more nucleoli.

b. more heterochromatin.
c. fewer ribosomes.
d. fewer mitochondria.
General Feedback:
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A cell that is active in protein synthesis has more nucleoli,

less heterochromatin (and more euchromatin), and more mitochondria and
ribosomes.
13. Chapter 03-13

If the lysosomal membrane ruptures, what is the consequence to the
cell?
a. Activates cell nucleus to replicate DNA.

b. Enhances protein synthesis by ribosomes.
*c. Damages internal cell structures.
d. Facilitates rearrangement of intracellular organelles.
General Feedback:
When the lysosomal membrane is ruptured, its contents denature
and digest DNA, RNA, and intracellular proteins; and ultimately the
cell lyses.
14. Chapter 03-14

After birth, where does hematopoiesis predominantly occur?
*a. Bone marrow

b. Spleen
c. Liver
d. Lymph nodes
General Feedback:
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After birth, hematopoiesis predominantly occurs in the bone
marrow.
15. Chapter 03-15

Erythropoietin is a growth factor affecting erythroid progenitors and
is produced by what organ?
a. Bone marrow
b. Spleen
*c. Kidney
d. Liver
General Feedback:
Erythropoietin is a growth factor affecting erythroid
progenitors and is produced by the kidney when it senses hypoxia.
16. Chapter 03-16

In what stage of the cell cycle does DNA replication occur?
a. G1
*b. S
c. G2
d. M
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General Feedback:
S is the stage where DNA replication occurs. G1 is a period of
cell growth and synthesis of components. M is mitosis. Stage G2 has
tetraploid DNA and a large cell volume.
17. Chapter 03-17

Which morphologic characteristic is representative of apoptosis?
a. Inflammation
b. Cell swelling
*c. Cell shrinkage
d. Cell lysis
General Feedback:
Only cell shrinkage is characteristic of apoptosis. The other
three are characteristic of cell death by necrosis.
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1. Chapter 04-01
What are the major hematopoietic sites in the fetus and in the adult?
Fetus Adult
a. Lymph node spleen

*b. Liver bone marrow
c. Liver spleen
d. Bone marrow liver
General Feedback:
The major site of hematopoiesis in the fetus is in the liver,
which retains some minor production until about 2 weeks after birth. In
the adult, it is the bone marrow, where production begins in the fifth
month of fetal life.
2. Chapter 04-02
How do cells get from the bone marrow into peripheral circulation?
a. Stem cells escape the bone marrow and mature in peripheral

circulation.
b. Mature cells attach to a carrier protein for transport.
c. Capillaries flow into the marrow and pluck out precursor
cells.
*d. Mature cells squeeze through spaces in the vessel endothelial
lining.
General Feedback:
NURScome
As mature blood cells INGinto
TB.Ccontact
OM with endothelial cells
in the bone marrow, they bind to the surface via a receptor-mediated
process. The binding creates a space between the luminal adventitial
and endothelial cells. The adventitial cells are capable of
contracting, which allows mature blood cells to pass through the
basement membrane and interact with the endothelial layer. This allows
the bone marrow cells to escape into circulation.
3. Chapter 04-03
When hematopoiesis occurs in the liver in an adult, it is called:
a. intramedullary.
b. intermedullary.
c. normal.
*d. extramedullary.
General Feedback:
Whenever hematopoiesis occurs outside the bone marrow in an
adult, other than lymphopoiesis in lymphatic tissue, it is called
extramedullary. This is abnormal.
4. Chapter 04-04
Where are developing red cells located in the bone marrow?
*a. Adjacent to the outer surfaces of the vascular sinuses

b. Outside the vascular walls of the sinusoids
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c. Deep in the cords

d. Randomly spaced throughout the cords
General Feedback:
Maturing red cells are found in two places in the bone marrow:
(1) adjacent to the outer surfaces of the vascular sinuses and (2)
surrounding iron-laden macrophages.
5. Chapter 04-05
Which splenic process removes inclusions from circulating red blood
cells?
a. Hemorrhage
b. Macrophage
c. Culling
*d. Pitting
General Feedback:
Macrophages in the spleen normally remove abnormal inclusions
from red cells, which is called pitting. Culling occurs when the cells
are phagocytized with subsequent degradation of cell organelles.
6. Chapter 04-06
Where are the venous sinuses of the spleen located?
a. White pulp
*b. Red pulp
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c. Gray matter
d. White matter
General Feedback:
The venous sinuses are located in the red pulp of the spleen.
7. Chapter 04-07
What condition is most associated with autosplenectomy?
a. Abdominal trauma
b. Thrombocytopenia
*c. Sickle cell anemia
d. Iron deficiency
General Feedback:
In sickle cell anemia, repeated sickling events in the spleen,
where the red cells are stressed, result in multiple splenic infarcts.
Eventually, the spleen is no longer functional. This results in
functional loss of the spleen and is called an autosplenectomy.
8. Chapter 04-08
Which is a characteristic of lymph?
a. Solid substance
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*b. Low protein

c. Low red blood cells
d. Superficial
General Feedback:
Lymph is the fluid portion of blood that escapes into the
connective tissue and is characterized by a low protein concentration
and the absence of RBCs.
9. Chapter 04-09
What bone marrow cells can differentiate into all of the blood cells?
a. Burst-forming unit—erythroid (BFU-E)

b. Colony-forming unit—granulocyte-monocyte (CFU-GM)
c. Colony-forming unit—granulocyte, erythrocyte, monocyte, and
megakaryocyte (CFU-GEMM)
*d. Hematopoietic stem cells (HSCs)
General Feedback:
The stem cell from which all blood cells are derived is the
HSC. The other stem cells mentioned are all committed to one or more
blood cell lineage: BFU-E to erythroid; CFU-GM to granulocytes and
monocytes; and CFU-GEMM to granulocytes, erythroid, monocytes, and
megakaryocytes (from which platelets are derived).
10. Chapter 04-10

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Which condition can nondevelopment of the thymus during gestation
cause?
*a. Failure to thrive

b. Sickle cell disease
c. Anemia
d. Renal disease
General Feedback:
Nondevelopment of the thymus during gestation can result in
failure to thrive, uncontrollable infections, and death in infancy.
11. Chapter 04-11

Having swollen lymph nodes is called:
a. niche.
b. porphyrias.
*c. adentitis.
d. hypersplenism.
General Feedback:
Adentitis is infection or inflammation of the lymph node.
12. Chapter 04-12

Blood enters the spleen through:
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a. lymph nodes.
b. vena cava.
c. right renal artery.
*d. central splenic artery.
General Feedback:
Blood enters the spleen through the central splenic artery
located at the hilum and branches outward through the trabeculae.
13. Chapter 04-13

Which function is performed by cytokines except:
a. proliferation.
*b. regeneration.
c. differentiation.
d. maturation.
General Feedback:
Cytokines are responsible for stimulation or inhibition of
production, differentiation, and trafficking of mature blood cells and
their precursors.
14. Chapter 04-14

Which is a hematopoietic growth factor?
*a. Interleukin
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b. BFU-E
c. Fibroblast
d. HSC
General Feedback:
Only interleukin, of those listed, is a hematopoietic growth
factor. The rest are cells found in the bone marrow. Actually several
interleukins exist, each of which has a number (IL-1, IL-3, IL-6), that
can affect various hematopoietic cells. In addition, other cytokines
(e.g., erythropoietin, thrombopoietin) affect blood cell production.
15. Chapter 04-15

What is the primary mechanism for the anemia associated with kidney
disease?
a. Hemolysis
b. Hemorrhage
*c. Inadequate synthesis of erythropoietin
d. Inadequate synthesis of interleukins
General Feedback:
Erythropoietin is the cytokine that has its primary effect on
red cell production. It is synthesized in the kidney; thus when the
kidney is diseased, erythropoietin synthesis is decreased. This
decreases red cell production, leading to anemia.
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16. Chapter 04-16

Which is not a function of macrophages in the bone marrow?
*a. Activating adipose cells

b. Secreting cytokines
c. Storing iron
d. Phagocytizing senescent cells
General Feedback:
Macrophages do not activate adipose cells. They perform all
the other listed functions.
17. Chapter 04-17

Kupffer cells, found in the liver, are:
a. adipose cells.
*b. macrophages.
c. immature red cells.
d. immature granulocytes (neutrophils).
General Feedback:
Kupffer cells are specialized macrophages found in the liver.
18. Chapter 04-18

Germinal centers in lymph nodes
NURScontain
INGTB.primarily:
COM
*a. B cells.
b. macrophages.
c. neutrophils.
d. T cells.
General Feedback:
Germinal centers contain primarily B cells and their progeny.
19. Chapter 04-19

The thymus is responsible for the initial development of:
a. macrophages.
*b. T cells.
c. B cells.
d. neutrophils.
General Feedback:
The thymus contains lymphoid cells that undergo conditioning
in the thymus and become T cells.
20. Chapter 04-20

Apoptosis is:
a. enhanced red cell production.
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*b. programmed cell death.

c. directed exit of cells from the bone marrow.
d. accidental cell death from trauma.
General Feedback:
Apoptosis is programmed cell death, which is a normal
physiologic process eliminating unwanted, abnormal, or harmful cells.
It is different from accidental death because of trauma—this is called
necrosis.
21. Chapter 04-21

Colony-stimulating factors:
a. have poor affinity for their target cells.

b. require high concentrations to be effective.
*c. are produced by many cells.
d. are all lineage specific.
General Feedback:
Colony-stimulating factors need only be present in a very low
concentration to be effective. They have a high affinity for their
target cells, binding to specific receptors on the cell surface. Many
different cells produce them, and many of them affect several different
cell lines.
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1. Chapter 05-01
Where is erythropoietin synthesized?
a. Bone marrow
*b. Kidney
c. Lymph nodes
d. Spleen
General Feedback:
Erythropoietin is synthesized primarily in the kidney. A very
small amount is produced in the liver.
2. Chapter 05-02
What stimulates production of erythropoietin?
a. Decreased red cell number in the bone marrow

b. Increased peripheral red cell number
c. Decreased iron stores
*d. Decreased oxygen level in tissue
General Feedback:
Peritubular cells in the kidney detect an undersupply of
oxygen in tissue (also called hypoxia). They then synthesize
erythropoietin. This increases red cell production in the bone marrow,
unless the marrow is unable to respond the erythropoietin stimulus.
3. Chapter 05-03
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Erythropoietin increases the number of red cells by all of the
following mechanisms except:
*a. prolonging cell life span.

b. shortening cell division times.
c. allowing earlier cell egress from the bone marrow.
d. increasing the rate of hemoglobin synthesis.
General Feedback:
Erythropoietin has no effect on red cell life span. It does
perform all the other functions listed.
4. Chapter 05-04
Why do men typically have higher erythrocyte counts than women?
a. They weigh more and have more blood vessels.

b. They do not lose as much blood each month.
*c. Testosterone stimulates erythropoiesis.
d. They have more oxygen in their blood.
General Feedback:
Testosterone stimulates red cell production.
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5. Chapter 05-05
Programmed cell death is called:
a. necrosis.
*b. apoptosis.
c. hemolysis.
d. phagocytosis.
General Feedback:
Apoptosis is programmed cell death, a normal physiologic
process to remove damaged, abnormal, or unneeded cells. Necrosis is
abnormal death because of trauma or damage. Hemolysis is cell death by
rupture (which is abnormal). Phagocytosis is the primary mechanism for
removal of senescent cells, but it also can remove damaged cells.
6. Chapter 05-06
What is the main site for iron storage in the bone marrow?
a. Stem cells
b. Transferrin molecules
c. Endothelial cells
*d. Macrophages
General Feedback:
Macrophages are the primary site for storage of iron in the
bone marrow. Stem cells of various kinds are precursors to blood cells.
Transferrin is the protein that binds and transports iron to either
NURScells
storage or developing red blood INGT(RBCs).
B.COM Endothelial cells are the
lining cells of the bone marrow and blood vessels.
7. Chapter 05-07
Which is true of red cell precursors as they mature?
a. The nuclear-to-cytoplasmic ratio increases.

b. The cells become larger.
*c. The cytoplasm becomes less basophilic.
d. The nucleoli become more prominent.
General Feedback:
In general, basophilia decreases as the red cell matures (one
exception to this: the basophilic normoblast is characteristically more
basophilic than its precursor, the pronormoblast). The nuclear-to-
cytoplasmic ratio actually decreases, the cells become smaller, and
nucleoli become less prominent and eventually disappear.
8. Chapter 05-08
Which has a pyknotic nucleus?
a. Pronormoblast
b. Basophilic normoblast
c. Polychromatophilic normoblast
*d. Orthochromic normoblast
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General Feedback:
The orthochromic normoblast has a pyknotic nucleus, meaning
that the chromatin is fully condensed. After this stage, the cell no
longer needs the nucleus and it is extruded or expelled. The nucleus of
the pronormoblast is diffuse (dispersed), that of the basophilic is
beginning to show some condensing, and that of the polychromatophilic
is condensing even more.
9. Chapter 05-09
When compared with mature erythrocytes, reticulocytes:
*a. are larger and bluer on Wright stain from remnant ribonucleic
acid (RNA).
b. are larger and have more vacuoles on Wright stain from remnant
deoxyribonucleic acid (DNA).
c. stain pinker with new methylene blue.
d. still have a nucleus.
General Feedback:
Reticulocytes still contain some RNA, as well as mitochondria
and other organelles; these stain with the basic component of Wright
stain and so lend some “blueness” to the cytoplasmic color. They are
also slightly larger in both diameter and volume than a mature red
cell. New methylene blue is a vital stain used to precipitate residual
RNA in these cells so that they can be enumerated. The precipitated
material, called reticulum, stains blue with new methylene blue.
Reticulocytes no longer have a nucleus; they are the first stage of
development after extrusionNof
URthe
SINnucleus.
GTB.COM
10. Chapter 05-10

Which correctly describes a normal mature erythrocyte?
*a. A 7- to 8-ìm biconcave disc that lives 120 days

b. A 7- to 8-ìm spheroid that lives 120 days
c. A 12- to 15-ìm spheroid that lives 80 days
d. A 12- to 15-ìm biconcave disc that lives 80 days
General Feedback:
A normal mature red cell has a diameter of 7 to 8 ìm, is
biconcave, and lives 120 days in circulation.
11. Chapter 05-11

Abnormal concentrations of cations inside erythrocytes cause:
*a. spherocytosis.
b. senescence.
c. prolongation of survival.
d. sickling.
General Feedback:
Red cells have a high concentration of potassium and a low
concentration of sodium when compared with the plasma environment. To
maintain this difference in gradient, adenosine triphosphate (ATP)–
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dependent enzymes are needed. When this system fails, sodium increases
and potassium falls in the red cells. This results in loss of selective
permeability of the red cell membrane, and water enters the cell
causing it to sphere. Senescence is a normal aging process that
eventually leads to red cell phagocytosis by splenic macrophages.
12. Chapter 05-12

What mechanism is responsible for the destruction of the majority of
normal senescent erythrocytes?
a. Intravascular hemolysis
b. Rupture by complement
c. Phagocytosis by peripheral neutrophils
*d. Phagocytosis by splenic macrophages
General Feedback:
As red cells become old (senescent), changes occur in the
membrane and intracellularly that lead to their phagocytosis by
macrophages in the spleen.
13. Chapter 05-13

The breakdown products of heme go through several biochemical
degradations to form:
*a. bilirubin.
b. protoporphyrin.
c. amino acids.
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d. haptoglobin.
General Feedback:
After phagocytosis by the splenic macrophages, hemoglobin is
released. It is broken down into its component parts of globin chains
and heme. Heme is further degraded in a series of steps eventually
forming bilirubin, which is taken to the liver and further processed.
Globin chain amino acids are returned to the amino acid pool for use in
protein synthesis.
14. Chapter 05-14

Haptoglobin performs which function when red blood cells are lysed in
circulation?
a. Prevent hypoxia.
b. Cease apoptosis.
*c. Salvage hemoglobin.
d. Release hematocrit.
General Feedback:
When the membrane of a red blood cell has been lysed, the cell
contents enter the surrounding blood. The body reacts by activating
haptoglobin, a plasma protein, to salvage the released hemoglobin so
that its iron is not lost in the urine.
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1. Chapter 06-01
Why is the mature erythrocyte unable to synthesize proteins or lipids?
*a. It has no nucleus.

b. It has no ribonucleic acid (RNA).
c. It cannot generate adenosine triphosphate (ATP).
d. Carrying oxygen interferes with synthesis.
General Feedback:
The mature red cell lacks a nucleus, mitochondria, and other
organelles. It is therefore unable to synthesize proteins or lipids. It
also cannot perform oxidative phosphorylation.
2. Chapter 06-02
The principle energy source for mature red blood cells (RBCs) is:
a. the Krebs cycle.

b. the hexose monophosphate pathway.
*c. ATP generated from anaerobic glycolysis.
d. adenosine diphosphate (ADP) generated from aerobic glycolysis.
General Feedback:
Anaerobic glycolysis is the pathway by which glucose is
metabolized in the red cell, and ATP is generated through this pathway.
The hexose monophosphate pathway, through which aerobic glycolysis
occurs, is the pathway that generates reduced glutathione. Reduced
glutathione is essential to prevent oxidant injury to the red cell. The
NURSINGTinB.the
Krebs cycle is no longer operational COMmature RBC.
3. Chapter 06-03
Which erythrocyte activity requires energy?
a. Oxygen delivery
b. Carbon dioxide exchange
c. Glucose transport into the RBC
*d. Protecting proteins from oxidative damage
General Feedback:
Energy is required to protect proteins in the red cell from
oxidative damage. This includes hemoglobin and membrane proteins. It is
not required for oxygen transport, carbon dioxide exchange, or glucose
transport into the cell.
4. Chapter 06-04
What is the fate of erythrocytes when anaerobic metabolic enzymes are
reduced in concentration or are absent?
a. Destruction by the liver

b. Destruction by monocytes in the blood
*c. Hemolysis
d. Destruction by complement
General Feedback:
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When metabolic enzymes in the anaerobic pathway of glycolysis

are reduced or absent, energy production in the form ATP is diminished.
This ultimately results in hemolysis of the RBC because the functions
requiring energy in the form of ATP are not fully operational. This
hemolysis occurs primarily in the spleen and so is called extravascular
hemolysis (as opposed to occurring in the blood vessels, where it would
be considered intravascular hemolysis).
5. Chapter 06-05
What is the normal life span of a red cell in circulation?
a. 2 weeks
b. 90 days
*c. 120 days
d. 6 months
General Feedback:
The normal red cell survives 120 days in circulation after its
release from the bone marrow. By that time, changes that have occurred
both internally and on the RBC membrane result in its phagocytosis and
thus removal by splenic macrophages.
6. Chapter 06-06
Select the metabolic pathway that converts toxic hydrogen peroxide
produced by oxidant drugs to water:
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a. Embden-Meyerhof pathway (EMP).
b. 2,3-biphosphoglycerate (2,3-BPG).
c. methemoglobin reductase reaction.
*d. hexose monophosphate pathway.
General Feedback:
Hydrogen peroxide is an oxidant and is detoxified via the
hexose monophosphate pathway using reduced glutathione. The EMP
generates energy in the form of ATP; the 2,3-BPG pathway is a shunt off
of the EMP that is important for the reversible binding of oxygen.
Methemoglobin reductase is an enzyme that reduces the oxidized form of
hemoglobin, called methemoglobin, to its reduced functional form.
7. Chapter 06-07
What important function does 2,3-BPG perform?
a. Maintains iron in the hemoglobin molecule in the ferrous

state.
b. Prevents oxidative injury to the red cell.
*c. Facilitates the delivery of oxygen to tissue.
d. Aids in the exchange of membrane lipids with lipids in plasma.
General Feedback:
2,3-BPG plays a critical role in the effective transport of
oxygen to tissue. It is produced via a shunt off the EMP. Elevations in
2,3-BPG are seen in a number of situations such as anemia; they result
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in more effective delivery of oxygen to tissue. It has no role in the

other functions listed.
8. Chapter 06-08
Which is the metabolic pathway that generates a net gain of two
molecules of ATP for erythrocyte energy needs?
*a. EMP
b. 2,3-BPG
c. Methemoglobin reductase reaction
d. Hexose monophosphate pathway
General Feedback:
A net gain of two molecules of ATP occurs for every molecule
of glucose metabolized via the EMP. When the 2,3-BPG shunt off of the
EMP pathway is taken, no net gain of ATP occurs. No energy is generated
via the hexose monophosphate pathway. The methemoglobin reductase
reaction reduces methemoglobin, the oxidized form of hemoglobin, to its
reduced functional form and does not generate energy.
9. Chapter 06-09
Which is the metabolic pathway that regulates oxygen delivery to
tissues?
a. EMP
*b. 2,3-BPG
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c. Methemoglobin reductase reaction
d. Hexose monophosphate pathway
General Feedback:
2,3-BPG plays a critical role in the effective transport of
oxygen to tissue. It is produced via a shunt off of the EMP; elevations
in 2,3-BPG are seen in a number of situations such as anemia. Elevated
levels result in more effective delivery of oxygen to tissue. None of
the other pathways or systems listed play a role in the way oxygen is
delivered to tissue.
10. Chapter 06-10

What is responsible for erythrocyte deformability and maintaining cell
shape?
*a. Membrane proteins

b. Na+ and K+ pump
c. Membrane lipids
d. Ca2+ pump
General Feedback:
Proteins in the membrane are responsible for maintaining the
shape and deformability of
the red cell. Cation pumps maintain the Na+ and K+ gradient within the
red cell. Membrane lipids form the fluid foundation into which the
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membrane proteins are inserted. The Ca2+ pump maintains intracellular

levels of Ca2+.
11. Chapter 06-11

What components of the erythrocyte membrane are responsible for its
negative charge and are also blood group antigens?
a. Peripheral proteins
b. Cholesterol
c. Cation pumps
*d. Transmembrane proteins
General Feedback:
Transmembrane proteins include the glycophorins, which give
the red cell its overall negative charge and are also responsible for
the blood group antigens including those of the ABO and Rh systems. The
peripheral proteins form the skeletal network of the red cell membrane.
12. Chapter 06-12

Which is most responsible for the strength and pliancy of the red cell
membrane?
a. Glycophorin A
*b. Spectrin
c. Cholesterol
d. Ankyrin NURSINGTB.COM
General Feedback:
Spectrin composes the majority of the membrane’s skeletal mass
and is the primary peripheral protein involved in maintaining the
skeletal structure of the red cell. By the way it lines up with other
spectrin molecules, it also plays an important role in making the red
cell membrane deformable (pliant). This flexibility is important for
permitting the red cell to “squeeze” through pores that have a diameter
smaller than that of the red cell.
13. Chapter 06-13

Glucose-6-phosphate dehydrogenase (G6PD) is:
a. an extremely rare enzyme deficiency.

*b. necessary to maintain reduced glutathione in the mature red
cell.
c. important for the production of ATP in the mature red cell.
d. important for the transport of carbon dioxide by the mature
red cell.
General Feedback:
G6PD is an enzyme in the hexose monophosphate pathway and is
important for maintaining reduced glutathione in the red cell. This
substance (reduced glutathione) is critical for preventing oxidative
damage to red cell proteins. This pathway does not produce any energy
and has no function in carbon dioxide transport. Its deficiency is very
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common worldwide, affecting millions of people; in fact, it is the most

common human enzyme deficiency in the world.
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2. Chapter 07-02
How many molecules of oxygen can one molecule of hemoglobin carry?
a. One
b. Two
c. Three
*d. Four
General Feedback:
Each heme group is capable of carrying one molecule of oxygen.
Because four heme groups exist in one molecule of hemoglobin, each
hemoglobin molecule can carry four molecules of oxygen.
3. Chapter 07-03
Why is heme located inside a globin chain pocket surrounded by
hydrophobic amino acids?
*a. Protects iron from being oxidized to its ferric form.

b. Necessary for oxygen release to tissues.
c. Makes hemoglobin insoluble.
d. Keeps heme from being dissolved.
General Feedback:
This arrangement helps keep iron in the divalent (ferrous)
form regardless of whether or not it is carrying oxygen. This is
critical for hemoglobin’s ability to reversibly bind oxygen.
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4. Chapter 07-04
Where is heme produced?
a. Liver
b. Macrophages in the bone marrow
*c. Red blood cell (RBC) precursors in the bone marrow
d. Mature RBCs in peripheral circulation
General Feedback:
Heme is produced in RBC precursors in the bone marrow.
6. Chapter 07-06
The A1c-modified component of Hb A is increased in what condition?
a. Sickle cell anemia

b. Thalassemia
c. Disorders of heme
*d. Uncontrolled diabetes mellitus
General Feedback:
Hb A1c is a posttranslational modification of hemoglobin in
which the hemoglobin molecule is glycated. Its concentration is
increased when diabetes is uncontrolled.
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7. Chapter 07-07
Which is true of hemoglobin if the oxygen dissociation curve shifts to
the left?
a. Has a lower affinity for oxygen.

b. Picks up less oxygen in the lungs but delivers more to
tissues.
*c. Picks up more oxygen in the lungs but delivers less to
tissues.
d. Picks up and delivers more oxygen.
General Feedback:
When the oxygen dissociation curve shifts to the left, it will
load oxygen more easily in the lungs but also will hold onto it more
tightly in tissue, thus delivering less oxygen to tissue. This is an
example of high oxygen affinity.
8. Chapter 07-08
Which causes a shift to the right on the oxygen dissociation curve?
*a. Severe anemia

b. Alkalosis
c. High levels of Hb F
d. Decreased levels of 2,3-biphosphoglycerate (2,3-BPG)
General Feedback:
Severe anemia causes a right shift of the oxygen dissociation
curve. This means that the N URSINGof
affinity TBhemoglobin
.COM for oxygen is less,
so more oxygen will be released to tissue (more effective delivery of
oxygen). Alkalosis (increased pH), Hb F, and decreased levels of 2,3-
BPG all shift the curve to the left.
9. Chapter 07-09
Why does Hb F have a higher oxygen affinity than adult hemoglobin?
a. Fetal blood has a higher pH than adult blood.

b. Fetal blood has a higher hematocrit than adult blood.
c. Body temperature is lower in fetus.
*d. It is necessary to extract oxygen from the maternal blood
supply.
General Feedback:
The fetus has a need for oxygen. In order for the fetus to
extract oxygen from the mother’s blood (cord blood), its affinity for
hemoglobin must be higher than that of the mother.
10. Chapter 07-10

Select the form of hemoglobin that contains iron in the ferric rather
than the ferrous state.
a. Myoglobin
*b. Methemoglobin
c. Deoxyhemoglobin
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d. Carboxyhemoglobin
General Feedback:
Methemoglobin contains iron in the ferric form. This is
nonfunctional hemoglobin (i.e., it cannot bind and carry oxygen).
11. Chapter 07-11

In which condition would patients have an increased concentration of
methemoglobin?
a. Patient receiving drug containing sulfonamide

b. Patient exposed to reducing agents
c. Patient with hemoglobin S (Hb S)
*d. Patient with methemoglobin reductase deficiency
General Feedback:
A patient with methemoglobin reductase deficiency will have an
elevated concentration of methemoglobin. It is normal for some small
amount of hemoglobin to be oxidized on a daily basis. However, this
does not build up in the RBCs because the iron is constantly being
reduced to its functional ferrous state. When this enzyme is deficient,
methemoglobin increases in the RBCs. Rare patients taking sulfonamide-
containing drugs may develop sulfhemoglobin. Oxidizing agents can
increase hemoglobin M (Hb M), but not reducing agents. Patients with Hb
S have normal levels of methemoglobin.
12. Chapter 07-12

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Which is true regarding carboxyhemoglobin?
*a. Smokers have increased levels.

b. It has hydrogen sulfide added to hemoglobin.
c. Normal people have none.
d. Levels of 15% to 20% cause coma and death.
General Feedback:
Smokers, depending on how much and what they smoke (e.g.,
cigarettes, cigars), may have as much as 15% carboxyhemoglobin in their
blood. The concentration of carboxyhemoglobin in normal blood varies
depending on the environment in which a person lives (more in an urban
environment, for example, than in a rural location), but it is
generally less than 1%. Levels greater than 40% cause coma and death.
The addition of hydrogen sulfide to hemoglobin forms sulfhemoglobin.
13. Chapter 07-13

Identify the primary organelle of synthesis site for globin chain and
heme in developing RBCs.
Globin chains Heme
a. Ribosomes ribosomes
b. Golgi complex mitochondria
*c. Ribosomes mitochondria
d. Mitochondria Golgi complex
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General Feedback:
Globin chains are synthesized on the ribosomes in the
cytoplasm of a developing RBC; heme synthesis takes place primarily in
the mitochondria.
14. Chapter 07-14

Which statement is true about Hb F?
*a. It is the major hemoglobin during fetal life.

b. It is increased in concentration in children up to 2 years
old.
c. It is evenly distributed at low concentration in all RBCs of
an adult.
d. It has a low oxygen affinity.
General Feedback:
Hb F is the major hemoglobin during fetal life and at birth,
but its concentration decreases after birth so that by age 6 months it
should be less than 1% of the total hemoglobin. It is distributed
unevenly in the RBCs of an adult (“F cells”), meaning that it is only
found in some RBCs (not in all of them). It has a high oxygen affinity
to enable it to extract oxygen from the maternal circulation.
15. Chapter 07-15

The reference range for hemoglobin concentration:
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a. is lower in a newborn than in a male adult.
b. is lower in a newborn than in a female adult.
*c. is higher in a newborn than in a male adult.
d. is higher in a woman than in a man.
General Feedback:
The reference range for hemoglobin concentration is higher in
a newborn than in either an adult man or woman. In adults, it is higher
in men than in women.
16. Chapter 07-16

Which is true for the relative affinity of hemoglobin for oxygen in the
lungs and tissue with the oxygen dissociation curve in its normal
position?
Lungs Tissue
*a. High low

b. Low low
c. High high
d. Low low
General Feedback:
The affinity of hemoglobin for oxygen is high in the lungs, so
that loading of hemoglobin with oxygen is facilitated. It is lower in
tissue to facilitate the delivery of oxygen to tissue.
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17. Chapter 07-17

An increase in the concentration of 2,3-BPG:
a. puts hemoglobin the relaxed conformation form.

b. shifts the oxygen dissociation curve to the left.
c. increases the affinity of hemoglobin for oxygen.
*d. is present in patients with severe anemia and decreased blood
pH (acidosis).
General Feedback:
Patients who are severely anemic and those with a decreased
blood pH, among others, have increased levels of 2,3-BPG. This shifts
the oxygen dissociation curve to the right, thus decreasing the
affinity of hemoglobin for oxygen. The result is more effective
delivery of oxygen to tissue. An elevated concentration places the
hemoglobin molecule in the tense conformational form.
18. Chapter 07-18

Why is it important that synthesis of globin chains and heme be
balanced in the RBCs?
a. Excess concentration of protoporphyrin increases bilirubin in

plasma.
*b. An excess of one of the components of hemoglobin decreases
RBC survival.
c. An excess of one of the components of hemoglobin increases RBC
NUeventual
survival leading to an RSINGTelevated
B.COM RBC count.
d. An excess of globin chains significantly decreases the
concentration of globin chain messenger ribonucleic acid (mRNA)
in the developing RBCs.
General Feedback:
An excess of one of the components of hemoglobin can decrease
RBC survival in circulation. None of the other listed items are true in
the presence of an excess.
19. Chapter 07-19

Which is true of the oxygen dissociation curve?
a. The normal partial pressure of oxygen (PO2) at which

hemoglobin is 50% saturated is 20 mm Hg.
*b. A shift to the right or left in response to blood pH is
called the Bohr effect.
c. A shift to the left results in lower oxygen affinity.
d. A shift to the right results in less effective delivery of
oxygen to tissue.
General Feedback:
The Bohr effect describes the shift in position of the oxygen
dissociation curve in response to blood pH; a decrease in pH (acidosis)
shifts the curve to the right and results in a decreased oxygen
affinity and more effective oxygen delivery. A decrease in pH
(alkalosis) is the reverse—the curve shifts to the left resulting in
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increased oxygen affinity and less effective delivery of oxygen to

tissue.
20. Chapter 07-20

Which provides a negative feedback for heme synthesis, thus helping to
control, by decreasing, its synthesis?
*a. Concentration of heme in the developing RBC

b. Concentration of hemoglobin in blood
c. Concentration of globin chain in the developing RBC
d. Number of RBCs in circulation
General Feedback:
As the concentration of heme increases in the developing RBC;
it acts as a negative feedback to decrease further synthesis of heme.
This helps control its rate of production.
21. Chapter 07-21

The globin chains making up Hb A are:
a. two epsilon and two gamma chains.

b. two sigma and two epsilon chains.
c. two alpha and two gamma chains.
*d. two alpha and two beta chains.
General Feedback:
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Hb A is composed of two alpha and two beta chains; sigma and
epsilon chains are embryonic chains and are seen only in fetal life. Hb
F is composed of two alpha and two gamma chains.
22. Chapter 07-22

What is the effect of an increased concentration of 2,3-BPG in the RBC?
a. Puts hemoglobin in the relaxed conformation.

*b. Shifts the oxygen dissociation curve to the right.
c. Increases the affinity of hemoglobin for oxygen.
d. Decreases the synthesis of globin chains.
General Feedback:
An increased concentration of 2,3-BPG shifts the oxygen
dissociation curve to the right and decreases the affinity of
hemoglobin for oxygen. It has no effect on the synthesis of globin
chains.
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1. Chapter 08-01
Where is the largest percentage of iron in the body located?
a. Stored in the bone marrow

b. Stored in the liver
*c. Attached to hemoglobin in erythrocytes
d. In the cytoplasm of macrophages
General Feedback:
Approximately 70% of total body iron is found in hemoglobin.
Almost 20% of body iron is in storage, mostly within hepatocytes and
macrophages in the spleen and bone marrow. The remaining
approximately10% is divided among the muscles, the cytochromes, various
iron-containing enzymes, and the plasma.
2. Chapter 08-02
What is the mechanism for iron toxicity if iron is present in excess
amounts?
*a. Acts as a catalyst in forming hydroxyl (free) radicals.

b. Impedes hematopoiesis.
c. Reduces hemoglobin to methemoglobin.
d. Interferes with globin synthesis.
General Feedback:
Iron has reduction (redox) potential, and easily cycles
between ferrous (reduced) and ferric (oxidized) forms. If it is found
NURin
in excess, it plays a key role SIN GTB.Charmful
forming OM oxygen radicals that
can damage cellular structures and harm cells in the process.
3. Chapter 08-03
What is the plasma carrier protein for iron?
a. Apoferritin
*b. Apotransferrin
c. Albumin
d. Hemosiderin
General Feedback:
Apotransferrin is the carrier protein for iron. Apoferritin
and hemosiderin are storage forms of iron. Albumin is a carrier protein
for many substances but not for iron.
4. Chapter 08-04
Heme is composed of iron and:
a. globin chains.
b. oxygen.
c. methemoglobin.
*d. protoporphyrin IX.
General Feedback:
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Zinc protoporphyrin (ZPP) accumulates in red blood cells when

iron is not incorporated into heme and zinc binds instead to
protoporphyrin IX.
5. Chapter 08-05
Good dietary sources of iron include all except:
a. meat.
*b. fruit.
c. fortified flour.
d. legumes.
General Feedback:
Fruit does not contain iron. Meat is a source of heme iron,
and legumes and fortified flour are sources of nonheme iron.
6. Chapter 08-06
Which two organs are the major storage sites for iron in a normal
individual?
a. Lymph nodes and muscle

b. Bone marrow and pancreas
c. Spleen and heart
*d. Liver and spleen
General Feedback:
NURSINGTB.COM
The liver and spleen have a large amount of apoferritin, the
protein that stores iron; they thus are major storage sites for iron.
7. Chapter 08-07
A patient has a serum iron of 10 g/dL and a total iron-binding capacity
(TIBC) of 490 g/dL. What is the percent saturation of transferrin?
*a. 2%
b. 25%
c. 40%
d. 60%
General Feedback:
Percent transferrin saturation is calculated by dividing the
serum iron by TIBC and multiplying by 100. Thus in the example here, %
saturation = (10/490) × 100 = 2%.
8. Chapter 08-08
The serum iron and TIBC results given in Question 7 are consistent
with:
a. iron overload.
b. iron toxicity.
*c. iron deficiency.
d. acute infection.
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General Feedback:
Under normal circumstances, approximately one-third of
transferrin is saturated with iron. Iron overload and iron toxicity are
situations in which the percent saturation would be high. In an acute
infection, the anemia of chronic inflammation (also called anemia of
chronic disease) might develop if the infection becomes chronic.
Percent saturation would be decreased below normal, but it would not
become this low (and the infection would have to be fairly long-
standing and chronic).
9. Chapter 08-09
The serum ferritin is used more often than bone marrow or liver
biopsies to assess iron stores because it is:
a. a more direct measurement.

b. more accurate.
c. more precise.
*d. less invasive.
General Feedback:
The measurement of ferritin is performed on a serum sample;
therefore, it requires nothing more than a venipuncture to obtain a
blood specimen. It is proportional to the iron in stores, but it is not
a more direct measurement. In fact, a bone marrow biopsy followed by
staining with Prussian blue to assess iron stores (in the form of
hemosiderin) is perhaps the best measurement of iron stores that are
NUhemoglobin
readily available for use in RSINGTB.synthesis.
COM This is much more
invasive.
10. Chapter 08-10

Which is true of apotransferrin?
*a. It can bind two molecules of ferric iron.

b. It binds to a ferritin receptor found on the cell membrane.
c. It is synthesized in the kidney.
d. It is normally about 50% saturated with iron.
General Feedback:
Transferrin binds two molecules of ferric iron. It binds to
receptors on the cell membrane, which are called transferrin receptors.
It is synthesized in the liver and is normally about one-third
saturated.
11. Chapter 08-11

Which stains blue with the Prussian blue stain?
a. Ferritin
*b. Hemosiderin
c. Transferrin
d. Both Ferritin and Hemosiderin
General Feedback:
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Only the insoluble form of storage iron, which is hemosiderin,

stains with the Prussian blue stain. Ferritin is soluble and is not
stained.
12. Chapter 08-12

Soluble transferrin receptor (sTfR) levels increase when intracellular
iron levels are:
*a. decreased.
b. elevated.
c. constant.
d. both decreased and elevated.
General Feedback:
When iron is deficient, the concentration of transferrin
receptors (sTfR) increases. sTfR levels are decreased when iron levels
are elevated, such as in chronic disease.
13. Chapter 08-13

Select the condition where an acute increase in ferritin levels can be
detected without a specific increase in the amount of systemic body
iron?
a. Myocardial infarction
*b. Infection
c. Malignancy
d. Liver disease
NURSINGTB.COM
General Feedback:
Ferritin levels are acutely increased when a patient has an
infection. This is a response of the body to sequester the iron away
from the bacteria. These increases can be subtle and may or may not be
outside the reference interval.
14. Chapter 08-14

Acute (24-hour) assessment of the amount of iron that is available for
hemoglobin production is best identified by measuring the:
a. sTfR levels on the cell membrane.

*b. amount of hemoglobin in reticulocytes.
c. amount of hemosiderin with Prussian blue stain.
d. zinc protoporphyrin levels in red blood cells.
General Feedback:
The amount of hemoglobin in reticulocytes is a real-time
assessment of iron available for hemoglobin production. The number of
circulating reticulocytes represents the status of erythropoiesis in
the prior 24-hour period. The hemoglobin content of reticulocytes will
acutely decrease when iron for erythropoiesis is restricted.
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2. Chapter 09-02
What pools of neutrophils are included in the marginal neutrophil pool
(MNP)?
a. All neutrophils inside the blood vessels

b. Only freely circulating neutrophils
*c. Only cells loosely localized to the vessel walls
d. All leukocytes in the body
General Feedback:
A pool of neutrophils exists that is marginated (clinging to
the sides of capillaries). The circulating neutrophils are included in
the circulating neutrophil pool (CNP). Cells can move freely between
the two pools.
3. Chapter 09-03
What is the last granulocyte in the maturation sequence able to undergo
mitosis?
a. Myeloblast
b. Promyelocyte
*c. Myelocyte
d. Band
General Feedback:
The myelocyte is the last granulocyte in the normal maturation
sequence that can undergo mitosis. The myeloblast and promyelocyte
precede the myelocyte; bothNcan
URSand
INGdoTBundergo
.COM mitosis. The band cell
is no longer able to replicate its deoxyribonucleic acid (DNA) and so
does not undergo mitosis.
4. Chapter 09-04
Mature mast cells are:
a. leukocytes.
*b. tissue effector cells.
c. progenitor cells.
d. cytokines.
General Feedback:
Mast cells are not considered to be leukocytes. They are
tissue effector cells of allergic responses and inflammatory reactions.
They originate from the bone marrow and spleen.
5. Chapter 09-05
What directs the mitosis and maturation action of progenitor neutrophil
cells in the bone marrow?
a. Erythropoietin
b. The number of stem cells
c. The number of mature cells in the peripheral circulation
*d. Colony-stimulating factor cytokines
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General Feedback:
Colony-stimulating factor cytokines (G-CSF) bind to receptors
on progenitor cells to direct them to undergo mitosis and to mature to
identifiable neutrophil precursor cells. Erythropoietin is the primary
cytokine for red cell development. Neither the number of stem cells nor
the number of mature cells in circulation function in this role.
6. Chapter 09-06
What is the earliest morphologically identifiable cell in the
granulocyte maturation sequence?
a. Hematopoietic stem cell

b. Colony-forming unit–granulocyte, erythrocyte, monocyte, and
megakaryocyte (CFU-GEMM)
*c. Myeloblast
d. Myelocyte
General Feedback:
The earliest cell that can be identified by morphology, using
Wright stain, as belonging to the granulocyte maturation sequence is
the myeloblast. The stem cell pool that includes the hematopoietic stem
cells (HSC) and the common myeloid progenitor cells (CMPs) is not
distinguishable with the light microscope. The myelocyte is a later
stage of development than the myeloblast.
7. Chapter 09-07
NURSINGTB.COM
A cell having a round nucleus with delicate chromatin, two to four
prominent nucleoli, and a high N:C ratio of 8:1 with scant basophilic
cytoplasm is an accurate description of a:
*a. myeloblast.
b. myelocyte.
c. metamyelocyte.
d. band.
General Feedback:
The description fits a myeloblast. Often the myeloblast is
agranular (without any visible granules). The presence of multiple
nucleoli is often noted. A high N:C ratio is observed where the nucleus
occupies most of the cell.
8. Chapter 09-08
What is the earliest stage of maturation where a neutrophil can be
distinguished from an eosinophil?
a. Myeloblast
b. CFU-GEMM
c. Metamyelocyte
*d. Myelocyte
General Feedback:
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Eosinophil granules differentiate the eosinophils from the

neutrophil at the early myelocyte stage. Before this, the myeloblast
and promyelocyte stages are indistinguishable by morphology.
9. Chapter 09-09
Select the correct maturation sequence for granulocytes starting with
youngest.
a. Promyelocyte, myeloblast, metamyelocyte, myelocyte, segmented

*b. Myeloblast, promyelocyte, myelocyte, metamyelocyte, band,
segmented
c. Segmented, band, metamyelocyte, myelocyte, promyelocyte,
myeloblast
d. CFU-GEMM, promyelocyte, metamyelocyte, myelocyte, segmented
General Feedback:
The correct maturation sequence is myeloblast, promyelocyte,
myelocyte, metamyelocyte, band, segmented.
10. Chapter 09-10

Which neutrophil is capable of chemotaxis?
a. Stem cell
b. Progenitor cell
c. Myelocyte
*d. Segmented neutrophil
NURSINGTB.COM
General Feedback:
The segmented neutrophil is capable of chemotaxis (i.e., it
can move along a chemical gradient). It is a mature polymorphonuclear
neutrophil and has full motility, active adhesion properties, and
phagocytic ability.
11. Chapter 09-11

Which has the most controversial morphologic identification system?
a. Progenitor cells
b. Stem cells
c. Promyelocytes
*d. Bands
General Feedback:
At least three systems exist for morphologic identification of
band neutrophils. They vary with the shape of the nucleus. Hematology
analyzers that perform automated differentials classify them (bands)
with polymorphonuclear (segmented) neutrophils; therefore, many
laboratories now use the same criteria when identifying cells using the
microscope.
12. Chapter 09-12

Which is a feature of a normal segmented neutrophil?
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a. Basophilic cytoplasm
b. Round nucleus with fine chromatin
*c. Small lavender-pink granules
d. Prominent primary granules
General Feedback:
Segmented neutrophils contain many lavender-pink granules in
their cytoplasm. Secondary neutrophilic granules slowly spread through
the cell until its cytoplasm is more lavender-pink than blue. As the
cell divides, the number of primary granules per cell is decreased, and
their membrane chemistry changes so that they are much less visible.
13. Chapter 09-13

Segmented neutrophils are present in the highest number in:
a. central blood of adults.

b. central blood of children.
*c. peripheral blood of adults.
d. peripheral blood of neonates.
General Feedback:
Segmented neutrophils are present in the highest numbers in
the peripheral blood of adults (50% to 70% of leukocytes in relative
numbers and 2.3 to 8.1 × 109/L in absolute terms).
NURSINGTB.COM
14. Chapter 09-14
Response to parasitic infections is associated with an increase of
which type of granulocyte?
a. Promyelocytes
b. Band neutrophils
c. Segmented neutrophils
*d. Eosinophils
General Feedback:
Eosinophil production is increased in infection by parasitic
helminthes.
15. Chapter 09-15

Which cell is described as a large cell with abundant blue-grey
cytoplasm containing minute granules, lacy or stringy chromatin, and an
indented or folded nucleus?
*a. Monocyte
b. Macrophage
c. Lymphocyte
d. Basophil
General Feedback:
The description fits that of a monocyte. This is a transition
cell found in blood; it becomes a macrophage once it enters tissue.
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16. Chapter 09-16

When monocytes reside in the tissues, they are referred to as:
a. mast cells.
b. T cells.
c. plasma cells.
*d. macrophages.
General Feedback:
Monocytes migrate to the tissues and differentiate into
macrophages. Macrophages reside in the tissues and have a longer life
span than tissue neutrophils.
17. Chapter 09-17

Which cells are normally produced in multiple sites including the bone
marrow and thymus?
a. Monocytes
*b. Lymphocytes
c. Eosinophils
d. Basophils
General Feedback:
Lymphocytes are produced in the sites mentioned. All the
others are produced only in the bone marrow.
NURSINGTB.COM
18. Chapter 09-18

Which cells are responsible for antibody production?
a. Macrophages
b. Monocytes
c. Neutrophils
*d. Plasma cells
General Feedback:
The terminally differentiated B cell is the plasma cell; its
function is to make and secrete specific antibody.
19. Chapter 09-19

B cells and T cells are subgroups of what cell type?
a. Monocytes
*b. Lymphocytes
c. Macrophages
d. Plasma cells
General Feedback:
These are both subgroups of lymphocytes.
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20. Chapter 09-20

Why is the bone marrow (storage) pool of granulocytes so large compared
with the total number found in peripheral blood?
a. They prefer bone marrow to peripheral blood.

*b. They can be quickly released when needed to fight bacterial
infection.
c. It enhances their ability to function.
d. It prolongs their life span in circulation.
General Feedback:
The storage pool of granulocytes in the bone marrow is
composed primarily of mature segmented neutrophils, a smaller number of
bands, and metamyelocytes. These cells are fully functional and can be
readily released to peripheral blood when needed in response to
infection.
NURSINGTB.COM
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1. Chapter 10-01
How many circulating platelets are produced from a single
megakaryocyte?
a. 200 to 400
*b. 2000 to 4000
c. 6000 to 8000
d. 10,000 to 12,000
General Feedback:
A single megakaryocyte sheds approximately 2000 to 4000
platelets with a total turnover in 8 to 9 days.
2. Chapter 10-02
From where are additional platelets first derived when the circulating
count decreases?
a. Bone marrow
b. Stem cells
c. Cells marginated on vessel endothelial cells
*d. Spleen
General Feedback:
When the circulating platelet count decreases, platelets are
first derived from those sequestered or stored in the spleen (normally
one-third of those available).
NURSINGTB.COM
3. Chapter 10-03
Which is true of megakaryocytes as they mature?
*a. Nucleus becomes polyploid.

b. Cytoplasmic basophilia becomes more pronounced.
c. Size decreases.
d. Nucleoli become more prominent.
General Feedback:
Platelets arise from unique bone marrow cells called
megakaryocytes. Megakaryocytes are the largest cells in the bone marrow
and possess multiple chromosome copies (polyploid). On a Wright-stained
bone marrow aspirate smear, each megakaryocyte is 30 to 50 ìm in
diameter with a multilobulated nucleus and abundant granular cytoplasm.
Megakaryocytes account for less than 0.5% of all bone marrow cells, and
on a normal Wright-stained bone marrow aspirate smear two to four
megakaryocytes per 10× low-power field may be identified.
4. Chapter 10-04
How are platelets released into peripheral circulation from the bone
marrow?
a. Mature platelets squeeze between sinusoid endothelial cells.

*b. Megakaryocyte cytoplasmic fragments extend through the
endothelial cells, lining the sinusoids, into blood and then shed
platelets.
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c. Platelets adhere to white cells and exit with them.

d. Megakaryocytes exit the marrow with white cells, and then
platelets fragment off once they reach the blood.
General Feedback:
Cytoplasmic extensions elongate and pierce between the
endothelial cells that line the marrow sinuses; then they extend into
venous blood. These extensions release platelets once they enter blood.
The cytoplasmic extensions are called proplatelet processes.
5. Chapter 10-05
Which accurately describes reticulated (stress) platelets?
a. They appear in compensation for thrombocytopenia.

b. They are smaller than mature circulating platelets.
c. Their diameter exceeds 6 µm.
*d. Both a and c are true.
General Feedback:
Reticulated platelets, or stress platelets, are released in
compensation for a decrease in platelet count. They are larger than
normal platelets and appear round in EDTA whole blood.
6. Chapter 10-06
Which is not a function of the platelet surface-connected canalicular
system (SCCS)?
NURSINGTB.COM
*a. Produces energy for the cell.
b. Delivers granule contents to the surface.
c. Connects the internal contents to the surface.
d. Stores hemostatic proteins.
General Feedback:
Granule contents are delivered to the surface of the platelet
and released through the SCCS. It twists throughout the platelet,
providing a large system in which additional plasma coagulation
proteins are found in the glycocalyx. Because this is part of the
platelet membrane, it connects the internal contents to the surface. It
does not produce energy.
7. Chapter 10-07
Identify the platelet receptor and plasma protein required for normal
platelet adhesion.
Platelet receptor Plasma protein
a. Glycoprotein (GP) IV factor VIII

b. Platelet factor 4 (PF4) factor V
c. Gp IIb/IIIa fibrinogen
*d. Gp Ib/IX/V von Willebrand factor (VWF)
General Feedback:
VWF must bind to its receptor GP Ib/IX/V on the platelet
membrane for normal platelet adhesion.
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8. Chapter 10-08
Identify the platelet receptor and plasma protein required for normal
platelet aggregation.
Platelet receptor Plasma protein
*a. GP IIb/IIIa fibrinogen

b. GP IV factor VIII
c. GP Ib/IX/V VWF
d. PF4 factor V
General Feedback:
Fibrinogen must bind to its receptor GP IIb/IIIa assembled on
the platelet membrane after activation for normal platelet aggregation.
9. Chapter 10-09
Which is the liver-secreted plasma enzyme that digests “unused VWF”?
a. ADP
b. TXA2
*c. ADAMTS-13
d. GPIb
General Feedback:
ADAMTS-13 is a VWF-cleaving protease. ADP and TXA2 are
NUaRreceptor
platelet activators. GPIb is SINGTB.for
COMadhesion.
10. Chapter 10-10

Which megakaryocyte membrane marker disappears as differentiation
proceeds?
*a. CD34
b. CD41
c. CD42
d. CD61
General Feedback:
CD34 is a stem cell and common myeloid progenitor membrane
marker that is not present in mature cells. CD41 and immunologic
markers CD42 and CD61 are all present throughout the maturation
process.
11. Chapter 10-11

Which glycoprotein platelet membrane receptor increases the avidity of
integrins á2â1and áIIbâ3?
a. GP Ia/IIa
b. GP Ib/IX/V
*c. GP VI
d. GP IIb/IIIa
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General Feedback:
GP VI is a key collagen receptor that triggers activation and
releases agonists that increase the avidity of integrins á2â1and
áIIbâ3.
12. Chapter 10-12

Phospholipids in the platelet membrane are important for all of the
following functions except:
a. supply of arachidonic acid.

*b. receptor for plasma fibrinogen.
c. receptor for plasma coagulation enzymes.
d. forms part of the platelet glycocalyx.
General Feedback:
Fibrinogen binds to the receptor GP IIb/IIIa. Membrane
phospholipids supply arachidonic acid, which becomes converted to
thromboxane during platelet activation. They form part of the platelet
glycocalyx, which is the platelet surface. Many of the coagulation
enzymes bind to platelet phospholipids, including factors V, VIII, IX,
and X.
13. Chapter 10-13

What system is the “control center” for platelet activation?
NURSINGpathway
a. Eicosanoid (prostaglandin) TB.COM
b. Surface connect canalicular system
c. Membrane glycoproteins
*d. Dense tubular system
General Feedback:
The dense tubular system is a condensed remnant of the rough
endoplasmic reticulum. It sequesters Ca++ and bears a series of enzymes
that support platelet activation. It is the control center for platelet
activation.
14. Chapter 10-14

Platelet agonists are substances that:
a. bind to phospholipid in the platelet membrane.

b. promote apoptosis.
*c. activate platelets.
d. enhance megakaryocyte proliferation.
General Feedback:
Platelet agonists include thromboxane A2 (TXA2), ADP, and
thrombin. Each of them binds to its transmembrane receptor, and
platelet activation is the result.
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15. Chapter 10-15

Which substance is stored in dense granules?
*a. Serotonin
b. Platelet factor 4
c. Fibronectin
d. Protein C inhibitor
General Feedback:
Serotonin is a vasoconstrictor that binds endothelial cells
and platelet membranes. It is stored in the dense granules. Platelet
factor 4, fibronectin, and protein C inhibitor are not stored in the
dense granules.
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1. Chapter 11-01
Manual cell counting methods in automated hematology laboratories are
used for all of the following except:
*a. routine testing.

b. very low counts.
c. malfunctioning automated instruments.
d. field testing in a disaster.
General Feedback:
A hematology analyzer does routine testing in an automated
hematology laboratory. However, when counts are very low, if the
instrument is malfunctioning, or if a disaster occurs that mandates
field testing, manual cell counting is usually performed.
2. Chapter 11-02
What is the total volume of one side of a hemocytometer if the ruled
area is 3 × 3 mm and the depth is 0.1 mm?
a. 0.3 mm3
*b. 0.9 mm3
c. 1.0 mm3
d. 9 mm3
General Feedback:
Volume = area × depth = (3 × 3) × 0.1 = 0.9 mm3.
NURSINGTB.COM
3. Chapter 11-03
Twenty cells are counted in one of the nine large squares of a
hemocytometer. The sample is diluted 1:10. How many cells are present
per ìL?
a. 200
b. 1000
*c. 2000
d. 20,000
General Feedback:
Plugging the appropriate numbers into the formula: (20 ×
10)/(1 mm2 × 0. 1 mm) = 2000/mm3 = 2000/ìL (= 2.0 × 103/ìL = 2.0 ×
109/L).
4. Chapter 11-04
In the four large corner squares of a hemocytometer, 95, 102, 105, and
98 white cells were counted from a 1:20 dilution. Select the correct
interpretation for the white blood count calculated from these values.
*a. Normal for infant and elevated for an adult

b. Normal for any patient
c. Elevated for any patient
d. Normal for an infant and decreased for an adult
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General Feedback:
The cell count is (95 + 102 + 105 + 98) × 20)/(4 mm2 × 0.1 mm)
= 20.0 × 103/ìL = 20.0 × 109/L. This count is elevated for an adult but
normal for a newborn.
5. Chapter 11-05
Ten nucleated red blood cells (NRBCs) are found in a blood film when
differentiating 100 white cells. What is the corrected white blood
count if the automated cell counter printed a count of 10.0 × 109/L?
a. 0.91 × 109/L
*b. 9.1 × 109/L
c. 91 × 109/L
d. Ten NRBCs are not enough to require a correction
General Feedback:
The corrected white count = (10.0 × 100)/(100 + 10) = 9.1 ×
9
10 /L. Corrections for the white count must be made when greater than 5
NRBCs/100 WBCs.
6. Chapter 11-06
Why is it important to have a scrupulously clean hemocytometer when
manually counting platelets?
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a. So few platelets exist that they can be missed if dirt is
present.
b. They are so refractile they can be confused with dirt.
*c. Their small size makes them easily confused with dirt.
d. They are easily confused with the red cells that are present.
General Feedback:
Platelets are small and can be easily confused with dirt, thus
invalidly increasing the platelet count.
7. Chapter 11-07
In the center square on one side of a hemocytometer, 100 platelets were
found; 200 were found in the center square on the other side. Select
the best course of action.
a. Report the count as 150 × 109/L.

b. Verify the count by estimating the platelet number on the
blood film.
c. Recount the hemocytometer on a phase microscope.
*d. Repeat the procedure—the two counts are not close enough.
General Feedback:
The cell counts on the two opposite sides of the
hemocytometers must agree within 10% of each other. Thus if the count
is 100 on one side, the other side must be no higher than 100 + (0.1 ×
100) = 110. Because 200 exceeds this, the counts do not agree—an error
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has been made. The dilutions must be repeated and then the new
dilutions counted.
8. Chapter 11-08
The platelet count from the automated cell counter is 80 × 109/L.
Platelet satellites around neutrophils are observed on the blood film
estimate. A sodium citrate tube is drawn, and the count reads 300 ×
109/L from the cell counter. What platelet count × 109/L should be
reported?
a. 80
b. 300
*c. 330
d. The estimated count from the blood film
General Feedback:
The platelet count from the automated cell counter cannot be
accepted because it is falsely low because of the platelet satellites
seen on the blood film. This is an occasional problem in some patients
when their blood is drawn in ethylenediaminetetraacetic acid (EDTA).
Drawing the blood into sodium citrate eliminates the satellites.
However, this tube results in a dilution of the blood (nine parts blood
plus one part anticoagulant = 9:10 dilution of blood). The platelet
count from the instrument must therefore be multiplied by 1.1 (= 10/9)
to obtain the valid platelet count. Therefore the platelet count =
(300) × (1.1) = 330 (× 109/L).
NURSINGTB.COM
9. Chapter 11-09
Interpret the following results (all tests performed manually) on an
adult female.
RBC: 3.22 × 1012/L

Hemoglobin: 16.0 g/dL
Hematocrit: 30.0%
a. All are normal.

b. All are decreased.
c. Hemoglobin is elevated and other two are normal.
*d. Values do not agree with the “rule of three.”
General Feedback:
The rule of three suggests that the hematocrit ?6˜ (3 ×
hemoglobin). For this example, the hematocrit ?6˜ (3 × 16.0) ?6˜ 48 ?0?
30.0. Therefore one of the values has to be invalid unless the red cell
morphology is abnormal. However, in this instance no red cell
morphology supports these results (mean cell hemoglobin concentration
[MCHC] = 16/30 × 100 = 53 g/dL, which is impossible). Note: An
expansion of the rule of three states that the hematocrit ?6˜ 9 × RBC
count ?6˜ 9 × 3.22 ?6˜ 27%. In this case, some agreement exists between
the two values. Thus just from the information given in this question,
it appears that the incorrect value is the hemoglobin.
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10. Chapter 11-10

The calculated indices on the patient from Question 9 are:
MCV (fL) MCH (pg) MCHC (g/dL)
*a. 93 50 53
b. 105 29 37
c. 93 22 28
d. 105 34 35
General Feedback:
When the red cell indices are calculated, they are as follows:
Mean cell volume (MCV) = (30.0/3.22) × 10 = 93 fL.
Mean cell hemoglobin (MCH) = (16.0/3.22) × 10 = 50 pg.
MCHC = (16.0/30.0) × 100 = 53 g/dL.
11. Chapter 11-11

What should the laboratory technician do before working with hemoglobin
reagent?
*a. Consult the safety data sheet.

b. Call the reagent manufacturer.
c. Stop working with the reagent.
d. Discard the reagent in the sink.
General Feedback:
Because the hemoglobin reagent contains cyanide, it is highly
toxic and must be used cautiously. Consult the safety data sheet
NURAcidification
supplied by the manufacturer. SINGTB.COMof cyanide in the reagent
releases highly toxic hydrogen cyanide gas. A licensed waste disposal
service should be contracted to discard the reagent; reagent-specimen
solutions should not be discarded into sinks.
12. Chapter 11-12

Which could cause the microhematocrit to be falsely decreased?
*a. Introduction of interstitial fluid

b. Trapped plasma from abnormally shaped red cells
c. Dehydration
d. Insufficient centrifugation
General Feedback:
Proper specimen collection is an important consideration. The
introduction of interstitial fluid from a skin puncture or the improper
flushing of an intravenous catheter causes decreased hematocrit
readings. Trapped plasma from abnormally shaped red cells will elevate
the microhematocrit. If a person is dehydrated, he or she has lost
plasma volume to extracellular space, and this falsely increases the
microhematocrit. Insufficient centrifugation means that the red cells
will not be maximally packed, and this too will falsely elevate the
microhematocrit.
13. Chapter 11-13

The MCV on a patient is calculated to be 115 fL and the MCHC is 35
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g/dL. What, in general terms, must be true of the MCH if it is

consistent with the previous two indices?
a. It is impossible to know.
b. It should be in the reference range.
c. It should be below reference range.
*d. It should be above reference range.
General Feedback:
The MCV is elevated, suggesting that the red cells are
macrocytic. The actual weight of hemoglobin/red cell (the MCH) must
therefore be elevated (above reference range) for the concentration of
hemoglobin/volume (the MCHC) to be reference range.
14. Chapter 11-14

On a standard reticulocyte preparation with new methylene blue, 100 of
1000 total cells that are counted contain blue-stained
granulofilamentous material. The red blood count is 3.22 × 1012/L, and
the hematocrit is 30%. Calculate the reticulocyte count as a
percentage.
a. 0.1%
b. 1.0%
*c. 10.0%
d. 100.0%
General Feedback:
NUcells
A total of 1000 red RSING TB.reticulocytes
plus COM are always
counted (and thus 1000 is the denominator when performing a
reticulocyte count). The reticulocyte count (%) = (100/1000) × 100 =
10%.
15. Chapter 11-15

Which red cell indices support microcytic hypochromic red cell
morphology?
a. 120 36 35
*b. 68 22 28
c. 90 30 34
d. 75 30 34
General Feedback:
Because the red cells are microcytic, the MCV must be below
reference range. They are also hypochromic, so the MCHC must be below
reference range. Both the smaller volume and lower concentration of
hemoglobin mean that the MCH has to be significantly below reference
range.
16. Chapter 11-16

Which red cell indices support normocytic normochromic red cell
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morphology?
a. 120 36 35
b. 68 22 28
*c. 90 30 34
d. 75 30 34
General Feedback:
Because the red cells are both normal in size and normal in
hemoglobin concentration, all the red cell indices must be in the
reference range.
17. Chapter 11-17

Which red cell indices support macrocytic normochromic red cell
morphology?
*a. 120 36 35
b. 68 22 28
c. 90 30 34
d. 75 30 34
General Feedback:
The red cells are large but have a normal concentration of
hemoglobin. The MCV and MCH must therefore be above reference range,
whereas the MCHC is in the reference range.
NURSINGTB.COM
18. Chapter 11-18
1000 cells that are counted contain blue-stained granulofilamentous
material. The red blood count is 3.22 × 1012/L, and the hematocrit is
30%. Calculate the absolute reticulocyte count.
*a. 0.32 × 1012/L

b. 3.2 × 1012/L
c. 32.2 × 1012/L
d. 0.99 × 1012/L
General Feedback:
The absolute reticulocyte count is = relative % reticulocytes
× the red count. In this example, the absolute reticulocyte count =
(0.10) × 3.22 × 1012/L = 0.32 ×1012/L.
19. Chapter 11-19

30%. Calculate the corrected reticulocyte count.
a. 1.5%
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b. 3.0%
*c. 6.7%
d. 15.0%
General Feedback:
The corrected reticulocyte count “normalizes” the hematocrit
to 45%. Thus it is the reticulocyte % × patient’s hematocrit/“normal”
hematocrit = 10% × (30/45) = 6.7.
20. Chapter 11-20

30%. Calculate the MCV.
a. 80 fL
*b. 93 fL
c. 98 fL
d. 108 fL
General Feedback:
The MCV = 30/3.22 × 10 = 93 fL.
21. Chapter 11-21

1000 cells that are countedNcontain
URSINGblue-stained
TB.COM granulofilamentous
30%. Calculate the reticulocyte production index (RPI).
a. 1.5
b. 2.7
*c. 3.4
d. 13.4
General Feedback:
The RPI uses the corrected reticulocyte count (calculated in
Question 25). It then takes into account, based on the patient’s
hematocrit, the early release of RBCs from the marrow so that when the
reticulocytes are counted, it is not just those released in the last 24
hours (1 day) but a piling up of those released over a longer period of
time. For a hematocrit of 30%, the average length of time a
reticulocyte spends in the blood is 2.0 days. Thus the corrected
reticulocyte count of 6.7 is divided by 2 = 3.4.
22. Chapter 11-22

Which is a good use of the erythrocyte sedimentation rate (ESR)?
*a. Monitor patients with rheumatoid arthritis.

b. Diagnose acute appendicitis.
c. Diagnose multiple myeloma.
d. Monitor patients with osteoarthritis.
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General Feedback:
The ESR is elevated in patients with rheumatoid arthritis. It
decreases when the disease is in remission and increases when it
exacerbates; therefore, it is useful for monitoring this disease. It is
normal in the first 24 hours of acute appendicitis, so is not useful in
diagnosis. It is elevated in multiple myeloma, but also in many other
clinical conditions, so it is not diagnostic for it. It is normal in
osteoarthritis and thus of no value for monitoring those patients.
23. Chapter 11-23

Why is testing the ESR not recommended when testing for inflammation in
asymptomatic individuals?
a. It is too complicated and time-consuming.

b. It yields too many false-negative results.
c. It is not affordable to most people.
*d. It is not a reliable predictor of inflammation.
General Feedback:
Because of its low specificity and sensitivity, the ESR is not
recommended as a screening test to detect inflammatory conditions in
asymptomatic individuals. Other tests for inflammation, such as the C-
reactive protein level, may be a more predictable and reliable
alternative to monitor inflammation.
24. Chapter 11-24

NURSINGTB.COM
Which can cause a falsely increased ESR?
a. Concentration of anticoagulant increased

*b. Tube not totally vertical
c. Tuberculosis
d. Increased plasma viscosity
General Feedback:
The ESR tube must be kept at the absolute perpendicular to
obtain a valid ESR result. Even only a slight tilt of the pipette
(tube) causes the ESR to increase.
25. Chapter 11-25

How do sickle cells or spherocytes interfere with the ESR?
*a. Prevent rouleaux formation, so falsely decrease.

b. Encourage rouleaux formation, so falsely increase.
c. Agglutinate and increase red cell mass, so falsely increase.
d. Decrease plasma viscosity, so falsely decrease.
General Feedback:
Abnormally shaped red cells such as sickle cells or
spherocytes interfere with rouleaux formation, so they falsely decrease
the ESR result.
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26. Chapter 11-26

A manual hemoglobin is determined on a patient, and the dilution still
appears turbid after letting it sit for 15 minutes. The stained blood
film is examined, and sickle cells are observed on the blood film.
Equal volumes of the diluted hemoglobin sample and water are mixed
together, and the absorbance of this read on a spectrophotometer. How
should the hemoglobin result be determined from the standard calibrated
graph?
a. Add the results from the turbid and second dilution together
and divide by 2.
*b. Multiply the result from the standard curve by 2.
c. Divide the result obtained from the graph on the diluted
specimen by 2.
d. There was no reason to perform this second dilution.
General Feedback:
Red cells that contain Hb S (sickle hemoglobin) are resistant
to lysis in some cyanmethemoglobin reagents. When this occurs, the
cyanmethemoglobin dilution should be mixed with an equal part of water,
and the optical density (percent transmission) read. Because the
diluted specimen was diluted 1:2 by water, this result must be
multiplied by 2 to obtain the patient’s result.
27. Chapter 11-27

A manual WBC count is performed using a system that makes a 1:20
dilution of blood. When the cells in the four large corner mm2 of the
hemocytometer are counted, N URfollowing
the SINGTB.C OM
numbers of cells are obtained:
8, 12, 9, and 11. What would be the next step?
*a. Count the cells in all 9 mm2 of the hemocytometer.

b. Redo the dilution of blood using a new 1:20 dilution.
c. Redo the dilution of blood using a 1:100 dilution.
d. Calculate the count using the values from the 4 mm2 and report
the result.
General Feedback:
This white count appears to be very low, in the neighborhood
of 2.0 × 109/L [(8 + 12 + 9 + 11) × 20/0.4]. To make the cell count
more accurate, the number of cells counted must be increased. This can
be done by counting the cells in all 9 mm2 of the hemocytometer.
28. Chapter 11-28

A 1:20 dilution of blood is made for a white count, and the following
number of cells counted in the four large corner mm2 of the
hemocytometer: 12, 28, 18, and 15. What should be done next?
a. Report the white count as 3.7 × 109/L.

*b. Clean the hemocytometer and recharge with a well-mixed
dilution.
c. Increase the number of mm2 counted.
d. Compare this cell count to the one on the other side.
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General Feedback:
The distribution of cells in these four mm2 is unacceptable
(exceeds 10 cells); this is not random distribution. Unacceptable
distribution makes the cell count invalid. Ideally, another dilution
should be made, and it should be well mixed before charging the
chamber. Other possible reasons for poor distribution include uneven
flow when charging the chamber, dirt or oil on the surface of the
chamber or coverslip, and disturbing the coverslip while counting the
cells.
29. Chapter 11-29

Diagnostic testing at or near the site of patient care is known as:
a. preanalytic testing.
*b. point-of-care testing.
c. waived testing.
d. Clinical Laboratory Improvement Amendments (CLIA) testing.
General Feedback:
Diagnostic testing at or near the site of patient care is
known as point-of-care testing.
30. Chapter 11-30

Which regulatory standards mandate the concept of “test site
neutrality” for all laboratory
NURprocedures?
SINGTB.COM
a. OSHA
*b. CLIA
c. Joint Commissions
d. CAP
General Feedback:
The Clinical Laboratory Improvement Amendments (CLIA) requires
test site neutrality, which means that all testing sites must follow
the same regulatory requirements based on the complexity of the test
method. OSHA sets standards for safety in the workplace. Joint
Commissions and CAP are accrediting agencies.
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1. Chapter 12-01
Counting the number and size of electrical interferences created by
blood cells as they pass through a small aperture is a description of
which principle?
*a. Electronic impedance

b. Optical scatter
c. Conductivity
d. Laminar flow
General Feedback:
The electronic impedance principle of cell counting is based
on the detection and measurement of changes in electrical resistance
produced by cells as they pass through a small aperture.
2. Chapter 12-02
What technology minimizes the problems of a rigid aperture?
a. Forward scatter
b. Radiofrequency
*c. Hydrodynamic focusing
d. Fluorescence
General Feedback:
The use of hydrodynamic focusing avoids pitfalls and potential
problems when using a rigid aperture. The outer sheath fluid minimizes
protein buildup and plugs, eliminates recirculation of cells, and
NURSIN
reduces pulse height irregularity GTcoincident
and B.COM passage loss.
3. Chapter 12-03
Forward angle light scatter, when used in an instrument using the
optical scatter principle, correlates with cell:
a. granules.
*b. volume.
c. nuclear chromatin.
d. number.
General Feedback:
Forward light scatter correlates with cell volume (size).
4. Chapter 12-04
What does the pneumatic system of cell counters do?
*a. Operates the valves and moves the sample.

b. Controls computer software.
c. Digitizes the pulses generated by cell passage.
d. Controls the laser light.
General Feedback:
The pneumatic system includes the vacuums and pressures
required for operating the valves and moving the sample through the
hydraulics system.
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5. Chapter 12-05
How do Beckman Coulter and Abbott instruments count red cells and
platelets?
a. Florescent staining and enumeration

b. Survival staining and conductivity
c. Optical scatter
*d. Electrical impedance
General Feedback:
Instruments manufactured by these companies both use
electrical impedance to count and discriminate red blood cells (RBCs)
and platelets.
6. Chapter 12-06
Which is determined by light transmission between 525 and 555 nm on
automated counting instrumentation?
a. Reticulocytes
*b. Hemoglobin
c. Mean cell volume (MCV)
d. Mean cell hemoglobin (MCH)
General Feedback:
Hemoglobin is measured by light transmission between 525 and
555 nm.
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7. Chapter 12-07
Which is always calculated on cell counters?
a. Hematocrit
b. MCV
*c. Mean cell hemoglobin concentration (MCHC)
d. Red blood cell count
General Feedback:
The MCHC is always a calculated parameter on cell counters.
The clinician determines it by dividing the hemoglobin by the
hematocrit (which on some instruments is also calculated from the red
count and MCV) and multiplying by 100.
8. Chapter 12-08
What is the mechanism for the three-part differential found in older
Coulter machines or those designed for smaller laboratories?
a. Volume, conductivity, scatter

b. Multiangle polarized scatter separation
c. Peroxidase staining and light scatter
*d. Impedance after cytoplasm shrinkage
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General Feedback:
Older Coulter instruments use a special white blood cell (WBC)
lysing agent that causes differential shrinkage of white cells,
allowing the different white cells to be counted and sized based on
their impedance.
9. Chapter 12-09
How do CELL-DYN instruments differentiate red cells and platelets from
one another?
a. Differences in forward scatter using optical light scatter

principle
b. Use of a unique reagent that selectively lyses red cells while
preserving platelets
*c. Differences in volume (fL) using electrical impedance
principle
d. Use of a unique reagent that selectively lyses platelets while
preserving red cells
General Feedback:
CELL-DYN instruments use electrical impedance for counting and
discriminating red cells and platelets. Pulses between 1 and 35 fL are
included in the initial platelet data, whereas pulses greater than 35
fL are counted as red cells.
10. Chapter 12-10

NURSINGTB.COM
What principle does the Sysmex SE-9000/9500 use to analyze and separate
white cell populations?
a. Electronic impedance
b. Optical light scatter
c. Volume, conductivity, and scatter
*d. Low-frequency direct current and high-frequency current
General Feedback:
The Sysmex 9000 analyzes WBCs by low-frequency direct current
and high-frequency current. A scattergram of radiofrequency detection
signals (y-axis) versus direct-current detection signals (x-axis) is
plotted and yields separation of the white cells through the
application of floating discriminators.
11. Chapter 12-11

Which uses a peroxidase stain channel?
*a. Siemens Healthcare Diagnostics ADVIA 2120

b. Coulter LH750
c. Sysmex SE-9000
d. Abbott CELL-DYN 4000
General Feedback:
The ADVIA 2120 uses a peroxidase channel to help differentiate
white cells based on their peroxidase content.
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12. Chapter 12-12

Compared with manual methods, automated reticulocyte counting improved
which concept?
a. Distribution error
b. Statistical sampling error
c. Interobserver error
*d. All of the options
General Feedback:
Automated reticulocyte counting improved all of the listed
problems encountered in manual reticulocyte counting. This has resulted
in an improvement in precision and accuracy.
13. Chapter 12-13

An elevated immature reticulocyte fraction is associated with:
a. bone marrow suppression.

b. chemotherapy.
*c. bone marrow response to anemia.
d. renal disease.
General Feedback:
An elevated immature reticulocyte fraction is associated with
a bone marrow response to anemia. It is a reliable indicator of changes
in erythropoietic activity and may prove to be a valuable monitoring
NURsuch
tool for patients with anemia, SINGasTBthose
.COMwith chronic renal failure
who are treated with recombinant erythropoietin.
14. Chapter 12-14

Which is true regarding automated reticulocyte counts?
a. This was one of the earlier cell-counting methods to be

automated.
*b. Ribonucleic acid (RNA) is stained with various dyes that
allow for detection of reticulocytes by optical scatter or
fluorescence.
c. They are more accurate but less precise than the manual
method.
d. They require significantly more time to count reticulocytes
than manual methods.
General Feedback:
Automated methods use various dyes that bind to RNA and thus
allow for counting of reticulocytes by either optical scatter or
fluorescence.
15. Chapter 12-15

What is the greatest limitation of automated cell counters?
a. Poor precision
b. Speed
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c. Unavailability of quality control materials

*d. Inherent specimen problems leading to occasional spurious
results
General Feedback:
Limitations and interferences may be related to either the
methodology or inherent problems in the blood sample. In its
literature, the manufacturer defines instrument limitations. Some of
the method limitations are, in fact, the result of inherent specimen
problems.
16. Chapter 12-16

Platelet clumps would most likely interfere with which other automated
parameter?
*a. WBC count

b. RBC
c. Hemoglobin
d. Red cell indices
General Feedback:
Large platelet clumps may be counted as WBCs. This results in
a falsely decreased platelet count and possibly an increased white cell
count.
17. Chapter 12-17

NURSINGTB.COM
An automated hematology analyzer is used to evaluate a blood specimen.
Which, coming off the instrument, would require performance of a manual
white cell differential as opposed to blood film review?
a. Flagged data
*b. Suppression of automated differential data
c. Abnormal red cell indices
d. A slightly elevated platelet count
General Feedback:
When internal instrument checks fail or cast doubt on the
data, the automated differential data are suppressed. This means that a
manual differential should be performed. Flagged data may be released
after appropriate blood film review, as dictated by the specific
laboratory policy.
18. Chapter 12-18

A patient sample comes off an automated cell counter with a failure of
the red cell “rule of three.” The red count is lower than expected
given the hemoglobin. The MCV and MCHC are elevated. Which is the most
likely reason for this failure?
a. Megaloblastic anemia
b. Lyse-resistant red cells
*c. Cold agglutinin
d. Lipemia
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General Feedback:
The red count is lower than expected for the data; this
suggests a cold agglutinin is present. The red cells are thus clumped
at room temperature, and the clumps are being counted as one large
cell. This lowers the red count and raises the MCV and MCHC. The only
red cell parameter that is probably valid is the hemoglobin
measurement.
19. Chapter 12-19

Select the most appropriate action for the results in Question 18.
a. Report the results.

b. Lyse the red cells manually and rerun.
*c. Warm sample to 37°C and rerun.
d. Replace plasma with saline and rerun.
General Feedback:
The blood sample should be warmed to 37°C and rerun when a
cold agglutinin is present or suspected of being present. The antibody
will disassociate from the red cell membrane at this temperature, and
the red cells will “unclump.” This raises the red count and lowers the
MCV, MCH, and MCHC.
20. Chapter 12-20

All will be invalid when lipemia is present in a blood sample except:
a. MCHC.
NURSINGTB.COM
*b. MCV.
c. MCH.
d. hemoglobin.
General Feedback:
When a blood sample is lipemic, the hemoglobin is falsely
elevated. The MCH and MCHC are also falsely elevated because they use
the hemoglobin measurement for their calculation. The MCV is valid
because it does not depend on the hemoglobin measurement.
21. Chapter 12-21

Which occurs if testing is not performed within 24 hours of specimen
collection?
a. White blood count rises.

*b. WBCs deteriorate and RBCs swell.
c. Hemoglobin rises.
d. MCV decreases.
General Feedback:
Sample age can have a profound effect on blood cell analysis.
Specific problems with older samples include WBC fragility and loss,
swelling (which increases the MCV) and possible lysis of RBCs, and the
deterioration of platelets.
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22. Chapter 12-22

A patient’s white blood count comes off an automated cell counter as
380 × 109/L. Which could be reported without any additional testing?
a. Red blood count

b. Hemoglobin
c. Hematocrit
*d. Platelet count
General Feedback:
The platelet count could be reported, but none of the other
results are reportable. White cells are always counted with red cells;
however, there normally are so few of them in comparison to the number
of red cells that their presence does not significantly affect the red
count. When the white count is markedly elevated, it significantly
affects the red count and MCV and thus the hematocrit. The hemoglobin
is also invalid because the high number of white cells adds turbidity
to the hemoglobin measurement, thus falsely increasing the hemoglobin
determination (and then also the MCH and MCHC). The markedly elevated
white cell count necessitates at least a blood film review, if not a
manual white cell differential (varies with the instrument
limitations).
23. Chapter 12-23

When the electronic impedance principle is used to count blood cells,
what is done to increase platelet-counting sensitivity?
NURSINGTB.COM
*a. Decrease the size of the RBC/platelet aperture.
b. Increase the size of the RBC/platelet aperture.
c. Use a strong lysing agent to selectively lyse the RBCs.
d. Lower the upper threshold for counting platelets so that even
microcytic red cells are excluded.
General Feedback:
To improve the sensitivity when counting platelets, the size
of the RBC/platelet aperture is decreased.
24. Chapter 12-24

Platelet volume normally:
a. is 15 to 20 fL.
*b. increases as the sample sits in acid.
c. is 5 to 18 fL.
d. is not reliable on most electronic instruments.
General Feedback:
Platelet reference values are approximately 8 to 88 fL, and
the MPV increases slightly as the sample sits in the anticoagulant
EDTA.
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25. Chapter 12-25

What is the recommended method for establishing accuracy of automated
hematology analyzers?
a. Use at least three levels of controls for calibration.

b. Use whole blood calibration methodology.
*c. Use commercially prepared whole blood calibrators.
d. Perform manual methods for comparison.
General Feedback:
Whole blood calibrators are commercially available and are
used for calibration of instruments. However, inherent problems exist
with their use because these are stabilized and preserved cell
suspensions that can deteriorate, and the calibration must be validated
before the instrument is used for patient specimen analysis.
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1. Chapter 13-01
All can be determined from a blood film except:
a. red cell morphology.

b. white cell estimate.
*c. red cell estimate.
d. platelet estimate.
General Feedback:
A red cell count estimate cannot be made from a blood film.
White cell and platelet count estimates are routinely made, and red
cell morphology is evaluated.
2. Chapter 13-02
A patient’s blood film had marked echinocytes and many broken and
vacuolated neutrophils. The same patient’s blood film the day before
did not show these features. Select the best course of action.
a. Report the results.

b. Make a new film.
c. Disregard these findings as artifact.
*d. Make a new sample film within 5 hours.
General Feedback:
Blood films from EDTA tubes that remain at room temperature
for more than 5 hours often have unacceptable blood cell artifacts
(echinocytic red blood cells [RBCs], spherocytes, necrobiotic
leukocytes, and vacuolated N URSINGTB.C
neutrophils). OM should ideally be made
Slides
within 2 to 3 hours of drawing the specimen if good-quality morphology
is desired.
3. Chapter 13-03
Clumped platelets will cause which spurious results when cell counts
are performed on an automated hematology analyzer?
*a. Platelets low and white count high

b. Platelets high and white count low
c. Platelets low and white count unaffected
d. Platelets low and hemoglobin high
General Feedback:
The presence of clumped platelets in blood will cause the
platelet count to be low and the white count to be high when performed
using an automated analyzer. The clumps of platelets may be of a
similar size to white blood cells (WBCs) and the instrument cannot
distinguish them as nonwhite cells.
4. Chapter 13-04
How can the correct platelet count on a patient be determined when his
or her platelets repeatedly clump in an EDTA specimen?
a. Recollect in sodium citrate tube (blue top) and multiply by

0.5.
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*b. Recollect in sodium citrate tube (blue top) and multiply

count by 1.1.
c. Report the estimated number from the blood film.
d. Recollect in an EDTA tube.
General Feedback:
When platelet clumping repeatedly occurs in an EDTA blood, the
blood should be drawn in a sodium citrate tube. The dilution of blood
by the anticoagulant is 9:10 (9 parts blood to 1 part anticoagulant).
The platelet count obtained on this tube must therefore be multiplied
by the reciprocal of the dilution (10/9) = 1.1.
5. Chapter 13-05
Select the best course of action to remedy blood films that typically
are too thick from newborns.
a. Increase the spreader slide angle.

b. Use a larger drop.
c. Dilute the blood with saline.
*d. Decrease the spreader slide angle.
General Feedback:
Decreasing the angle of the spreader slide will make the blood
film thinner, as well as longer.
6. Chapter 13-06
NURSINGTB.COM
Why should bone marrow films be dried quickly?
a. To make the cells more visible

*b. To avoid drying artifact
c. To evaluate morphology
d. To decrease evaluation time
General Feedback:
Regardless of film preparation method, before staining, all
blood films and bone marrow smears should be dried as quickly as
possible to avoid drying artifact. In some laboratories, a small fan is
used to facilitate drying. Blowing breath on a slide is
counterproductive because the moisture in breath causes RBCs to become
echinocytic (crenated) or to develop water artifact (also called drying
artifact).
7. Chapter 13-07
Methods, such as using a fan to dry blood films faster, are especially
important when:
*a. the patient is very anemic or high humidity exists.

b. the patient has polycythemia or high humidity exists.
c. the sample is more than 6 hours old.
d. no one is available to blow on the blood film.
General Feedback:
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When the blood film dries slowly on the slide, red cell and
drying artifacts make it extremely difficult to evaluate red blood cell
(RBC) morphology. Humidity adds to this problem, as does the high
plasma volume found in an anemic patient. Drying the slide with a fan
can be beneficial.
8. Chapter 13-08
What is the most common reason for blood films having red cells that
are gray and white cells that are too dark?
a. Overrinsing
b. Buffering for too short a time
c. Stain or buffer that is too acidic
*d. Stain or buffer that is too alkaline
General Feedback:
When the stain or buffer is too alkaline, red cells will be
gray and white cells will stain too darkly for good morphologic
evaluation.
9. Chapter 13-09
Macroscopic holes in a blood film most likely mean the patient has:
a. increased blood proteins.

b. red cell agglutination.
*c. increased lipids.
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d. increased white blood count.
General Feedback:
Increased lipids in the plasma can cause the appearance of
holes all over the blood film. Some of the other hematology parameters
should be carefully evaluated because they may also be influenced by
the presence of these lipids (e.g., hemoglobin).
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1. Chapter 14-01
Which site is used for both aspiration and core biopsy of bone marrow?
a. Sternum
*b. Posterior iliac crest
c. Tibia
d. Ribs
General Feedback:
The posterior iliac crest in an adult is used for both bone
marrow aspiration and core biopsy. The anterior iliac crest, and
occasionally the ribs or vertebrae, can also be used. The sternum is
rich in marrow and a good specimen can be obtained from it, but it is
not recommended because of the risk of puncture to the underlying heart
and great vessels.
2. Chapter 14-02
The best use for bone marrow aspirate smears is:
*a. counting the differential.

b. determining overall cellularity.
c. estimating fat-to-cell ratio.
d. evaluating for focal lesions such as lymphoma.
General Feedback:
The best use for bone marrow aspirate smear is for counting
the differential. The biopsy is better for determining overall
cellularity, estimating theNfat-to-cell
URSINGTB.ratio,
COM and evaluating for the
possible presence of focal lesions.
3. Chapter 14-03
When is obtaining a bone marrow core biopsy mandatory?
a. Anemia is suspected.
b. Leukemia is suspected.
c. Megakaryocyte disorders are suspected.
*d. Aspirate is a dry tap.
General Feedback:
When the aspirate is a dry tap, it is imperative that a bone
marrow biopsy be obtained. This gives the hematologist and/or
pathologist a way of assessing the bone marrow in the absence of an
aspirate (dry tap). If the aspirate is a dry tap, then something
significant is present in the marrow and the biopsy will help determine
the cause.
4. Chapter 14-04
Which would be a valid indication for performing a bone marrow
aspiration?
a. Iron deficiency
b. Folate deficiency
*c. Unexpected pancytopenia
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d. Leukocytosis from a severe infection
General Feedback:
An unexpected pancytopenia is a valid reason for performing a
bone marrow aspiration so that the cause of the pancytopenia can be
determined. Iron deficiency, folate deficiency, and leukocytosis from a
severe infection can all be evaluated and diagnosed from tests
performed on peripheral blood (and perhaps other tissues and/or fluids
such as urine in a urinary tract infection).
5. Chapter 14-05
What type of preparation is preferred for bone marrow aspirates?
*a. Coverslip smears from a bone marrow fragment called a

spicule.
b. Wedge smears made from the blood surrounding marrow fragments.
c. Touch preps from rolling the biopsy on a glass slide.
d. Smears of the biopsy made with an automated slide maker.
General Feedback:
Coverslip smears from a bone marrow spicule are the preferred
type of preparation for bone marrow aspirates. The advantage to them
over slides is that less trauma occurs to the cells because they weigh
so much less (relatively speaking). If done correctly, a good monolayer
of cells in the marrow can be stained and then evaluated.
6. Chapter 14-06
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Low power (×10) is used to count and evaluate which factor?
a. Immature neutrophils
*b. Megakaryocytes
c. Nucleated red cells
d. Plasma cells
General Feedback:
Megakaryocytes are the largest cell in the bone marrow, and
they are easily seen and counted under ×10.
7. Chapter 14-07
Which is excluded in the M:E ratio?
a. Reticular cells
b. Nucleated erythrocytes
c. Phagocytes
*d. Lymphocytes
General Feedback:
Once the differential is completed, the myeloid-to-erythroid
(M:E) ratio is computed from the total myeloid to the total nucleated
erythroid cell stages. Excluded from the M:E ratio are lymphocytes,
plasma cells, monocytes, histiocytes, nonnucleated erythrocytes, and
nonhematopoietic stromal cells.
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8. Chapter 14-08
Osteoblasts can be easily confused with:
a. megakaryocytes.
b. osteoclasts.
*c. plasma cells.
d. macrophages.
General Feedback:
Osteoblasts can be easily confused with plasma cells. They
have an eccentric nucleus and blue cytoplasm; however, they do not have
a well-defined Golgi complex (area of “hof”). Osteoblasts tend to be
found in clusters, which is not true of normal plasma cells.
9. Chapter 14-09
A bone marrow aspirate shows copious blue granules with the Prussian
blue stain. Select the correct interpretation.
*a. Iron overload

b. Iron deficiency
c. Tumor cells present
d. Megakaryocytes increased
General Feedback:
The Prussian blue stain is an iron-specific stain (nonheme
iron). When iron is in the storage form of hemosiderin, it stains blue.
NURSIit
If copious granules are visible, NGsuggests
TB.COMiron overload. The
granules must be found in macrophage cytoplasm to rule out possible
contamination of the slide or stain with iron.
10. Chapter 14-10

Which cell type tends to be found in molded clusters in the bone
marrow?
a. Megakaryocytes
*b. Malignant cells
c. Immature granulocytes
d. Monocytes
General Feedback:
Malignant cells are often found in clusters or clumps in the
bone marrow. Because they are so large, they are most easily searched
for under ×10 while scanning, and they are often found at or near the
edge of the coverslip (or glass slide).
11. Chapter 14-11

What stain is most commonly used for bone marrow aspirates?
a. Prussian blue
b. New methylene blue
c. Hematoxylin and eosin (H&E)
*d. Wright
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General Feedback:
Wright stain is most commonly used for bone marrow aspirates.
Cells stain in a similar fashion as to what is seen in peripheral blood
cells, making it easy to assess their morphology.
12. Chapter 14-12

What bone marrow sample is best to determine fat-to-cell ratio and
overall cellularity, as well as for searching for malignant cells?
*a. Core biopsy

b. Aspirate smears
c. Peripheral blood
d. Prussian blue stain
General Feedback:
The core biopsy is the best sample for determining overall
cellularity and fat-to-cell ratio and searching for malignant cells. It
provides an intact portion of the bone marrow.
13. Chapter 14-13

Which is least helpful in evaluating bone marrow findings?
a. Differential performed on the aspirate

b. Clinical findings
*c. Laboratory data from chemistry, immunology, and microbiology
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d. Examination of peripheral blood
General Feedback:
All clinical laboratory findings should be interpreted in
light of the clinical findings (physical examination and history). It
is also important to compare the bone marrow findings from the
differential with what is in peripheral blood, because blood cells are
derived from the bone marrow. In general, laboratory data from other
sections of the laboratory are not needed; however, this is not the
case when working up patients for certain diseases (e.g., protein
electrophoresis in a patient suspected to have multiple myeloma).
14. Chapter 14-14

A cell is described as having an eccentric, heavily stained (condensed
chromatin) nucleus with blue cytoplasm. A pale perinuclear Golgi
complex is noted next to the nucleus. What is this cell?
a. Myelocyte
*b. Plasma cell
c. Lymphocyte
d. Myeloblast
General Feedback:
The description fits that of a plasma cell. These are fully
differentiated B cells, whose function is to make and secrete specific
immunoglobulin (antibody). Because the cytoplasm is rich in ribonucleic
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acid (RNA) needed for this synthesis, the cytoplasm often stains a
brilliant blue.
15. Chapter 14-15

The sites of active red marrow differ for adults and young children.
Which site is active in children but not in adults?
a. Proximal end of the long bones

b. Skull
*c. Distal ends of the long bones
d. Pelvis
General Feedback:
Red marrow is found in all the bones in children, including
the distal ends of the long bones. It also initially has no fat. As the
child grows and the bones lengthen and enlarge, all the available
marrow space is no longer needed for blood cell production. The marrow
space no longer needed becomes inactive and fatty (“yellow marrow”). It
can be converted to active marrow if the demand for blood cells becomes
excessive. Red marrow in an adult is composed of both blood-producing
cells and fat in a roughly 1:1 ratio.
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1. Chapter 15-01
Why should cell counts on body fluids be performed within 30 minutes of
collection?
a. Erythrocytes begin to deteriorate.

b. Plasma cells begin to deteriorate.
c. Red blood cells begin to deteriorate.
*d. White blood cells begin to deteriorate.
General Feedback:
Blood cell counts should be performed and cytocentrifuge
slides should be prepared as quickly as possible after collection of
the specimen, because WBCs begin to deteriorate within 30 minutes after
collection.
2. Chapter 15-02
A hazy spinal fluid has 400 white cells/mm3 that are mostly lymphocytes
and reactive lymphocytes. Which condition is most likely?
a. Bacterial meningitis
*b. Viral meningitis
c. Infectious mononucleosis
d. Multiple myeloma
General Feedback:
Meningitis can be either bacterial or viral. In general, WBC
counts are much higher (in the thousands) in patients with bacterial
meningitis than in patientsNwith
URSIviral
NGTBmeningitis
.COM (in the hundreds).
3. Chapter 15-03
What determines the amount of fluid used for a cytocentrifuge
preparation?
a. Type of fluid
b. Desired speed of centrifugation
*c. Number of cells
d. Amount of fluid collected
General Feedback:
The number of cells, determined when the cell count is done on
the body fluid, determines how much fluid should be used in making the
cytocentrifuge preparation. This preparation concentrates the cells so
that a representative number of them can be morphologically evaluated.
4. Chapter 15-04
What determines whether or not body fluids are diluted before counting?
*a. Appearance of the fluid

b. Type of fluid
c. Patient’s diagnosis
d. Whether or not the fluid needs to go to other sections of the
laboratory for additional testing
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General Feedback:
The appearance of the fluid is used to determine whether or
not a body fluid is diluted before counting. If the fluid is clear, no
dilution is made. If it is hazy or cloudy, an appropriate dilution is
made.
5. Chapter 15-05
A cloudy cerebrospinal fluid (CSF) is diluted 1:20. In nine large
squares, 99 white cells are counted. What is the total white blood
count/mm3 or /ìL?
a. 99
b. 1980
*c. 2200
d. 22,000
General Feedback:
The same formula used for calculating manual cell counts in
blood is used for body fluids. Thus this cell count = (99 × 20)/(9 mm2
× 0.1 mm) = 2200/ìL.
6. Chapter 15-06
If most of the white cells are neutrophils on the previously discussed
CSF, what additional test should be performed?
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a. Cytology
b. Flow cytometry
c. Lactate dehydrogenase
*d. Gram stain and bacterial cultures
General Feedback:
Neutrophils increase in response to a bacterial infection.
Thus if most of the cells seen in a CSF are neutrophils, a Gram stain
and bacterial cultures should be performed on the CSF. It is critical
that the specimen be handled in a sterile manner until these tests have
been performed; often a separate CSF tube is used for culture than that
for cell counts.
7. Chapter 15-07
A CSF is equally bloody in all tubes collected and has a yellowish
supernatant. On the differential, macrophages with hemosiderin are
noted. Which is most likely?
a. Bacterial meningitis
b. Viral meningitis
*c. Subarachnoid hemorrhage
d. Traumatic tap
General Feedback:
All tubes being equally bloody indicates hemorrhage. If it had
been a traumatic tap, there should have been a gradual decrease in the
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number of red cells in successive tubes with gradual clearing. The

yellow tinge to the supernatant suggests a subarachnoid hemorrhage.
8. Chapter 15-08
Nucleated red blood cells (NRBCs) and immature white cells in a CSF
most likely mean:
a. bacterial meningitis.
b. patient has NRBCs in the peripheral blood.
c. subarachnoid hemorrhage.
*d. bone marrow contamination.
General Feedback:
When immature bone marrow cells are seen in the CSF, it most
likely means that bone marrow contamination of the specimen has
occurred. If a significant number exist, the CSF differential will be a
reflection of what is in the marrow, not the CSF.
9. Chapter 15-09
Which is a feature of malignant cells in fluids?
a. Small size
*b. Three-dimensional clumps with no “windows”
c. Low nuclear-to-cytoplasmic (N:C) ratio
d. Uniformity
General Feedback:
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Mesothelial cells are the lining cells of body cavities and
are shed into these cavities. They can be confused with malignant
cells. However, when mesothelial cells appear in clumps (a frequent
occurrence), usually windows are noted between the cells. This is not
true of malignant cells that are also commonly found in clumps.
10. Chapter 15-10

Which is normal in a CSF?
*a. Ependymal cells

b. 100 white cells/mm3
c. Blasts
d. Mesothelial cells
General Feedback:
Ependymal cells, along with choroids plexus cells, are lining
cells of the central nervous system and are seen in CSF. None of the
other findings would be normal in CSF.
11. Chapter 15-11

A patient has a pleural fluid with 2000 WBCs/mL. Seventy percent of the
cells are neutrophils. Which is most likely?
a. Normal fluid
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b. Transudate on a patient with a pleural bacterial infection

*c. Exudate on a patient with a pleural bacterial infection
d. Exudate on a patient with heart failure
General Feedback:
Exudates are formed in response to an infection (viral or
bacterial), malignancy, pulmonary embolus, and systemic lupus
erythematosus. They generally have a white count greater than 1000/mL.
Because the primary cells seen in this fluid are neutrophils, the
infection is bacterial.
12. Chapter 15-12

Which is true regarding malignant cells in serous fluids?
a. All clumps of large cells should be considered malignant.

b. Malignant cells in serous fluids are rarely seen.
c. Malignant cells categorize the fluid as a transudate.
*d. Care must be taken to distinguish malignant cells from clumps
of mesothelial cells.
General Feedback:
Both malignant and mesothelial cells can be found in clumps in
serous fluids. Mesothelial cells are normal lining cells of body
cavities that are shed into these cavities; they are a normal finding
in serous fluids. They can be confused with malignant cells. However,
when mesothelial cells appear in clumps (a frequent occurrence),
usually windows are noted between the cells. This is not true of
NURcommonly
malignant cells that are also SINGTBfound
.COMin clumps.
13. Chapter 15-13

Which is a normal finding in serous fluids?
*a. Macrophages
b. Bacteria
c. Eosinophils (EOs)
d. LE cells
General Feedback:
Of the findings listed, only macrophages are a normal finding
in serous fluids. Other normal cells are lymphocytes and mesothelial
cells.
14. Chapter 15-14

How must synovial fluids be handled differently than other fluids?
a. Perform a Gram stain if bacteria are seen.

b. Dilute the fluid if the cell counts are high.
*c. Add hyaluronidase to overcome the viscous nature of fluid.
d. Carefully search the whole cytospin preparation for malignant
cells.
General Feedback:
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Synovial fluid contains hyaluronic acid, making it very

viscous. Adding a small amount of hyaluronidase powder to the fluid
will cause it to liquefy. Cell counts and/or cytocentrifuge slides can
then be made.
15. Chapter 15-15

A synovial fluid has a high white cell count and large intracellular
needlelike crystals that are yellow when the crystals are parallel to
the y-axis of a red compensator. What is the likely diagnosis?
a. Pseudo-gout
*b. Gout
c. Lupus erythematosus
d. Bacterial infection
General Feedback:
These are monosodium urate crystals and are seen in gout.
16. Chapter 15-16

Which is true regarding bronchoalveolar lavage (BAL) fluids?
a. The differential is not done on these fluids.

b. It is often received from patients suspected of having asthma.
c. Moving ciliated cells suggest that the patient has
Pneumocystis carinii.
*d. A mask should be worn when performing tests.
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General Feedback:
BAL examination is performed on patients with severe lung
dysfunction. They may contain airborne organisms because they are taken
from the interior of the lung; they often contain bacteria and/or yeast
when cytocentrifuge slides are examined. Aerosol production is a real
risk; thus it is critical to wear a mask when working with these
specimens.
17. Chapter 15-17

Three CSF tubes are received in the laboratory numbered 1 through 3
based on the order in which they were obtained, with 1 being the first.
The first tube is cloudy pink, but this color diminishes and clearing
occurs with each successive tube. What does this suggest?
a. Internal bleeding into the CSF has occurred.

*b. This is blood contaminating the CSF fluid from a traumatic
puncture.
c. Bacterial infection is likely present.
d. Metastatic tumor is likely present.
General Feedback:
The turbid and pink color is due to the presence of red cells
in the fluid. Because each succeeding tube becomes clearer and the pink
color diminishes, a traumatic tap is most likely the cause. If there
had been internal bleeding into the CSF, each tube would appear the
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same. The presence of bacterial infection or metastatic tumor cells

cannot be determined by simply a gross examination of the fluid.
18. Chapter 15-18

One clinical laboratory scientist is covering the “manual bench” in the
hematology laboratory, which is where body fluid examinations are done.
Just as she is preparing to go on break, she simultaneously receives
two specimens, one a CSF and one a BAL fluid. Both are marked “stat.”
What should she do first?
a. Analyze the BAL.

*b. Analyze the CSF.
c. Go on break and then return and do the BAL.
d. Go on break and then return and do the CSF.
General Feedback:
A CSF fluid is always “stat,” and evaluation is critical for
good patient care. The cells will rapidly disintegrate, just as for all
body fluid specimens, and so they must be examined within 30 minutes of
draw. Diagnostic information obtained from examination of CSF fluid can
be extremely important for timely and appropriate patient care;
therefore, in this scenario the CSF must be examined first and
immediately. The clinical relevance of information obtained from
hematologic examination of BAL fluid is minimal, and some hematology
laboratories no longer perform counts and/or cytocentrifuge
preparations on these specimens because the biohazard risk outweighs
the clinical usefulness.
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1. Chapter 16-01
What is the best definition of anemia?
a. Red cell count 10% lower than the patient’s baseline

*b. Decreased oxygen-carrying capacity of blood
c. Hemoglobin below 12 g/dL
d. Any clinical condition resulting in shortness of breath
General Feedback:
The best definition of anemia is a decreased hemoglobin,
hematocrit, and red cell count compared with typical results for
healthy people in the same demographic group. Ideally it would be a
decrease below the patient’s normal baseline, but that is often not
known. Reference ages for hemoglobin vary dependent on sex, age, and
environmental factors (e.g., altitude); for this reason a single cutoff
such as 12 g/dL cannot be used. The symptoms for anemia are
nonspecific, although they certainly help support the diagnosis.
2. Chapter 16-02
Two different patients both have hemoglobins in the 5.0 to 6.0 g/dL
range. One has pallor, fatigue, and headaches, whereas the other is
experiencing life-threatening shock. Which is probably the major
difference between the two patients?
a. The morphologic classification of the anemia

b. Whether other cell lines (platelets or white cells) are also
involved
c. The patient’s sex NURSINGTB.COM
*d. How quickly the anemia developed
General Feedback:
When anemia develops slowly, the body is able to make a number
of compensations so that the patient may have few if any symptoms.
Conversely, if it develops rapidly (e.g., massive blood loss), then
symptoms will be evident.
3. Chapter 16-03
The red cell histogram is wider than normal. Which is true?
a. The red blood cell distribution width (RDW) is decreased.

b. Most cells are larger than normal.
c. The coefficient of variation was calculated incorrectly.
*d. Anisocytosis is present.
General Feedback:
The coefficient of variation of the red cell histogram is the
RDW. Thus when the histogram is broader than usual, the RDW increases.
4. Chapter 16-04
The reticulocyte response in patients with moderate anemia is often
misinterpreted as adequate if:
*a. the count is not corrected for anemia.
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b. the red cell indices are not considered.

c. a bone marrow aspirate is not examined.
d. red cell morphology is not considered.
General Feedback:
If only the percentage of reticulocytes is considered, a
patient may appear to be making an adequate response to anemia.
However, when the red count is considered, and either the absolute
reticulocyte count or the reticulocyte production index is calculated,
a truer picture can be obtained regarding adequacy of bone marrow
response.
5. Chapter 16-05
Which red blood cell (RBC) finding is specific for a certain condition
as opposed to being nonspecific and found in many conditions?
a. Ovalocytes
b. Poikilocytosis
*c. Sickle cells
d. Burr cells
General Feedback:
Many different abnormally shaped RBCs are not specific for any
one cause for anemia. One exception is the sickle cell, which is almost
diagnostic for sickle cell disease.
6. Chapter 16-06
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Which condition would warrant a bone marrow aspiration?
a. Iron deficiency in a patient with colon cancer

b. Severe hereditary spherocytosis
c. Disseminated intravascular coagulation (DIC) with very low
hemoglobin and marked red cell fragments
*d. Not possible to determine obvious reason for anemia
General Feedback:
When a patient is anemic and testing reveals no obvious
reason, a bone marrow aspiration (smear) is warranted. The morphology
not only of erythroid but also of all other blood-forming cells in the
marrow can be evaluated. This can provide useful information as to the
cause of anemia. All the other situations listed can be diagnosed with
appropriate testing on blood (may include other tests besides
hematologic).
7. Chapter 16-07
What is the approximate average life span of a normal RBC in
circulation?
a. 10 Days
b. 20 Days
c. 80 Days
*d. 120 Days
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General Feedback:
The average life span of a normal RBC in circulation is 120
days.
8. Chapter 16-08
What percentage of red cells is destroyed and replaced daily in a
normal adult?
*a. 1%
b. 5%
c. 10%
d. 20%
General Feedback:
Because red cells have a normal life span of 120 days, roughly
1% of them die and are replaced daily.
9. Chapter 16-09
Which is an example of a morphologic classification of anemia?
*a. Normocytic
b. Loss of blood
c. Increased destruction
d. Impaired production
General Feedback:
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The morphologic classification uses the morphology of red
cells to separate anemias into groups that can then be related to
potential causes of anemia. The other listed items are possible
mechanisms for anemia.
10. Chapter 16-10

Which is typically a macrocytic anemia?
a. Thalassemia
b. Iron deficiency
*c. Folate deficiency
d. Aplastic
General Feedback:
Folate deficiency is a macrocytic anemia. Iron deficiency
anemia (stage 3) and thalassemia are microcytic; aplastic anemia is
normocytic.
11. Chapter 16-11

What test is used along with the mean cell volume (MCV) to
morphologically classify anemias?
a. Red blood count

b. Hemoglobin
c. Hematocrit
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*d. RDW
General Feedback:
By definition, the red count, hemoglobin, and hematocrit are
all decreased in anemia, so those cannot be used to separate one cause
from another. However, the RDW describes whether the red cell
population is homogenous or heterogeneous with respect to size.
Combining it with the MCV can provide very useful information as to
possible causes for an anemia.
12. Chapter 16-12

All are physiologic adaptations the body makes when a slow drop in the
number of red cells occurs except:
a. erythropoietin level increases.

*b. oxygen dissociation curve shifts to left.
c. cardiac output increases.
d. respiratory rate increases.
General Feedback:
When anemia develops, the concentration of 2,3-
biphosphoglycerate (2,3-BPG) increases. This causes a shift to the
right in the oxygen dissociation curve, which results in more effective
delivery of oxygen to tissue (oxygen affinity of hemoglobin decreases).
13. Chapter 16-13

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Describe the morphologic appearance of the red cells given the
following results.
RBC: 1.89 × 1012/L
Hemoglobin: 7.5 g/dL
Hematocrit: 21.0%
RDW: 18.5
*a. Macrocytic with anisocytosis

b. Normocytic normochromic with anisocytosis
c. Microcytic hypochromic with little anisocytosis
d. Macrocytic with most cells the same size
General Feedback:
The red cell indices are calculated as follows: MCV =
(7.5/1.89) × 10 = 111 fL; mean cell hemoglobin (MCH) = (7.5/1.89) × 10
= 40 pg; mean cell hemoglobin concentration (MCHC) = (7.5/21) × 100 =
36. The red cells are thus macrocytic (high MCV) and normochromic
(normal MCHC). The RDW is elevated at 18.5, so an increased variation
in size exists. This then is a macrocytic anemia with anisocytosis.
14. Chapter 16-14

Which disorder would be consistent with the previously mentioned
parameters?
a. Anemia of chronic disease

b. Aplastic anemia
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*c. Vitamin B12 deficiency

d. Thalassemia
General Feedback:
Vitamin B12 deficiency leads to a macrocytic anemia with
significant variation in size (therefore an increased RDW). Aplastic
anemia is normocytic normochromic with a normal RDW; the anemia of
chronic inflammation (disease) is either normocytic (MCV low normal) or
slightly microcytic but normochromic and a normal or only a mildly
elevated RDW. Thalassemia is a microcytic normochromic or hypochromic
anemia with a normal RDW.
15. Chapter 16-15

Which is true of ineffective erythropoiesis?
a. Lymphopenia and anemia are present.

*b. RBC production in bone marrow is increased.
c. Release of RBCs to the peripheral blood is normal.
d. RBC survival in circulation is less than 40 days.
General Feedback:
RBC production in the bone marrow is increased in ineffective
erythropoiesis (decreased M:E ratio). However, production is defective,
and many of the red cells are destroyed before leaving the marrow. Thus
release of RBCs to peripheral blood is decreased. Although survival of
these RBCs in circulation may be slightly shortened from the normal of
120 days, it is not significant (the increased rate of production in
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the marrow could fully compensate for the slight shortening if the red
cells were all released to circulation). Lymphopenia is not
characteristic of these anemias.
16. Chapter 16-16

Compare results of various tests in effective versus ineffective
erythropoiesis.
*a. Both have increased rate of erythropoiesis in the bone

marrow.
b. Both have an elevated reticulocyte production index (RPI)
greater than 3.
c. Both have normal release of RBCs from the bone marrow.
d. Both have significantly shortened red cell survival in
circulation.
General Feedback:
In both effective and ineffective erythropoiesis, the rate of
red cell production in the bone marrow is increased (increased
erythropoiesis). However, release to circulation differs in the two: it
is successful in effective but not in ineffective, where significant
intramedullary loss occurs. Thus the RPI is greater than 3 in
effective, but usually less than 2 in ineffective. Red cell survival in
circulation is significantly decreased in effective, but essentially
normal or insignificantly shortened in ineffective.
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17. Chapter 16-17

Which is a microcytic anemia?
a. Vitamin B12 deficiency

b. Sickle cell anemia
*c. Iron deficiency
d. Hereditary spherocytosis
General Feedback:
Iron deficiency anemia is microcytic. Vitamin B12 deficiency
is macrocytic; sickle cell anemia and hereditary spherocytosis are both
normocytic.
18. Chapter 16-18

The anemia found in liver disease is:
*a. macrocytic nonmegaloblastic.

b. microcytic hypochromic.
c. macrocytic megaloblastic.
d. microcytic normochromic.
General Feedback:
The anemia found in liver disease is macrocytic, but it is not
megaloblastic. The large red cells result because of membrane changes
resulting from disruption of the cholesterol-to-phospholipids ratio (in
the membrane). NURSINGTB.COM
19. Chapter 16-19

Which shape of red cell is described as a round, dense cell with no
area of central pallor?
a. Sickle cell
b. Target cell
c. Burr cell
*d. Spherocyte
General Feedback:
This description fits that of a spherocyte. The MCV of a
spherocyte is usually normal, although microspherocytes exist that have
a low MCV.
20. Chapter 16-20

An appropriately increased RPI greater than 3 is associated with:
a. iron deficiency anemia.

b. macrocytic megaloblastic anemia.
*c. hemolytic anemia.
d. sideroblastic anemia.
General Feedback:
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Only hemolytic anemias have an appropriately increased RPI.

The anemia develops notbecause production is defective but because
survival in circulation is significantly shortened. In iron deficiency
anemia, insufficient erythropoiesis occurs. In macrocytic megaloblastic
and sideroblastic anemias, erythropoiesis is ineffective.
21. Chapter 16-21

Which type of red blood cell has a single pointed extension resembling
a pear?
*a. Dacryocyte
b. Echinocyte
c. Acanthocyte
d. Keratocyte
General Feedback:
A dacrocyte is a red blood cell (RBC) with a single pointed
extension resembling a pear. A RBC with blunt or pointed, short
projections that are usually evenly spaced over the surface of cell is
an echinocyte. An acanthocyte is small, dense RBC with few irregularly
spaced projections of varying length. A keratocyte is a RBC fragment in
shape of a helmet.
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1. Chapter 17-01
Lack of accessible iron is the mechanism for iron deficiency in which
condition?
a. Hemochromatosis
b. Hemosiderosis
c. Lead poisoning
*d. Anemia of chronic inflammation (ACI)
General Feedback:
Lack of accessible iron results in ACI, as well as iron
deficiency. In iron deficiency iron stores are depleted. In ACI iron
stores are plentiful, but the iron is cannot be mobilized for use in
developing red cells.
2. Chapter 17-02
Which group of patients is most likely to develop iron deficiency from
increased need?
a. Young men
*b. Infants and young children
c. Postmenopausal women
d. Middle-aged men
General Feedback:
Infants and young children need more iron to support an
expanding erythron.
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3. Chapter 17-03
Where is most of the iron in the body found?
*a. Attached to hemoglobin in the red blood cells (RBCs)

b. Stored in macrophages in the bone marrow
c. Attached to transferrin
d. Myoglobin
General Feedback:
Approximately 65% of total body iron is found in hemoglobin.
Another 25% is stored as ferritin or hemosiderin, and about 10% is
divided among muscles, plasma, cytochrome of cells, and various iron-
containing enzymes of cells.
4. Chapter 17-04
Which is the best test to distinguish iron deficiency anemia from ACI?
a. Serum iron
b. Hemoglobin
c. Free erythrocyte protoporphyrin (FEP)
*d. Ferritin
General Feedback:
Of the tests listed, only ferritin distinguishes between iron
deficiency anemia and ACI; in iron deficiency anemia it is low, whereas
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in ACI it is normal to elevated. Serum iron and hemoglobin (if the

patient is anemic) are decreased in both; FEP is increased in both.
5. Chapter 17-05
How much iron do adult men need a day?
a. 0.5 mg
b. 0.75 mg
*c. 1.0 mg
d. 1.5 mg
General Feedback:
Adult men need about 1 mg of iron a day to maintain health.
6. Chapter 17-06
What parameter of the routine complete blood count (CBC) is a sensitive
indicator of preclinical iron deficiency?
*a. Red blood cell distribution width (RDW)

b. Hematocrit
c. Mean cell hemoglobin (MCH)
d. Red blood count
General Feedback:
As iron deficiency develops, hemoglobin synthesis begins to be
impaired leading to the production of microcytic red cells. As these
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small red cells begin to be released and mix in with the normocytic red
cells still circulating, anisocytosis develops. This increases the RDW,
which precedes the decrease in hemoglobin. Eventually the red count and
hematocrit begin to decrease, and the MCH decreases when enough small
cells become present to affect it.
7. Chapter 17-07
Which result is typical in stage 3 iron deficiency anemia?
a. Elevated reticulocyte percentage

b. Thrombocytopenia
c. Macrocytic red cells
*d. Low mean cell volume (MCV)
General Feedback:
In stage 3 iron deficiency, the red cells are microcytic and
hypochromic. Therefore the MCV, MCH, and MCHC are all low. (The MCH is
actually lower than would be expected for the red cell size if it had
been normochromic.) The reticulocyte count (%) is low, sometimes
thrombocytosis is seen, and the red cells are not macrocytic.
8. Chapter 17-08
What is most likely if a 10-month-old child who was fed only cow’s milk
has the following results?
· Serum iron decreased
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· Total iron-binding capacity (TIBC) increased

· Ferritin decreased
a. Lead poisoning
b. Chronic disease
*c. Iron deficiency from increased need and inadequate diet
d. Iron deficiency from chronic blood loss
General Feedback:
The iron studies all point to iron deficiency: low serum iron
and ferritin, with an elevated TIBC. Cow’s milk is a very poor source
of iron, so the infant is not getting adequate iron to support an
expanding erythron.
9. Chapter 17-09
What would be the likely findings if a bone marrow aspiration were
performed in a complicated case of iron deficiency anemia?
a. Increased myeloid-to-erythroid (M:E) ratio and increased

staining with Prussian blue
*b. Shaggy polychromatophilic normoblasts and no staining with
Prussian blue
c. Polychromatophilic normoblasts with copious pink cytoplasm and
no staining with Prussian blue
d. Increased M:E ratio and increased ringed sideroblasts
General Feedback:
NURSING
Shaggy polychromatophilic TB.COM are seen because of the
normoblasts
asynchronous maturation of developing red cells, with the cytoplasm
lagging behind that of the nucleus. Prussian blue is an iron-specific
stain; in iron deficiency anemia, iron stores are absent, and
sideroblasts and siderocytes are markedly decreased to absent. The M:E
ratio is increased late in iron deficiency because fewer red cell
precursors exist in the marrow, but no staining with Prussian blue
occurs.
10. Chapter 17-10

What is the mechanism for ACI?
*a. Acute phase reactants impair iron mobilization.

b. Inflammation and infections slow heme development.
c. Cytokines prevent iron incorporation into protoporphyrin.
d. Bone marrow iron stores are depleted by acute phase reactants.
General Feedback:
The acute phase reactants hepcidin, lactoferrin, and ferritin
all contribute to impairing the mobilization of iron for
erythropoiesis. Bone marrow iron stores are actually normal to
increased in ACI.
11. Chapter 17-11

Which are typical laboratory results for ACI?
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a. Decreased ferritin and decreased bone marrow Prussian blue

staining
b. Low serum iron and high TIBC
*c. Low serum iron and low TIBC
d. Increased transferrin saturation and decreased FEP
General Feedback:
Both serum iron and TIBC are low in ACI. Ferritin is normal to
increased, and Prussian blue staining reveals normal to increased
storage iron. However, the number of sideroblasts and siderocytes is
decreased to absent because iron cannot be moved to developing red
cells. FEP is increased, just as it is in iron deficiency anemia.
12. Chapter 17-12

Which red cell inclusion is often found in lead poisoning?
a. Howell-Jolly bodies
*b. Basophilic stippling
c. Heinz bodies
d. Cabot rings
General Feedback:
Basophilic stippling, sometimes quite coarse, is
characteristic of lead poisoning. Lead interferes with the breakdown of
pyrimidine 5?2'-nucleotides, which in turn are believed to retard the
breakdown of ribosomal ribonucleic acid (RNA), thus leading to
stippling.
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13. Chapter 17-13
How do lead exposure and the porphyrias cause anemia?
a. Cause destruction of red cells.

b. Chelate iron from the body.
c. Impair iron absorption.
*d. Interfere with heme production.
General Feedback:
Common to lead poisoning and the porphyrias is the impairment
of protoporphyrin synthesis, which is required for heme production.
14. Chapter 17-14

Most of the clinical findings in the porphyrias are related to:
*a. accumulated porphyrin compounds in tissue.

b. anemia.
c. reduction in heme production.
d. iron being unavailable.
General Feedback:
In the porphyrias (generally used to refer to the inherited
forms as opposed to acquired), an enzyme is missing in the
protoporphyrin IX synthesis pathway. When an enzyme is missing, the
products from earlier stages in the pathway accumulate in the blood.
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Some of these are excreted, but they also deposit in body tissues,
contributing to the clinical picture.
15. Chapter 17-15

Transfusion-related hemochromatosis is seen in patients who:
a. had an adverse reaction to a blood transfusion.

b. received the wrong type of blood.
*c. had repeated red blood cell transfusions.
d. received a transfusion from a relative.
General Feedback:
When patients with chronic severe anemias are maintained with
red cell transfusions, the iron in the transfused red cells adds to any
iron that is being absorbed normally. No mechanism exists to rid the
body of iron. Over years, this excess iron builds up and acquired
hemochromatosis develops. Red cell transfusions are thus a “double-
edged sword” for these patients. On one hand, they improve the quality
of life and perhaps even save it for the patient; on the other, the
eventual consequence after years of transfusions is acquired
hemochromatosis.
16. Chapter 17-16

Why is too much iron dangerous?
a. Transferrin, which carries iron, causes cellular swelling and

lysis.
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b. The oxygen carried by excess iron oxidizes neurologic cells.
c. Iron’s breakdown products cause excretion of vitamins C and E.
*d. Free radicals and superoxide formed from ferrous iron plus
oxygen damage cell membranes.
General Feedback:
When iron exceeds storage capacity, ferrous iron accumulates
in cells. Ferrous iron is easily oxidized and in so doing generates
superoxide and other free radicals, which are very damaging to cell
membranes, mitochondria, and other cell organelles. Cell death and
eventual possible organ failure are consequences.
17. Chapter 17-17

Which promotes increased iron absorption?
a. Repeated phlebotomy
*b. Diet high in ascorbic acid
c. Desferrioxamine
d. Vegetarian diet
General Feedback:
Ascorbic acid enhances iron absorption. Iron in vegetables is
nonheme iron, and it is not readily absorbed. Desferrioxamine chelates
iron and is used therapeutically for patients with transfusion-
dependent hemochromatosis. Repeated phlebotomy depletes iron, and it is
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the treatment used for patients with the hereditary form of

hemochromatosis.
18. Chapter 17-18

Which is decreased in patients with hereditary hemochromatosis?
*a. Albumin
b. Serum iron
c. Transferrin saturation
d. Ferritin
General Feedback:
Liver damage and disease is a consequence of hereditary
hemochromatosis; albumin is synthesized in the liver, and with liver
damage its concentration decreases. Serum iron, transferrin saturation,
and ferritin are all increased.
19. Chapter 17-19

Which test rises first after successful treatment for iron deficiency?
*a. Reticulocyte count

b. Ferritin
c. MCV
d. Hemoglobin
General Feedback:
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The reticulocyte count will begin to increase within 5 to 10
days after institution of therapy. Hemoglobin will take roughly 2
months to return to normal, although it will begin to slowly increase
within 2 weeks. The MCV will rise more slowly because the microcytic
red cells in circulation have to live out their normal life span; they
will gradually be replaced with more and more normocytic red cells.
Ferritin will be the last to rise; only after the erythron has been
restored to normal will there be any excess iron to go to stores.
20. Chapter 17-20

Which characterizes stage 1 iron deficiency?
Anemia MCV Ferritin
a. Present Decreased Decreased

b. Present Normal Normal
*c. Absent Normal Decreased
d. Absent Decreased Normal
General Feedback:
In early stage 1 iron deficiency, the red cell mass in
circulation is unaffected, so anemia is not present and the MCV is
normal. However, iron stores are being depleted, so ferritin is
decreased.
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21. Chapter 17-21

Which is true of stage 3 iron deficiency?
a. Serum transferrin receptors are decreased.

*b. FEP is increased.
c. The number of sideroblasts is normal.
d. The red cell count is increased, whereas the hematocrit is
decreased.
General Feedback:
FEP increases because not enough adequate iron is available to
insert into protoporphyrin IX. Transferrin receptors on the membrane of
developing cells increase as the cells try to capture as much iron as
possible (from what is bound to transferrin); these receptors are shed
into plasma so that they increase (actually happens in stage 2).
Sideroblasts will essentially be absent because no excess iron is going
to the developing red cells. The red cell count, as well as the
hematocrit, is decreased.
22. Chapter 17-22

Chronic blood loss leads to:
*a. iron deficiency anemia.

b. ACI.
c. megaloblastic anemia.
d. hemolytic anemia.

Chronic loss of blood leads to loss of red cells and their
iron content. Iron is conserved and recycled very tightly in the body.
To maintain normal stores, it requires that only the normal amount be
lost on a daily basis. Gradually iron stores will be depleted and iron
deficiency will develop.
23. Chapter 17-23

Which would point to iron deficiency anemia as opposed to the ACI?
a. Anemia
*b. High transferrin
c. Low serum iron
d. Elevated FEP
General Feedback:
Transferrin is high in iron deficiency anemia but low in the
ACI. All the other test results given are the same for both.
24. Chapter 17-24

Ringed sideroblasts are seen in:
*a. inherited sideroblastic anemia.

b. acquired hemochromatosis.
c. iron deficiency anemia.
d. ACI.
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General Feedback:
Ringed sideroblasts are seen in the inherited forms of
sideroblastic anemia but not in any of the other conditions listed.
25. Chapter 17-25

Ringed sideroblasts are a reflection of iron-laden:
*a. mitochondria.
b. Golgi complex.
c. ribosomes.
d. rough endoplasmic reticulum.
General Feedback:
In the sideroblastic anemias, where ringed sideroblasts are
present, plenty of iron is available to developing red cells. However,
for one reason or another, the iron cannot be inserted into the
protoporphyrin IX ring. Because this is the last step in heme synthesis
and it takes place in the mitochondria, the mitochondria become laden
with iron. When these cells are stained with Prussian blue, the iron
stains; mitochondria encircle the nucleus of the cell, so that what is
seen is a “ring” of stained iron granules encircling the nucleus (hence
called a ringed sideroblast).
26. Chapter 17-26

Why is lead poisoning of particular concern in children?
NURSINGTB.COM
a. Severe anemia may develop.
*b. Impaired mental development may occur.
c. Secondary iron deficiency may develop.
d. FEP may accumulate.
General Feedback:
In children who develop lead poisoning, the biggest concern is
the potential for impaired mental development.
27. Chapter 17-27

All are true about hepcidin except that:
a. it is an acute phase protein.

b. it is a hormone.
*c. it decreases in response to increased ferritin.
d. it increases in response to increased iron stores.
General Feedback:
Hepcidin is a hormone and is also an acute phase protein that
increases when iron levels are high. Ferritin is a form of storage
iron, so hepcidin increases when ferritin is increased, not decreased.
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1. Chapter 18-01
Megaloblastic anemias are caused by a defect in the synthesis of:
*a. deoxyribonucleic acid (DNA).

b. ribonucleic acid (RNA).
c. erythropoietin.
d. heme.
General Feedback:
Defects in DNA synthesis are the cause of most megaloblastic
anemias (an exception would be in the myelodysplastic syndrome).
2. Chapter 18-02
Which vitamins are required for the nuclear development of blood cells?
a. Vitamin C and folate

b. Vitamin B6 and folate
*c. Vitamin B12 and folate
d. Vitamin B12 and D
General Feedback:
Vitamins B12 and folate are required for normal nuclear
development (DNA synthesis).
3. Chapter 18-03
NUmacrocytic
Which is not associated with RSINGTB.red
COMcells?
a. Liver disease
*b. Iron deficiency anemia
c. Megaloblastic anemia
d. Myelodysplastic syndrome
General Feedback:
Iron deficiency is associated with microcytic, not macrocytic,
red cells. All the other conditions listed can be associated with
macrocytic red cells.
4. Chapter 18-04
Why are the red cells larger than normal in megaloblastic anemia?
a. Concentration of erythropoietin is increased.

b. Release of reticulocytes is increased.
c. Cells are made larger because fewer of them exist.
*d. Cell division is impaired.
General Feedback:
Red cell production is asynchronous in megaloblastic anemias,
with nuclear development lagging behind that of the cytoplasm. Because
DNA synthesis is affected, cell division does not occur normally and
the cells become larger.
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5. Chapter 18-05
Methotrexate and some other chemotherapeutic drugs work by:
a. killing cancer cells with immune complexes.

*b. competing with folate.
c. enhancing folate.
d. inhibiting vitamin B12 absorption.
General Feedback:
Methotrexate and some other chemotherapeutic drugs work by
competing with folate; thus a megaloblastic anemia can develop in these
patients.
6. Chapter 18-06
Patients with vitamin B12 or folate deficiency commonly experience
symptoms related to:
*a. gastrointestinal and neurologic systems.

b. liver and lymph node enlargement.
c. skeletal and muscle problems.
d. kidney and bladder infections.
General Feedback:
Any system in the body that depends on replacement of cells
with new ones will be affected by a deficiency of vitamin B12 or
NURSINcan
folate. Symptoms of the deficiency GTBthus
.COMbe seen in the
gastrointestinal tract, the skin, and the hematopoietic system.
7. Chapter 18-07
Decreased folate is often associated with which condition?
*a. Neural tube defects

b. Increased potassium
c. Microcytic anemia
d. Hyperhomocysteinemia
General Feedback:
Decreased folate in a pregnant woman can lead to neural tube
defects in the fetus. Neural tube defects are most commonly associated
with folate deficiency.
8. Chapter 18-08
All of the following have increased need for folate except:
a. patients on chemotherapy.
b. pregnant women.
c. infants and children.
*d. male adults.
General Feedback:
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Men (i.e., male adults) should have a diet adequate to meet

their folate requirements. Patients on chemotherapy often are given
drugs that interfere with DNA metabolism, and so they require more
folate. Pregnant women have an increased need to support the growing
fetus, as do infants and children, especially during growth spurts.
9. Chapter 18-09
Which is the best source of dietary vitamin B12?
a. Fruit
b. Green vegetables
*c. Meat
d. Legumes
General Feedback:
Meat provides the best source of vitamin B12; meat by-products
such as milk and eggs are sources other than meat. Plants have no need
for this vitamin, and so it is not available in green vegetables,
legumes, or fruit. Thus it is possible, over time, for a true dietary
deficiency to develop for a strict vegetarian (i.e., vegan).
10. Chapter 18-10

Which is normal in patients with pernicious anemia (PA)?
*a. Trypsin levels

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b. Intrinsic factor (IF)
c. Stomach acid
d. Absorption of vitamin B12
General Feedback:
Trypsin is normal in patients with PA. The root cause of PA is
a deficiency of IF because of autoimmune attack, either of IF itself or
of the parietal cells in which it is synthesized. Atrophic gastritis
develops; this affects the secretion of H+, which affects gastric
(stomach) acidity, important for normal digestive processes.
11. Chapter 18-11

PA can be distinguished from folate deficiency by the:
a. presence of hypersegmented neutrophils.

b. mean cell volume (MCV).
c. bone marrow findings.
*d. presence of autoantibodies to IF.
General Feedback:
Both PA and folate deficiency have an elevated MCV, the
presence of hypersegmented neutrophils, and megaloblastic bone marrow
findings. However, only PA has autoantibodies to IF present.
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12. Chapter 18-12

Which is decreased in megaloblastic anemia?
*a. Reticulocyte count

b. MCV
c. Lactic dehydrogenase (LD)
d. Bilirubin
General Feedback:
Impaired cell production results in a low absolute
reticulocyte count, especially in light of the severity of the anemia.
Intramedullary cell death occurs in ineffective erythropoiesis, and
this leads to both an increased LD (released from dying cells) and
increased bilirubin (increased breakdown of hemoglobin).
13. Chapter 18-13

Which is elevated in megaloblastic anemia?
a. White blood count

*b. Mean cell hemoglobin (MCH)
c. Red blood count
d. Platelet count
General Feedback:
Pancytopenia is found in the megaloblastic anemias because all
the blood-forming cells require DNA synthesis to proliferate and
replace those cells that die even under normal circumstances. Thus the
white count, red count, andNplatelet
URSINGTcount
B.COare
M all expected to be
decreased. However, because the red cells are macrocytic and
normochromic, the MCH is elevated (reflection of fully hemoglobinized
large red cells).
14. Chapter 18-14

Which would be an unusual finding in megaloblastic anemia?
*a. Marked polychromasia on the blood film

b. Hypersegmented neutrophils
c. Oval macrocytes
d. Pancytopenia
General Feedback:
Ineffective erythropoiesis leads to intracellular death so
that many red cells never make it to circulation; thus polychromasia is
not typical. However, hypersegmented neutrophils are a hallmark and, in
fact, appear before changes in red cells are obvious. This is because
of their short T1/2 of 6 to 10 hours in circulation. Oval macrocytes
are a characteristic red cell shape in the megaloblastic anemias, and
pancytopenia is usually present because all proliferating blood-forming
cells in the bone marrow require normal DNA synthesis.
15. Chapter 18-15

Which is true regarding hypersegmented neutrophils?
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a. Found in so many conditions that they are not significant

b. Reported when neutrophils have four or more nuclear segments
*c. Are an early, consistent, and specific finding in
megaloblastic anemia
d. Usually accompany microcytic red cells
General Feedback:
Hypersegmented neutrophils are consistently found early in
megaloblastic anemia. Because they are not found in any other
condition, they are considered specific. Thus they usually accompany
macrocytic red cells (including macroovalocytes). Laboratories may use
differing criteria for hypersegmentation. However, all would agree that
observation of one six-lobed neutrophil is evidence of
hypersegmentation. Some will do a neutrophil lobe count, and report
hypersegmentation when the average is greater than 3.4.
16. Chapter 18-16

Which bone marrow finding would be unexpected in megaloblastic anemia?
a. Nuclear cytoplasmic asynchrony

b. Giant bands and metas
c. Hypercellularity
*d. Myeloid-to-erythroid (M:E) ratio of 10:1
General Feedback:
An M:E ratio of 10:1 would imply that 10 times as many myeloid
cells exist as do erythroidNprecursors
URSINGTBin .Cthe
OM marrow. However,
erythroid hyperplasia occurs in the marrow, so the M:E ratio is
decreased to about 1:1. The marrow is hypercellular, nuclear
cytoplasmic asynchrony occurs in maturation because of the defect in
DNA synthesis, and giant bands and metas are characteristic.
17. Chapter 18-17

Which test for PA would be easiest for the patient?
*a. Vitamin B12 assay

b. Bone marrow
c. Gastric analysis
d. Schilling test
General Feedback:
The easiest test for the patient would be a vitamin B12 assay.
All that is required for this test is a venipuncture. The other tests
are all much more invasive.
18. Chapter 18-18

What is the most effective treatment for PA?
a. Oral folate
*b. Injections of vitamin B12
c. Oral vitamin B12
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d. Alterations in diet
General Feedback:
PA is a deficiency of vitamin B12 (not folate) because of a
lack of IF, which is required for absorption. The vitamin is usually
administered by injection through muscle. Because IF deficiency is the
actual defect, taking vitamin B12 orally will be of no benefit because
it cannot be absorbed. Administering it by injection bypasses the need
for absorption.
19. Chapter 18-19

A patient has a decreased vitamin B12 assay. The Schilling test detects
labeled vitamin B12 in the urine when it is given with IF. What is the
correct interpretation?
a. Vitamin B12 assay probably incorrect

*b. Pernicious anemia
c. Vitamin B12 deficiency that is not PA
d. Gastric analysis should be performed
General Feedback:
The Schilling test is used to determine if the reason for low
vitamin B12 is an inability to absorb because of lack of IF or if the
problem in absorption is related to something else. Because IF
apparently corrected the problem in absorption, PA is the diagnosis. If
some other malabsorption problem
NURSIexisted,
NGTB.Cthe
OM addition of IF would not
have corrected the problem and the labeled vitamin B12 would not have
appeared in the urine.
20. Chapter 18-20

A patient with moderate anemia has an elevated MCV and hypersegmented
neutrophils. Which should be ordered first?
a. Schilling test
b. Gastric analysis
c. Antibodies to IF
*d. Vitamin B12 and folate assays
General Feedback:
The blood picture findings point to a megaloblastic anemia.
The first test to order would be the vitamin B12 and folate assays to
determine which of these two vitamins is deficient.
21. Chapter 18-21

What salivary protein is important for the transport of dietary vitamin
B12 to the small intestine?
a. Trypsin
b. IF
*c. Haptocorrin
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d. Transcobalamin II
General Feedback:
Haptocorrin is a salivary protein that binds vitamin B12 found
in food. In the small intestine, the vitamin is released from
haptocorrin by the action of trypsin. IF is then required for its
absorption into circulation. Transcobalamin is the most important of
the plasma carrier proteins for vitamin B12.
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1. Chapter 19-01
Pancytopenia is a term that means:
*a. decrease in red cells, white cells, and platelets.

b. increase in red and white cells.
c. decrease in any two blood cell lines.
d. increase in white cells and platelets.
General Feedback:
A decrease in all the blood cells (i.e., red cells, white
cells, and platelets) is called pancytopenia.
2. Chapter 19-02
Bone marrow failure causes pancytopenia:
a. in the peripheral blood only.

b. in the bone marrow only.
*c. in both the bone marrow and the peripheral blood.
d. in the bone marrow, peripheral blood, and spleen.
General Feedback:
Bone marrow failure results in a decrease in all the blood
cells’ elements in the bone marrow (hence it is called bone marrow
failure). Because blood cells are not being produced in adequate
numbers in the bone marrow to enter the peripheral blood, pancytopenia
is also seen in the blood.
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3. Chapter 19-03
Which is most useful for considering the diagnosis of pancytopenia?
a. Hemoglobin less than 10g/dL

*b. Increased absolute neutrophil count
c. Increased absolute lymphocyte count
d. Decreased mean cell volume
General Feedback:
The absolute neutrophil count is decreased, and the absolute
lymphocyte count may be normal or decreased. The hemoglobin is usually
less than 10 g/dL, the mean cell volume (MCV) is increased or normal,
and the percent and absolute reticulocyte counts are decreased.
4. Chapter 19-04
Which patient fits the typical patient demographics for aplastic
anemia?
a. Infant
*b. A 65-year-old adult
c. A 45-year-old adult
d. A 7-year-old child
General Feedback:
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Aplastic anemia can be found at any age, but it is most

characteristically found in young adults 15 to 25 years old, as well as
in those older than 60 years.
5. Chapter 19-05
The red cell morphology associated with aplastic anemia is:
*a. normocytic normochromic with no polychromasia.

b. normocytic normochromic with marked polychromasia.
c. microcytic hypochromic with marked polychromasia.
d. microcytic normochromic with no polychromasia.
General Feedback:
Red cells are characteristically normocytic normochromic in
aplastic anemia, although occasionally some macrocytosis may exist.
Polychromasia is absent.
6. Chapter 19-06
Which would be an unusual bone marrow finding in aplastic anemia?
a. Predominance of lymphocytes, plasma cells, and mast cells

b. Hypocellular
*c. Increased megakaryocytes
d. Increased fat
General Feedback:
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In aplastic anemia, the marrow is hypocellular with increased
fat. The normal blood-forming cells are greatly diminished, and the
cells left in the bone marrow are lymphocytes, plasma cells, and mast
cells.
7. Chapter 19-07
What is the treatment of choice for long-term survival for patients
younger than 40 years old with aplastic anemia?
a. Blood transfusion
b. Growth factors
c. Antibiotic agents
*d. Bone marrow transplant
General Feedback:
Bone marrow transplant is the treatment of choice for patients
with severe aplastic anemia who are younger than 40 years of age and
have a human leukocyte antigen (HLA)-identical sibling.
8. Chapter 19-08
What is the treatment of choice for a patient older than 40 years old
with aplastic anemia?
a. Hematopoietic stem cell transplant

b. Antibiotic agents
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*c. Antithymocyte globulin (ATG)

d. Erythropoietin
General Feedback:
Immunosuppressive treatment, consisting of antithymocyte
globulin and cyclosporine, is used for patients older than 40 years of
age and for patients without an HLA-identical sibling.
9. Chapter 19-09
Which is an inherited disorder with pancytopenia, malformed kidneys,
and short stature?
a. Myelodysplasia
*b. Fanconi anemia
c. Diamond-Blackfan anemia
d. Secondary aplastic anemia
General Feedback:
Fanconi anemia is an autosomal recessive disorder, which means
that the gene must be inherited from both parents to express the
phenotype. Myelodysplasia and secondary aplastic anemia are both
acquired. Diamond-Blackfan anemia is an inherited form of pure red cell
aplasia (PRCA). Neutrophil and platelet precursors are normal.
10. Chapter 19-10

What distinguishes PRCAs such as Diamond-Blackfan syndrome from
aplastic anemia?
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a. Peripheral red blood count
b. Number of erythroid stem cells in the bone marrow
*c. Normal cellularity of myeloid cells
d. Red cell indices
General Feedback:
Diamond-Blackfan anemia is characterized by an isolated PRCA
and normal cellularity of myeloid cells. Red cell indices are not
useful.
11. Chapter 19-11

Which is a feature of type II congenital dyserythropoietic anemia (CDA
II)?
*a. Giant, multinucleated red cell precursors

b. Microcytic red cells
c. Positive sucrose hemolysis test
d. Negative acidified serum test (Ham test)
General Feedback:
CDA II is also known as hereditary erythroblastic
multinuclearity with positive acidified serum (HEMPAS). It is the most
common type of CDA, and is, as the alternate name suggests, associated
with giant, multinucleated erythroblastic precursors. The acidified
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serum test (Ham test) is positive, not the sucrose hemolysis test. Red
cells are usually normocytic, although often anisocytosis is noted.
12. Chapter 19-12

Normal bone marrow cells being replaced with malignant cells is called:
a. Diamond-Blackfan anemia.
b. CDA II.
c. PRCA.
*d. myelophthisic anemia.
General Feedback:
Myelophthisic anemia results when invading or infiltrating
cells replace normal bone marrow cells. These invading cells may be
malignant.
13. Chapter 19-13

The anemia associated with severe kidney disease is caused primarily
by:
a. damage to stem cells by urea.

b. replacement of bone marrow cells with fat.
*c. deficiency of erythropoietin.
d. bleeding into the urine.
General Feedback:
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A deficiency of erythropoietin is the primary cause of the
anemia found in chronic renal failure. The kidney is the primary site
of synthesis for erythropoietin, which controls red cell production.
14. Chapter 19-14

What surface antigen on cells identifies them as a hematopoietic stem
cell?
a. CD8+
*b. CD34+
c. CD55+
d. CD59+
General Feedback:
Hematopoietic stem cells are identified by the presence of
CD34+ on their surface. These are decreased in aplastic anemia.
15. Chapter 19-15

The cause of acquired idiopathic aplastic anemia is:
a. Epstein-Barr virus.
b. chemicals such as benzene.
c. radiation.
*d. unknown.
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General Feedback:
The term idiopathic means unknown; therefore, the cause of
idiopathic aplastic anemia is unknown. All the other items listed are
possible causes of secondary aplastic anemia.
16. Chapter 19-16

Diepoxybutane causes chromosomal breakage in which disorders?
a. Acquired aplastic anemia

*b. Fanconi anemia
d. CDA
General Feedback:
Diepoxybutane is a deoxyribonucleic acid (DNA) cross-linking
agent. When this is added to Fanconi anemia cells in culture, a
characteristic chromosomal breakage occurs. This is the diagnostic test
for Fanconi anemia.
17. Chapter 19-17

Paroxysmal nocturnal hemoglobinuria has a high degree of association
with which disorders?
*a. Aplastic anemia

b. Fanconi anemia
d. CDA
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General Feedback:
Approximately one-third of aplastic anemia patients develop
paroxysmal nocturnal hemoglobinuria.
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3. Chapter 20-03
How are normal red cells removed when they lose the ability to deform?
*a. Most are phagocytized by splenic macrophages.

b. Most are phagocytized by gastrointestinal macrophages.
c. Most are destroyed by complement.
d. Most are destroyed inside the blood vessels.
General Feedback:
At the end of their normal life span, red cells are removed
from circulation by splenic macrophages.
4. Chapter 20-04
Which breakdown product of hemoglobin is removed from the body instead
of being recycled?
a. Globin
b. Amino acids
*c. Protoporphyrin ring
d. Iron
General Feedback:
The protoporphyrin ring is gradually degraded into bilirubin
and eventually excreted from the body. Globin chains are broken down
into their component amino acids, which are returned to the amino acid
pool for future protein synthesis. Iron is very tightly conserved and
recycled.
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5. Chapter 20-05
Unconjugated or indirect bilirubin is normally found in:
*a. plasma.
b. erythrocytes.
c. urine.
d. intestines.
General Feedback:
The bilirubin originally released from macrophages after
degradation of the protoporphyrin ring is normally found in plasma
before conjugation in the liver.
6. Chapter 20-06
The presence of hemoglobinuria, hemosiderinuria, and hemoglobinemia
indicate that hemolysis is:
a. severe.
b. acquired.
c. compensated.
*d. intravascular.
General Feedback:
When hemolysis is intravascular, red cells are lysed within
the circulation releasing hemoglobin; this is called hemoglobinemia. If
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the renal threshold is exceeded, some hemoglobin may pass through the
kidney and thus be found in urine (i.e., hemoglobinuria). Renal tubular
epithelial cells, where the iron is separated from protoporphyrin, take
up some hemoglobin passing through the kidney. Some of these renal
tubular epithelial cells will gradually be sloughed off into the urine;
an iron-specific stain will demonstrate the presence of iron in the
form of hemosiderin (as in hemosiderinuria).
7. Chapter 20-07
Which is found normally in urine?
a. Conjugated bilirubin
*b. Urobilinogen
c. Stercobilin
d. Unconjugated bilirubin
General Feedback:
Bacteria in the gut oxidize conjugated bilirubin into various
water-soluble compounds that together are called urobilinogen. A small
amount of this is normally reabsorbed into the plasma and because of
its water solubility will be filtered by the renal glomerulus and
excreted into urine.
8. Chapter 20-08
Which are typical findings in extravascular hemolysis?
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a. Increased serum and urine conjugated bilirubin
b. Increased serum and urine unconjugated bilirubin
*c. Increased serum, unconjugated bilirubin, and increased urine
urobilinogen
d. Decreased urine and stool conjugated bilirubin
General Feedback:
During the process of extravascular hemolysis, macrophages
phagocytize and break down hemoglobin into its various component parts.
Unconjugated bilirubin is thus increased. This is taken to the liver,
where it is conjugated. Bacteria in the gut oxidize conjugated
bilirubin into various water-soluble compounds that together are called
urobilinogen. Some of this is reabsorbed into the plasma and because of
its water solubility will be filtered by the renal glomerulus and
excreted into urine. This results in an increase in urobilinogen in the
urine.
9. Chapter 20-09
A urine sediment stains with Prussian blue. The patient probably has:
*a. hemoglobinemia.
b. a membrane defect.
c. compensated hemolysis.
d. extravascular hemolysis.
General Feedback:
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When the amount of free hemoglobin exceeds the capacity of

plasma salvage systems (e.g., haptoglobin, hemopexin), free hemoglobin
can be found in plasma. This hemoglobin is filtered through the kidney;
some of the iron will be released and taken up by renal tubular cells
that are eventually sloughed off into the urine. The iron can be
detected in these renal tubular epithelial cells by giving a positive
Prussian blue stain.
10. Chapter 20-10

A plasma sample appears hemolyzed or red. Which is true?
a. The patient has extravascular hemolysis.

b. The patient has increased haptoglobin.
c. The patient has increased hemopexin.
*d. The plasma hemoglobin is greater than 50 mg/dL.
General Feedback:
Plasma hemoglobin can be detected when the concentration of
hemoglobin is equal to or greater than 50 mg/dL. Free hemoglobin is
seen in plasma, giving its red color when excessive intravascular
hemolysis exists. Both haptoglobin and hemopexin will be decreased as
an attempt to salvage iron occurs.
11. Chapter 20-11

Which is decreased in intravascular hemolysis?
*a. Haptoglobin
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b. Urine hemoglobin
c. Serum hemoglobin
d. Urine urobilinogen
General Feedback:
Haptoglobin will be decreased in intravascular hemolysis as
the free hemoglobin is bound in an attempt to salvage the iron.
12. Chapter 20-12

Which clinical finding specifically suggests, if it is present,
extravascular hemolysis?
a. Increased heart rate

*b. Splenomegaly
c. Pallor
d. Fatigue
General Feedback:
A chronic extravascular hemolytic process can lead to an
enlarged spleen (splenomegaly). All of the other clinical findings
listed may be found in anemia because of any cause—they are nonspecific
findings.
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13. Chapter 20-13

Which is the most specific indicator of accelerated intravascular red
cell destruction?
a. Increased serum bilirubin

b. Increased haptoglobin
c. Decreased hematocrit
*d. Decreased haptoglobin
General Feedback:
When red cells are destroyed in the circulation, hemoglobin is
released into plasma. Haptoglobin binds the free hemoglobin and thus
decreases in plasma. This is specific for intravascular hemolysis.
14. Chapter 20-14

An elevated reticulocyte count rules out which condition?
a. Acute blood loss

*b. Aplastic crisis
c. Acute hemolysis
d. Successful patient response to iron therapy
General Feedback:
An elevated reticulocyte count is seen after acute blood loss,
acute hemolysis, and after successful patient response to iron therapy.
It is not observed in an aplastic crisis.
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15. Chapter 20-15
The reticulocyte count is the most commonly used test to identify:
*a. accelerated erythropoiesis.

b. erythropoiesis clumping.
c. erythrocyte agglutination.
d. white blood cell differential.
General Feedback:
The reticulocyte count is the most commonly used laboratory
test to identify accelerated erythropoiesis, including an elevation of
the immature reticulocyte fraction.
16. Chapter 20-16

Which effect does red blood cell fragmentation have on serum?
*a. Increases total bilirubin.

b. Decreases indirect bilirubin.
c. Increases haptoglobin.
d. Increases hemopexin.
General Feedback:
Blood cell fragmentation in serum increases total bilirubin,
increases indirect bilirubin, decreases haptoglobin, and decreases
hemopexin.
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17. Chapter 20-17

Which is often seen in various types of hemolytic anemia except:
a. schistocytes.
b. spherocytes.
c. polychromasia.
*d. hypochromasia.
General Feedback:
Hypochromia is present when hemoglobin synthesis is abnormal
such as in iron deficiency anemia. It is not observed in hemolytic
anemias.
18. Chapter 20-18

Which is related to chronic inherited hemolytic anemia?
a. Edema
b. Hepatomegaly
*c. Cholelithiasis
d. Liver disease
General Feedback:
Major clinical features of chronic inherited hemolytic anemia
are varying degrees of anemia, jaundice, splenomegaly, and the
development of cholelithiasis.
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19. Chapter 20-19
What characteristic red cell shape is associated with extravascular
hemolysis?
*a. Spherocyte
b. Schistocyte
c. Target cell
d. Burr cell
General Feedback:
Spherocytes suggest extravascular hemolysis.
20. Chapter 20-20

Which test result suggests red blood cell (RBC) survival is
significantly decreased from the normal of 120 days?
*a. Decreased glycated hemoglobin

b. A T1/2 Cr of 30 days
c. Normal haptoglobin
d. Decreased lactic dehydrogenase
General Feedback:
Glycated hemoglobin increases over the life of the red cell as
it (the red cell and thus hemoglobin) is continually exposed to glucose
in plasma. In hemolytic disease, the red cells have a shortened
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survival and thus less exposure to glucose, which results in a lower

glycated hemoglobin than normal. Haptoglobin is an acute phase protein
and may be normal or even increased even in intravascular hemolysis if
the patient has concurrent inflammation; thus a normal haptoglobin does
not rule out intravascular hemolysis with a shortened RBC survival.
Lactic dehydrogenase is released from lysed red cells and increases
when RBC survival is shortened. A T1/2 Cr of 30 days is normal.
21. Chapter 20-21

The presence of schistocytes in the peripheral blood indicates which of
the following processes?
a. Iron deficiency anemia

*b. Intravascular hemolysis
c. Megaloblastic anemia
d. Extravascular hemolysis
General Feedback:
Schistocytes are fragmented red cells that result when the red
cell membrane is damaged by trauma as can be seen in some intravascular
hemolytic anemias.
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1. Chapter 21-01
The most common inherited anemia found in people of northern European
ancestry is hereditary:
a. elliptocytosis.
b. stomatocytosis.
*c. spherocytosis.
d. pyropoikilocytosis.
General Feedback:
The incidence of hereditary spherocytosis is highest in people
of northern European ancestry, although it is found worldwide. It is
the most commonly inherited hemolytic anemia in this population.
2. Chapter 21-02
Which disorder describes red cells that acquire a reduced surface area
from losing unsupported membrane when defective proteins disrupt
vertical interactions between transmembrane proteins and the
cytoskeleton?
*a. Spherocytosis
b. Stomatocytosis
c. Pyropoikilocytosis
d. Acanthocytosis
General Feedback:
Hereditary spherocytosis has membrane protein deficiencies
NURred
that result in an unsupported SIN GTBmembrane.
cell .COM This leads to a
reduced surface area.
3. Chapter 21-03
What causes the destruction of red cells in hereditary spherocytosis?
a. Complement activation
b. Bound autoantibodies
c. Phagocytosis by peripheral monocytes
*d. Phagocytosis by splenic macrophages
General Feedback:
The spherocytes found in hereditary spherocytosis are rigid
and not as deformable as the normal biconcave red cell. The spleen
selectively sequesters these abnormal red cells as they move through
the spleen, where they become further damaged and are selectively
removed by macrophages in the red pulp of the spleen.
4. Chapter 21-04
Which is normal in hereditary spherocytosis?
a. Red cell morphology

*b. Direct antiglobulin test
c. Osmotic fragility
d. Reticulocyte count
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General Feedback:
The direct antiglobulin test detects antibodies present on the
red blood cell (RBC) membrane. Because they are not present in
hereditary spherocytosis, this test will be negative (normal). Red cell
morphology ideally shows spherocytes (depending on the number present),
the osmotic fragility is increased, and the reticulocyte count is
increased.
5. Chapter 21-05
A patient with a previously compensated hereditary spherocytosis has a
severe drop in hemoglobin and reticulocyte count after a parvovirus
infection. This represents what type of crisis?
a. Megaloblastic
b. Hemolytic
*c. Aplastic
d. Anemic
General Feedback:
After some viral infections, particularly with parvovirus B19
(which invades developing red cells and inhibits their growth), a
severe drop in hemoglobin can occur. This is termed an aplastic crisis.
6. Chapter 21-06
Which can distinguish immune hemolytic anemia from hereditary
spherocytosis in a patient with spherocytes?
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a. Osmotic fragility
c. Presence of polychromasia
*d. Direct antiglobulin test
General Feedback:
The immune hemolytic anemias with spherocytes are
differentiated from hereditary spherocytosis by the presence of a
positive direct antiglobulin test. This test, when positive,
demonstrates the presence of antibodies on the red cell membrane.
7. Chapter 21-07
Which is a typical finding in hereditary spherocytosis?
*a. Increased mean cell hemoglobin concentration (MCHC)

b. Normal reticulocytes
c. Reduced fragility of red cells
d. Normal spectrin
General Feedback:
It is common for the MCHC to be abnormally increased greater
than 36 g/dL in patients with hereditary spherocytosis. This probably
results from cellular dehydration of cells that have gone through the
spleen and have low levels of water and potassium. The reticulocyte
count is increased, osmotic fragility increased, and spectrin is
abnormal.
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8. Chapter 21-08
A patient with a small number of spherocytes, increased reticulocytes,
and increased MCHC has a normal osmotic fragility. Select the best
course of action.
a. Dismiss the spherocytes as an artifact.

*b. Repeat the osmotic fragility after incubating the blood at
37°C for 24 hours.
c. Check the cell counter for errors in the MCHC.
d. Collect a new blood sample.
General Feedback:
Incubating the blood at 37°C for 24 hours can increase the
sensitivity of the osmotic fragility so that a previously normal result
becomes abnormal. During this incubation period, red cells become
metabolically deprived and tend to lose membrane surface because of
their relative membrane instability.
9. Chapter 21-09
All would be expected 1 year after a splenectomy on a patient with
severe hereditary spherocytosis except:
a. spherocytes on the blood film.

b. Howell-Jolly bodies.
*c. reticulocyte count of 10%.
d. siderocytes.
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General Feedback:
After splenectomy, the anemia is usually corrected and
reticulocyte counts return to high normal. However, the consequences of
splenectomy, done for whatever reason, are the appearance of Howell-
Jolly bodies, siderocytes, and target cells in red cells. Spherocytes
will still be observable in hereditary spherocytosis.
10. Chapter 21-10

What treatment is most common for hereditary elliptocytosis patients
who are anemic and show signs of hemolysis?
a. No treatment available
b. Drugs to prolong RBC life span
*c. Splenectomy
d. Transfusions
General Feedback:
Hereditary elliptocytosis patients who are significantly
anemic and show signs of hemolysis respond well to splenectomy.
Transfusions are occasionally needed for life-threatening anemia before
splenectomy. No drugs are available to prolong the life of a RBC.
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11. Chapter 21-11

Cells with a slit (stomatocytes) instead of a round central pallor can
be found in all of the following except:
a. liver disease of alcoholism.

b. Rh null disease.
*c. hereditary elliptocytosis.
d. blood films with a drying artifact.
General Feedback:
The characteristic red cell morphology in hereditary
elliptocytosis is elliptic. All other situations listed can show the
presence of stomatocytes.
12. Chapter 21-12

What red cell morphology is often seen in patients with uremia?
a. Spherocytes
*b. Echinocytes
c. Elliptocytes
d. Stomatocytes
General Feedback:
Echinocytes, also called burr cells, are seen in uremic
patients and neonates.
13. Chapter 21-13

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What red cell morphology is associated with abetalipoproteinemia, liver
disease, and McLeod blood group?
*a. Acanthocytes
b. Stomatocytes
c. Spherocytes
d. Elliptocytes
General Feedback:
Acanthocytes are seen in all these situations.
14. Chapter 21-14

What ethnic group most often has glucose-6-phosphate dehydrogenase
(G6PD) A?2- in the United States?
a. Northern European male subjects

b. Asian American female subjects
c. African American female subjects
*d. African American male subjects
General Feedback:
In the United States, African American male subjects are the
ethnic group that most commonly has G6PD A?2- deficiency. From 10% to
11% of these subjects carry this gene. The gene is X linked, so that
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female subjects are carriers and generally do not have clinical

problems.
15. Chapter 21-15

What is the typical clinical course for those with G6PD A?2-?
a. Severe anemia from infancy onward

b. Moderate anemia throughout adulthood
*c. No anemia until exposure to an oxidant drug causes acute
hemolysis
d. Benign because it does not cause anemia
General Feedback:
Patients with G6PD A?2- are clinically normal unless exposed
to an oxidant drug. This can result in acute hemolysis.
16. Chapter 21-16

What red cell morphology, using Wright stain, is seen in patients with
G6PD deficiency during a hemolytic episode?
*a. Bite cells and polychromasia

b. Heinz bodies
c. Acanthocytes and crenated cells
d. Red cells are normal

Bite cells and polychromasia are seen with a Wright stain
during a hemolytic episode. Heinz bodies, although present, are not
visible with a Wright stain.
17. Chapter 21-17

A patient in the hospital for a hemolytic crisis after an infection has
Heinz bodies when his blood is incubated with crystal violet. The
fluorescent enzyme-screening test for G6PD is normal. Select the best
course of action.
a. Repeat the red cell examination with new methylene blue stain.
*b. Repeat the enzyme test several weeks after the hemolytic
crisis.
c. Perform an osmotic fragility test.
d. Perform a haptoglobin test.
General Feedback:
Reticulocytes have higher levels of G6PD than older red cells.
Because reticulocytes are increased after a hemolytic episode, their
presence can give a false-negative (normal) result in the screening
test for G6PD. Testing should be repeated when the patient has returned
to normal, with a normal cohort of red cells (all ages).
18. Chapter 21-18

What is the most common enzyme deficiency of the glycolytic pathway?
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a. Aldolase
b. Enolase
c. Lactic dehydrogenase (LDH)
*d. Pyruvate kinase (PK)
General Feedback:
PK is the most common enzyme deficiency in the glycolytic
pathway.
19. Chapter 21-19

What is the most common red cell morphologic finding in PK deficiency?
a. Elliptocytes
*b. Polychromasia and echinocytes (crenated)
c. Heinz bodies and spherocytes
d. Microcytes and hypochromasia
General Feedback:
Polychromasia and echinocytes are the most common red cell
morphologic findings in PK deficiency.
20. Chapter 21-20

What is the best test to confirm the diagnosis of PK?
*a. PK enzyme assay

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c. Haptoglobin test
d. Urine hemosiderin test
General Feedback:
The clinician makes a diagnosis of PK deficiency by performing
an assay for the enzyme.
21. Chapter 21-21

What destroys the red cells in paroxysmal nocturnal hemoglobinuria?
a. Macrophages in the bone marrow

b. Antibodies against red cell membrane antigens
*c. Increased susceptibility to complement
d. Macrophages in the spleen
General Feedback:
Red cells in paroxysmal nocturnal hemoglobinuria are
abnormally sensitive to complement, which is activated on their surface
and results in premature destruction of the red cells.
22. Chapter 21-22

Which is a typical finding in paroxysmal nocturnal hemoglobinuria?
*a. Hemosiderin in urine sediment
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b. Normal levels of decay accelerating factor (CD55)

c. Hemolysis when blood is alkaline
d. Elevated white cells and platelets
General Feedback:
Hemosiderin is present and a useful diagnostic tool in
paroxysmal nocturnal hemoglobinuria. Levels of CD55 are decreased in
paroxysmal nocturnal hemoglobinuria. Hemolysis occurs when blood is
acidic, and platelets and white cells are usually decreased so that the
patient is pancytopenic.
23. Chapter 21-23

Which test can confirm a paroxysmal nocturnal hemoglobinuria diagnosis
in a patient?
a. Sucrose hemolysis test (sugar water test)

c. Ham test (acidified serum lysis test)
*d. Flow cytometry for cell surface markers
General Feedback:
The reticulocyte count is elevated in all hemolytic anemias at
the time of hemolysis (unless an aplastic crisis is present). Of the
other procedures listed only flow cytometry is sensitive enough to be
useful for the diagnosis of paroxysmal nocturnal hemoglobinuria. The
sucrose hemolysis and Ham tests have been replaced by flow cytometry.
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24. Chapter 21-24
In most patients with hereditary spherocytosis, the condition is:
*a. inherited as an autosomal dominant trait.

b. inherited as an autosomal recessive trait.
c. inherited as an X-linked recessive trait.
d. acquired after viral infection.
General Feedback:
Most patients (75% of families) inherit hereditary
spherocytosis as an autosomal dominant trait, although autosomal
recessive forms exist.
25. Chapter 21-25

Which of the following is a true statement regarding G6PD?
a. The gene is located on chromosome 22.

*b. The gene has the greatest degree of variability in the human
genome.
c. The deficiency is primarily expressed as a clinical disease in
heterozygous female subjects.
d. The normal enzyme is called G6PD A.
General Feedback:
The G6PD gene has the greatest degree of variability in the
human genome; this results in multiple clinical variants. The gene is
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found on the X chromosome, so it is only rarely clinically expressed in

heterozygous female subjects who have one normal X chromosome. However,
they can be shown to have varying numbers of G6PD-deficient red cells.
The normal enzyme is called G6PD B. G6PD A contains one mutation so
that its electrophoretic pattern is different, but it is a benign
change.
26. Chapter 21-26

Why is G6PD important for normal red cell survival?
a. Hemoglobin oxygen affinity is increased in its absence.

*b. It is required to regenerate reduced glutathione.
c. It is required for insertion of iron into the protoporphyrin
ring to form heme.
d. Alpha chains are produced in excess in its absence.
General Feedback:
G6PD is required to regenerate reduced glutathione in the red
cell. Reduced glutathione is essential to generate nicotinamide adenine
dinucleotide phosphate, which is necessary to prevent oxidative damage
to the red cell.
27. Chapter 21-27

Paroxysmal nocturnal hemoglobinuria is:
a. inherited as an X-linked recessive trait.

NURSINGTB.COM
*b. acquired as a clonal disorder.
c. inherited as an autosomal dominant disorder.
d. acquired after a viral infection.
General Feedback:
Paroxysmal nocturnal hemoglobinuria is an acquired disorder
that can be shown to be clonal in nature. Some patients have two
populations of red cells: (1) normal and (2) defective.
28. Chapter 21-28

The inability to attach proteins requiring a
glycosylphosphatidylinositol (GPI) link to the membrane surface is
found in:
*a. paroxysmal nocturnal hemoglobinuria.

b. hereditary spherocytosis.
c. paroxysmal cold hemoglobinuria.
d. hereditary elliptocytosis.
General Feedback:
Proteins missing on the surface of paroxysmal nocturnal
hemoglobinuria cells are all linked by GPI to the membrane. This has
led to identification of the PIGA (phosphatidylinositol glycan anchor
biosynthesis, class A) gene, which is mutated in paroxysmal nocturnal
hemoglobinuria; this gene is located on the X chromosome.
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1. Chapter 22: Extrinsic Defects Leading to Increased-01

All are examples of microangiopathic hemolytic anemias (MAHAs) except:
a. thrombotic thrombocytopenia purpura (TTP).

b. hemolytic uremic syndrome (HUS).
c. disseminated intravascular coagulation (DIC).
*d. immune thrombocytopenia purpura.
General Feedback:
Thrombotic thrombocytopenia purpura, hemolytic uremic
syndrome, and disseminated intravascular coagulation are all examples
of MAHAs. An antibody against platelets causes immune thrombocytopenia
purpura, and only the platelet count is affected. No anemia exists
unless the patient is bleeding because of the low platelet count; if
the bleeding is occult, this eventually could result in iron deficiency
anemia but not MAHA.

Which condition is difficult to differentiate from thrombotic
thrombocytopenia purpura (TTP)?
a. Disseminated intravascular coagulation (DIC)

*b. Hemolytic uremic syndrome (HUS)
c. Hemolysis, elevated liver enzymes, low platelet count (HELLP)
d. Aplastic anemia
General Feedback:
TTP and HUS can beNU RSINGTBto.Cdifferentiate
difficult OM because they
have overlapping clinical and laboratory findings. Definitive
diagnosis, however, is critical because they have different etiologies
and require different treatments.

What is the pathogenesis of MAHA?
*a. Microthrombi and fibrin formed on damaged endothelial cells

trap and break red cells.
b. Chemicals or heat destroy red blood cells (RBCs).
c. The spleen sequesters red cells in an attempt to remove
abnormal inclusions.
d. Antibodies that activate complement are formed and destroy the
red cell membrane.
General Feedback:
As red cells pass through fibrin deposits that have been
abnormally formed inside the lumen of blood vessels, they are
fragmented as the force of blood flow forces them through the fibrin.
Red cell fragments may also be formed by turbulence of red cells as
they pass over damaged endothelial cells that line the blood vessels.

MAHA is often secondary to all conditions except:
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a. infections, especially sepsis.

b. obstetric complications.
*c. renal disease.
d. cancer.
General Feedback:
Renal disease does not characteristically result in MAHA. All
the other conditions listed can lead to MAHA.

A mild intravascular hemolytic anemia resulting from forceful repeated
effect of the feet on hard surfaces is called:
a. traumatic cardiac hemolytic anemia.

*b. exercise-induced hemoglobinuria.
c. bartonellosis.
d. thrombotic thrombocytopenic purpura.
General Feedback:
Exercise-induced hemoglobinuria occurs in some individuals
after repeated forceful effect of the feet on hard surfaces. This also
may be called march hemoglobinuria.

Which infection is responsible for the most deaths in Africa?
*a. Malaria
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b. Babesia infection
c. Bartonella infection
d. Clostridial septicemia
General Feedback:
The majority of deaths are in Africa (91%), followed by
Southeast Asia (6%) and the Eastern Mediterranean region (2%). There
are more than 216 million people worldwide who have malaria. None of
the other agents listed produce such an enormous rate of death.

Which organism is responsible for the majority of human malaria cases?
a. Plasmodium malariae
b. Plasmodium ovale
*c. Plasmodium falciparum
d. Plasmodium knowlesi
General Feedback:
Plasmodium falciparum is responsible for the majority of human
malaria cases.

Which technique most often diagnoses malaria and Babesia infections?
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a. Polymerase chain reaction (PCR)

*b. Observing the organisms in blood films
c. Serologic tests
d. Culture
General Feedback:
The clinician most often diagnoses malaria and Babesia by
observing the organisms in blood films.

A patient’s red cells show globular fragmentation, budding, and
microspherocytes. To what have the red cells probably been exposed?
*a. Heat
b. Chemicals
c. Oxidant drugs
d. Bartonellosis
General Feedback:
Patients with third-degree burns over more than 20% of their
bodies may have a severe acute hemolytic anemia. Morphologic red cell
changes include globular fragmentation, budding, and microspherocytes.
These cells are present for about 24 hours after the injury before they
are removed from circulation.
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Renal failure is a prominent feature of:
*a. hemolytic uremic syndrome.

b. thrombotic thrombocytopenic purpura.
c. Plasmodium malariae infection.
d. march hemoglobinuria.
General Feedback:
Renal failure is prominent in hemolytic uremic syndrome but
not in the other conditions listed.

Individuals lacking Duffy antigens are resistant to:
a. P. knowlesi
*b. P. vivax
c. P. falciparum
d. P. ovale
General Feedback:
P. vivax requires Duffy antigens on RBCs for invasion, so
individuals lacking Duffy antigens are resistant to infection with P.
vivax. The expansion of the Duffy-negative population in West Africa
seems to be an effective genetic adaptation because P. vivax infection
is almost nonexistent in West Africa.
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Why does P. falciparum infection result in the most serious hemolysis
of the various forms of malaria?
a. Only reticulocytes are invaded.

b. Reticulocytes and RBCs less than 10 days old are invaded.
c. Only mature RBCs are invaded.
*d. RBCs of all ages are invaded.
General Feedback:
RBCs in all stages of development are invaded by P.
falciparum. This is not true of the other malarial species, which
invade only a portion of the circulating RBCs.

Which describes the appearance of babesia?
*a. Rings
b. Triads
c. Hexagons
d. Squares
General Feedback:
Babesia appears as tiny rings or occasionally as tetrads
inside the RBCs. The ring forms may be round, oval, or ameboid; they
have a dark purple chromatin dot and a minimal amount of blue cytoplasm
surrounding a vacuole. NURSINGTB.COM

Which condition is associated with a deficiency of von Willebrand
factor (VWF)–cleaving protease?
a. Hemolytic uremic syndrome

*b. Thrombotic thrombocytopenic purpura
c. March hemoglobinuria
d. DIC
General Feedback:
A severe deficiency of VWF–cleaving protease has been
described in patients with thrombotic thrombocytopenic purpura.
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An Rh-negative woman is pregnant with her third child. She received
little or no prenatal care during the first two pregnancies. Her anti-D
titer is 1:512 at 30 weeks of gestation. What is the likely outcome for
the baby?
a. ABO hemolytic disease of the newborn

*b. Rh hemolytic disease of the newborn
c. No or mild hemolysis but spherocytes on the blood film
d. Most likely not survive
General Feedback:
This baby will most likely have Rh hemolytic disease of the
newborn. The mother’s antibody titer does not predict the severity of
hemolytic disease of the newborn.

Which is true regarding the mechanism of warm-reactive autoimmune
hemolytic anemia?
a. Immunoglobulin G (IgG) autoantibodies cause intravascular

hemolysis.
*b. IgG autoantibodies cause extravascular hemolysis.
c. Immunoglobulin M (IgM) alloantibodies cause complement
activation.
d. IgM autoantibodies cause immune complex formation.

Red cell destruction in warm-reactive autoimmune hemolytic
anemia is caused by IgG autoantibodies. IgG-sensitized red blood cells
are removed from circulation by macrophages in the spleen.

A patient’s blood film shows a moderate number of spherocytes and
polychromasia. Select the best test to distinguish warm autoimmune
hemolytic anemia from hereditary spherocytosis.
*a. Direct antiglobulin test

b. Bilirubin test
c. Haptoglobin test
d. Reticulocyte count
General Feedback:
The only test that distinguishes warm autoimmune hemolytic
anemia from hereditary spherocytosis is the direct antiglobulin test,
which is positive in warm autoimmune hemolytic anemia and negative in
hereditary spherocytosis.

Secondary cold-reactive autoimmune hemolytic anemia is found most often
in patients with:
a. hemolytic disease of the newborn caused by anti-A or anti-D.
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b. acute myeloid leukemia and chronic myleogenous leukemia.

*c. Mycoplasma pneumoniae or infectious mononucleosis.
d. hereditary spherocytosis or hereditary elliptocytosis.
General Feedback:
Cold-reactive autoimmune hemolytic anemia is sometimes
secondary after infections with organisms such as M. pneumoniae and
Epstein Barr Virus (infectious mononucleosis).

Red cell agglutination is found on a blood film. Select the best course
of action.
a. Report the morphology and all automated results.

*b. Warm the blood, and rerun it through the automated cell
counter.
c. Warm the blood, and make a new blood film.
d. Perform a cold agglutinin test.
General Feedback:
When red cell agglutination is noted on a blood film, the
blood should be warmed to 37°C for 15 minutes and the automated
analysis of the specimen repeated while the blood is warm. This patient
most likely has a cold agglutinin, and it will disassociate from the
red cell membrane and agglutination reverse when the specimen is
warmed. Valid results can thus be obtained.
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Monospecific anti-C3b/C3d reveals agglutination with patient’s red
cells. Monospecific IgG antisera gives a negative result. Which red
cell morphology would most likely be observed?
a. Spherocytes
b. Schistocytes
c. Acanthocytes
*d. Agglutination
General Feedback:
When only complement is present on the membrane, giving a
positive direct antiglobulin test using monospecific anti-C3b/C3d, a
cold agglutinin is most likely present. Agglutination of red blood
cells (RBCs) would be seen on the blood provided it is at room
temperature.

All have been linked to excess erythrocyte destruction except:
a. drugs.
b. IgM autoimmune antibodies.
*c. immunoglobulin E (IgE) alloantibodies.
d. IgG alloantibodies.
General Feedback:
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Of the items listed, only IgE antibodies have not been

associated with excess red cell destruction.

Which causes of alloimmune hemolytic anemia accounts for the largest
number of deaths?
*a. ABO blood type errors from patient misidentification

b. Drug reactions to antibiotic agents
c. ABO hemolytic disease of the newborn
d. ABO blood type technical testing errors
General Feedback:
Of those situations listed, ABO blood type errors from patient
misidentification account for the largest number of deaths.

Which is most often the result of human error?
a. Erythroblastosis from anti-D

b. ABO erythroblastosis
c. Delayed hemolytic transfusion reaction
*d. Immediate hemolytic transfusion reaction
General Feedback:
An immediate hemolytic transfusion reaction, often because of
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ABO incompatibility, is most often the result of human error.
Erythroblastosis, whether because of ABO or anti-D, occurs as a result
of a maternal-fetal incompatibility. A delayed hemolytic transfusion
reaction occurs as a result of undetected alloantibodies, where the
level of antibody was below the level of sensitivity at the time of
transfusion.

A type-A Rh-negative infant has spherocytes on his blood film and a
weakly positive direct antiglobulin test. What antibody will most
likely be found on the infant’s red cells?
*a. IgG anti-A antibody

b. IgM anti-A antibody
c. D antibody
d. Kell antibody
General Feedback:
This occurs in infants whose mothers make an IgG anti-A (in
this case) or anti-B at a low level. The disease is usually mild
because most ABO antibodies are IgM and do not cross the placenta
because of their large size.
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A warm-reactive autoimmune hemolytic anemia found in combination with
thrombocytopenia in a patient is called:
*a. Evans syndrome.

b. Wiskott-Aldrich syndrome.
c. hereditary spherocytosis with thrombocytopenia.
d. paroxysmal cold hemoglobinuria.
General Feedback:
When thrombocytopenia and a warm-reactive autoimmune hemolytic
anemia are found together, the clinical condition is called Evans
syndrome. This syndrome occurs primarily in children.

The Donath-Landsteiner antibody:
a. binds to the red cell membrane at 37°C.

*b. is found in serum and causes lysis of donor RBCs.
c. has specificity for Ii blood group antigens.
d. is associated with lymphoma.
General Feedback:
The Donath-Landsteiner antibody is found in paroxysmal cold
hemoglobinuria. It is demonstrated by adding patient serum to donor
RBCs that have been chilled to 4°C. The antibody binds at this
temperature and activates complement. When the cells are warmed to
NURSIfrom
37°C, the antibody disassociates NGTthe
B.Cred
OM cell membrane, after
which intense hemolysis occurs because complement has been activated.
This antibody is directed against the P blood group antigen. It is not
associated with lymphoma but is usually idiopathic. However, it is
associated with tertiary or congenital syphilis and is found after some
viral infections.
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1. Chapter 24-01
The qualitative hemoglobinopathies cause disease by producing
hemoglobin chains that are:
a. too long.
b. produced in inadequate amounts.
*c. structurally altered.
d. missing.
General Feedback:
Structural defects are present in the qualitative
hemoglobinopathies.
2. Chapter 24-02
Which hemoglobinopathies is most common?
*a. Sickle cell diseases

b. Hb E disorders
c. Hb C disorders
d. Unstable hemoglobins
General Feedback:
Sickle cell diseases are the most common form of
hemoglobinopathies.
3. Chapter 24-03
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What clinical feature of sickle cell disease accounts for the highest
number of hospital admissions?
a. Megaloblastic crisis
*b. Vasoocclusion
c. Autosplenectomy
d. Hand-foot dactylitis
General Feedback:
Vasoocclusive events are the hallmark features of sickle cell
disease, accounting for most hospital and emergency department visits.
4. Chapter 24-04
Sickle cell disease is found in individuals descended from ancestors
from all of the following places except:
a. Africa.
b. Middle East.
c. the Mediterranean.
*d. Scandinavia.
General Feedback:
Individuals having an ethnic origin from Scandinavia do not
express sickle cell diseases. This hemoglobin is observed in people
originating from all the other areas listed.
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5. Chapter 24-05
Sickle cell presence in the blood results in all of the following
except:
*a. decrease in blood viscosity.

b. decrease in oxygen tension.
c. decrease in blood pH.
d. increase in 2,3-biphosphoglycerate.
General Feedback:
Blood becomes more viscous when polymers are formed and sickle
cells are created. This transformation results in reduced blood flow,
which prolongs exposure of the sickle cells to a hypoxic environment
(decreased oxygen tension). A reduction in pH occurs and 2,3-
biphosphoglycerate levels.
6. Chapter 24-06
Which would be an unusual finding in the blood film of an adult with
sickle cell disease crisis?
*a. Heinz bodies

b. Target cells
c. Howell-Holly bodies
d. Leukocytosis
General Feedback:
The blood film of Nan
URadult
SINGin
TB. COM cell disease crisis
sickle
exhibits target cells, Howell-Jolly bodies, and an elevated white count
(leukocytosis). Heinz bodies are not present.
7. Chapter 24-07
What is the most likely causative association between malaria and
sickle cell trait?
a. Sickle gene makes people more prone to malaria infection.

b. Sickle gene prevents Plasmodium ovale infection.
c. They are both found in Asia.
*d. Sickle gene offers some protection against malaria.
General Feedback:
Sickle cell trait (heterozygosity for hemoglobin S [Hb S])
confers resistance against infection with Plasmodium falciparum. It is
believed that this is why the abnormal hemoglobin has such high
prevalence in areas where this form of malaria is endemic.
8. Chapter 24-08
Which would be unexpected in homozygous Hb S?
a. High reticulocyte count

*b. Hemoglobin A (Hb A)
c. Elevated hemoglobin F (Hb F)
d. Hemoglobin that is less soluble
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General Feedback:
Both beta-globin genes are abnormal in homozygous Hb S.
Therefore Hb A is not present unless the patient has received a red
cell transfusion. Hb S is less soluble than normal Hb A, the
reticulocyte count is elevated, and patients usually have a high Hb F.
9. Chapter 24-09
A patient has target cells and a positive tube solubility test. This
patient probably:
a. is normal.
b. has sickle cell anemia.
c. has sickle trait.
*d. has either sickle cell anemia or trait.
General Feedback:
The tube solubility test is positive in both sickle cell trait
and sickle cell anemia (Hb SS).
10. Chapter 24-10

Select the best test to confirm the diagnosis of the patient in
Question 9.
a. Mean cell volume (MCV)

b. Osmotic fragility
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*c. Hemoglobin electrophoresis
d. Presence of sickle cells
General Feedback:
The best test to differentiate sickle cell trait from anemia
is hemoglobin electrophoresis. Sickle cell trait should have roughly
40% Hb S and 55% Hb A, whereas sickle cell anemia should have
predominantly Hb S with a variably increased Hb F and no Hb A.
11. Chapter 24-11

A patient has two bands on alkaline hemoglobin electrophoresis. One
lines up with Hb A and the other is in the S position. Select the best
course of action.
a. Report as normal.
b. Report as sickle trait.
c. Report as sickle disease.
*d. Confirm sickle gene with tube solubility test.
General Feedback:
Other abnormal hemoglobins migrate with Hb S on alkaline
hemoglobin electrophoresis; Hb D is an example. However, these
hemoglobins are not sickling hemoglobins. Therefore, a positive tube
solubility test would confirm that the hemoglobin in the S position is
Hb S.
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12. Chapter 24-12

All improve the clinical outcome of sickle cell anemia (Hb SS) except
which of the following?
a. Aggressive prevention and treatment of infection

b. Presence of Hb F
c. Transfusions during crises
*d. Keeping the oxygen saturation low
General Feedback:
Hb S forms insoluble polymers when the oxygen saturation is
low. Thus this would precipitate sickling, not improve the outcome of
sickle cell anemia. All the other therapies mentioned have been shown
to be clinically helpful.
13. Chapter 24-13

A patient has 45% Hb S, 55% Hb A, and a positive tube solubility. Which
would likely be found?
a. Normal blood film and no disease

*b. Target cells on the blood film and no disease
c. Normal blood film and severe disease
d. Sickle cells on the blood film and severe disease
General Feedback:
Target cells are present in sickle cell trait (Hb A and Hb S).
This condition is benign. NURSINGTB.COM
14. Chapter 24-14

Moderate to marked target cells are found on a blood film. Which can
most likely be eliminated?
a. Hb C disease
*b. Hereditary spherocytosis
c. Hb E disease
d. Sickle cell disease
General Feedback:
Target cells are not seen in hereditary spherocytosis. They
are present in all the other conditions listed.
15. Chapter 24-15

Which would be an unexpected finding for patients with Hb SC disease or
S/beta0- thalassemia?
a. Target cells
b. Shortened red cell survival
*c. Normal tube solubility test
d. Mild to moderate clinical features
General Feedback:
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The presence of Hb S will give a positive tube solubility

test. Thus finding a normal result would not be expected.
16. Chapter 24-16

Which is a typical finding in patients with Hb M?
a. Severe anemia requiring repeated blood transfusions

b. Elevated levels of ferrous iron (Fe2+) in the red cells
c. Presence of Heinz bodies on Wright-stained blood film
*d. Elevated methemoglobin
General Feedback:
Methemoglobin is elevated in Hb M. Affected persons may have
30% to 50% methemoglobin (Fe3+). The amino acid substitutions found in
the various Hb Ms cause heme iron to autooxidize, forming
methemoglobin. Heinz bodies may be present, but they are not visible
with a Wright stain.
17. Chapter 24-17

Heinz bodies are found when hemoglobin:
*a. precipitates.
b. has higher oxygen affinity.
c. concentration is decreased.
d. forms crystals.
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General Feedback:
Heinz bodies are found when hemoglobin is unstable and
precipitates.
18. Chapter 24-18

What is the correct relationship between red cells’ affinity for oxygen
and red cell production?
a. When affinity is low, more oxygen is released and the body

compensates by making red cells larger.
b. When affinity is low, less oxygen is released and the body
compensates by increasing erythropoietin and making more red
cells.
*c. When affinity is high, less oxygen is released and the body
compensates by increasing erythropoietin and making more red
cells.
d. When affinity is high, more oxygen is released and fewer red
cells are needed.
General Feedback:
When hemoglobin’s oxygen affinity is high, less oxygen is
released to tissue. The normal physiologic response to less oxygen
delivery is to increase erythropoietin and make more red cells.
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19. Chapter 24-19

What is a point mutation?
a. Mutation of the stop codon

*b. Replacement of one nucleotide in the normal gene with a
different nucleotide
c. Addition of one nucleotide in the normal gene
d. Deletion of one nucleotide in the normal gene
General Feedback:
Replacement of one nucleotide in the normal gene with a
different nucleotide is a point mutation. This results in a different
amino acid and can affect the protein’s function.
20. Chapter 24-20

Cellulose acetate is performed on a patient with known homozygous Hb S
who has received red cell transfusions in the past week. What
hemoglobins would be expected to be found?
a. Hb S and Hb F
b. Hb A and Hb F
c. Hb S, Hb A, and Hb F
*d. Hb S, Hb A, Hb F, and Hb A2
General Feedback:
Hb S, Hb A, Hb F, and Hb A2 would be seen. Hb A, which is not
present in patients with homozygous Hb S, is from the transfused red
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cells. Hb F and Hb A2 are normal hemoglobins.
21. Chapter 24-21

An adult female patient from Southeast Asia has no anemia, but her
complete blood count (CBC) shows an MCV of 68 fL and marked target
cells are observed on her blood film. Cellulose acetate alkaline
electrophoresis shows two large bands: approximately 55% migrating with
Hb A and 40% migrating with Hb C. What is the patient’s most likely
genotype?
a. Hb A and Hb C
*b. Hb A and Hb E
c. Hb C and Hb E
d. Homozygous Hb E
General Feedback:
Hb E is a variant found in Southeast Asian populations. It
migrates with Hb C on cellulose acetate alkaline electrophoresis.
Because Hb A is also present, this patient probably has Hb E trait (is
not homozygous for Hb E). The MCV is low and target cells are present
in this trait.
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2. Chapter 25-02
Which is the normal approximate percentage of hemoglobins in adults?
á2â2 á2ä2 á2ã2
a. 2% 2% 96%
b. 2% 96% 2%
*c. 96% 2% 2%
d. 40% 20% 40%
General Feedback:
In adults, the approximate concentration of hemoglobin A (Hb
A) (á2â2) is 96%; of Hb A2 (á2ä2), 2%; and of hemoglobin F (Hb F)
(á2ã2), 2%.
3. Chapter 25-03
Why are infants with â-thalassemia major not ill until approximately 6
months of age?
*a. Infants are protected by their high concentration of Hb F.

b. Infants have less need for hemoglobin because of their small
body size.
c. Infants have less need for hemoglobin because of their smaller
lung capacity.
d. Infants have a high red count and thus higher hemoglobin from
a higher than normal concentration of erythropoietin.

The â globin chain is decreased to absent in â-thalassemia
major; however, á globin chain synthesis is normal. Infants up until
approximately 6 months of age have an elevated Hb F that does not
require â chains. They become symptomatic after the ã-to-â switch.
4. Chapter 25-04
Which is the primary mechanism for anemia in the thalassemias?
*a. An imbalance in the rate of globin chain synthesis

b. Impaired iron incorporation into the protoporphyrin ring
c. Erythroid hypoplasia in the bone marrow
d. Abnormal amino acid structure of a globin chain
General Feedback:
An imbalance exists in the rate of globin chain synthesis in
the thalassemias, and this is the primary mechanism leading to anemia.
A buildup of the globin chain is produced in excess, and this causes
damage to the red cell. Erythroid hyperplasia is present in the bone
marrow (ineffective erythropoiesis).
5. Chapter 25-05
Which is true regarding the clinical features of thalassemias?
a. Are mild conditions rarely requiring treatment.

b. Are serious conditions requiring frequent blood transfusions.
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c. Have abnormal red cells but little clinical implications for

patients.
*d. Vary from benign forms to those incompatible with life.
General Feedback:
The thalassemias are a heterogeneous group of disorders that
range from asymptomatic (benign) to death (incompatible with life).
6. Chapter 25-06
Which is an expected finding in â-thalassemia minor?
*a. Basophilic stippling

b. Normal levels of Hb F and Hb A2
c. Normocytic normochromic red cells
d. Hemoglobin levels in the 4- to 6-g/dL range
General Feedback:
Basophilic stippling is seen in red cells in â-thalassemia
minor. Hb F and Hb A2 are both increased. The red cells are microcytic
normochromic to microcytic hypochromic, and hemoglobin concentration is
generally in the 10- to 13-g/dL range.
7. Chapter 25-07
All can distinguish â-thalassemia minor from major except:
a. clinical findings.NURSINGTB.COM
b. hemoglobin concentration.
*c. presence of microcytosis, hypochromasia, and target cells.
d. presence of Hb A.
General Feedback:
Microcytes, hypochromasia, and target cells are found in both
â-thalassemia major and minor, so these findings do not distinguish one
from the other. All the other findings listed vary significantly
between the two types of â-thalassemia.
8. Chapter 25-08
Which would be an unexpected finding in homozygous â0-thalassemia?
a. Decreased reticulocyte production index

*b. Normal Hb F
c. Bone marrow erythroid hyperplasia
d. Severe anemia
General Feedback:
The primary hemoglobin in homozygous â0-thalassemia is Hb F,
with the remainder being Hb A2. Because no â globin chains are made, no
Hb A exists.
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9. Chapter 25-09
A patient has 30% Hb F. Which can be eliminated?
*a. Four missing genes for á chain production

b. Heterozygous hereditary persistence of Hb F
c. Thalassemia intermedia
d. The patient is a normal 1-month-old infant.
General Feedback:
á Chains are required for Hb F synthesis; therefore, if all
four genes for á chain synthesis are missing, no Hb F can be produced.
Thirty percent Hb F can be seen in all the other situations listed.
10. Chapter 25-10

What finding is present in all types of á-thalassemias?
a. Hemoglobin H (Hb H) inclusions seen with brilliant cresyl blue

b. Anemia
c. Microcytic hypochromic red cells
*d. Barts hemoglobin present at birth
General Feedback:
Barts (ã4) hemoglobin is present at birth in all forms of á-
thalassemia. Hb H inclusions, anemia, and microcytic red cells are not
found in all forms.
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11. Chapter 25-11
Which is true of patients with Hb H disease?
a. Have a severe anemia.

*b. Have three missing genes for á chain production.
c. Have excess unpaired â chains present.
d. Are of Northern European ethnicity.
General Feedback:
Hb H disease occurs when three genes are missing for á globin
chain synthesis and an excess of â chains (b4), which is named Hb H, is
present and easily detectable. A mild to moderate anemia is present.
These individuals are primarily of Asian ethnicity.
12. Chapter 25-12

Which can help distinguish the combination Hemoglobin S (Hb S) â0-
thalassemia from sickle cell anemia?
a. Hematocrit
b. Hemoglobin electrophoresis
c. Ethnic background
*d. Mean cell volume (MCV)
General Feedback:
Hb S is a structurally abnormal â globin chain; this gene is
inherited from one parent. The â0 gene is inherited from the other
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parent, which means that no â chain production occurs from that gene.
Thus the patient will not have any normal â chains to combine with á
chains and form Hb A. The patient will have primarily Hb S, with an
elevated Hb F, which is the same pattern seen in homozygous Hb S (i.e.,
sickle cell anemia). However, in sickle cell anemia the red cells are
normocytic, whereas in Hb S â0-thalassemia the red cells will be
microcytic.
13. Chapter 25-13

Which is least useful in diagnosing and differentiating the
thalassemias from each other?
a. Complete blood count (CBC) results

b. Hemoglobin electrophoresis
*c. Osmotic fragility
d. Clinical findings
General Feedback:
The osmotic fragility is not useful in differentiating the
various forms of thalassemia from one another. Hemoglobin
electrophoresis is an important tool for differentiating them, whereas
CBC results and clinical findings vary depending on the severity of the
thalassemic syndrome present and so can be useful.
14. Chapter 25-14

Which is useful in helping N
toUR
distinguish
SINGTB.Cmild
OM asymptomatic iron
deficiency from thalassemia trait?
*a. Low MCV with relatively high red blood count

b. Mild anemia
c. Increased osmotic fragility
d. Increased ferritin
General Feedback:
The red blood cell (RBC) count is relatively high with a low
MCV in thalassemia trait. In iron deficiency the MCV can be low, but
the red count is also low. None of the other findings listed
distinguish the two from one another.
15. Chapter 25-15

Hb Barts is composed of:
a. á4.
*b. ã4.
c. â4.
d. æ4.
General Feedback:
Hb Barts is composed of four gamma (ã) chains. It is present
at birth in all forms of á-thalassemia, even the silent carrier state
(one gene deletion).
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16. Chapter 25-16

A patient with â+-thalassemia has, from that gene locus,
*a. variable but decreased â globin chain synthesis.

b. no â globin chain synthesis.
c. variable but decreased ã chain synthesis.
d. no ã chain synthesis.
General Feedback:
â Globin chain synthesis is decreased from the â+ gene locus.
17. Chapter 25-17

Iron overload in severe â-thalassemia (â-thalassemia major) patients is
primarily a consequence of:
a. an increased rate of absorption of iron because of the severe

anemia.
b. a decreased need for iron because fewer RBCs are made.
*c. accumulation of iron from massive RBC transfusion therapy.
d. decreased rate of use of iron because smaller RBCs are made.
General Feedback:
Patients with â-thalassemia major have a severe anemia; many
of their clinical problems are related to this anemia. Giving the
NURSINGTtherapy
patient massive red cell transfusion B.COMcan ameliorate some of
these clinical problems. Unfortunately, a serious consequence of this
is the buildup of iron in the body from all the transfused RBCs because
the body has no mechanism for excreting iron.
18. Chapter 25-18

Patients who are heterozygous for Hb Lepore have a clinical course:
a. that is completely benign.

*b. similar to that of â-thalassemia minor.
c. similar to that of á-thalassemia minor (one gene deletion).
d. similar to that of â-thalassemia major.
General Feedback:
Hb Lepore is a ä-â fusion globin chain with decreased
synthesis of the chain. Heterozygotes have a clinical course similar to
that of â-thalassemia minor.
19. Chapter 25-19

Hemoglobin E (Hb E) is primarily found in individuals of which ethnic
origin?
a. Mediterranean
b. African
*c. Southeast Asian
d. Northern European
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General Feedback:
Hb E has a high prevalence in Southeast Asia.
20. Chapter 25-20

Hb A2 and Hb F can be quantified by:
a. performing a brilliant cresyl blue stain and counting the

number of positive cells.
*b. performing high-performance liquid chromatography.
c. performing cellulose acetate hemoglobin electrophoresis.
d. performing citrate agar hemoglobin electrophoresis.
General Feedback:
High-performance liquid chromatography can separate and
quantify Hb A2 and Hb F, which is important to do when working up
patients with possible thalassemic syndromes. None of the other methods
quantify them.
NURSINGTB.COM
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1. Chapter 26-01
A chemotherapy patient’s white blood cell (WBC) count is 1.0 × 109 /L.
There are 60% segmented neutrophils, 38% lymphocytes, and 2% monocytes.
What is the correct interpretation of the relative differential?
*a. Normal
b. Neutrophilia
c. Neutropenia
d. Lymphopenia
General Feedback:
The relative differential is normal.
2. Chapter 26-02
A chemotherapy patient’s WBC count is 1.0 × 109 /L. There are 60%
segmented neutrophils, 38% lymphocytes, and 2% monocytes. What is the
absolute neutrophil count?
a. 60 × 109/L
b. 6 × 109/L
*c. 0.6 × 109/L
d. 0.16 × 109/L
General Feedback:
The absolute count is determined by multiplying the total
white count by the relativeNpercent
URSINGof TBa.C
specific
OM cell type. Thus in
this case it is (0.60) × (1.0 × 109 /L) = 0.6 × 109/L.
3. Chapter 26-03
What is the correct interpretation of the absolute neutrophil count in
the chemotherapy patient in Question 1?
a. Normal
b. Neutrophilia
*c. Neutropenia
d. Qualitative neutrophil disorder
General Feedback:
An absolute neutrophil count below the reference range is
termed neutropenia.
4. Chapter 26-04
A patient has a white count of 15.0 × 109/L. What is the correct
interpretation?
*a. Normal for an infant

b. Abnormal for an infant
c. Abnormal for any patient
d. Normal for any patient
General Feedback:
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This is a normal white count for an infant.
5. Chapter 26-05
Necrotic nuclei are rounded fragments of nucleus that lack:
*a. filaments.
b. light chromatin.
c. granulation.
d. vacuoles.
General Feedback:
Necrotic nuclei are rounded fragments of nucleus with no
filaments and no chromatin pattern. Increased numbers of pyknotic or
necrotic cells suggest that an extended amount of time has elapsed
between blood collection and blood smear preparation.
6. Chapter 26-06
Neutrophilia accompanied by immature neutrophils and nucleated red
cells is what kind of reaction?
*a. Leukoerythroblastic
b. Leukemoid
c. Myelophthisic
d. Myeloproliferative
General Feedback:
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The presence of both immature neutrophils and nucleated red
cells in blood is termed leukoerythroblastic.
7. Chapter 26-07
Döhle bodies are most often found in patients with:
a. autoimmune disorder.
*b. acute bacterial infection.
c. hemolytic anemia.
d. acute viral infection.
General Feedback:
Patients with a bacterial infection often have Döhle bodies.
8. Chapter 26-08
Which is a prognostic sign for a patient with infectious mononucleosis?
a. Decrease in T cells
b. Granules fused with liposomes
c. Decrease in B cells
*d. Natural killer lymphocytes with cytoxic T cells
General Feedback:
The cellular response in infectious mononucleosis is important
in the control of the infection and is characterized by proliferation
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and activation of natural killer (NK) lymphocytes, CD4+ T cells, and

CD8+ memory cytotoxic T cells (EBV-CTLs) in response to B cell
infection. Most of the circulating reactive lymphocytes seen in
circulation represent activated T cells.
9. Chapter 26-09
A patient has 20% eosinophils. Which can probably be eliminated?
a. Allergy
b. Parasitic infection
*c. Pertussis
d. Chronic myelogenous leukemia
General Feedback:
Pertussis can be eliminated; a lymphocytosis exists in this
condition. All the other listed conditions can show elevated
eosinophils.
10. Chapter 26-10

A patient has a white count of 8.3 × 109/L and 65% lymphocytes. What is
the correct interpretation?
*a. Depends on the patient’s age

b. Lymphocytosis
c. Lymphopenia
NURinfectious
d. Patient probably has SINGTB.C OM
mononucleosis
General Feedback:
The absolute number of lymphocytes varies with age. This would
be normal for a young child but elevated for an adult.
11. Chapter 26-11

Nonmalignant disorders of leukocytes are:
a. inherited and cause no symptoms.

b. acquired and cause serious disease.
c. acquired and affect the nuclei of cells.
*d. acquired or inherited and range from benign to life
threatening.
General Feedback:
Benign (nonmalignant) disorders of leukocytes are inherited or
acquired alterations that do not possess the characteristics of
dysplasia or malignancy. Many are asymptomatic, whereas others are life
threatening.
12. Chapter 26-12

Nuclear hyposegmentation and denser than normal chromatin clumping are
features of:
a. Alder-Reilly anomaly.
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b. Chédiak-Higashi syndrome.
c. May-Hegglin anomaly.
*d. Pelger-Huët anomaly.
General Feedback:
Nuclear hyposegmentation with denser than normal chromatin
clumping is found in Pelger-Huët anomaly.
13. Chapter 26-13

What is the concern if Pelger-Huët anomaly is not recognized?
a. Without treatment, the patient will probably die.

*b. The cells could be misclassified as immature neutrophils.
c. The patient could develop pseudo–Pelger-Huët followed by
leukemia.
d. The cells could be misclassified as blasts, indicating that
the patient has acute leukemia when he or she does not.
General Feedback:
Pelger-Huët cells, because they often have bilobed nuclei, may
be mistaken for band neutrophils or metamyelocytes. Those with a round
nucleus may be mistakenly reported as myelocytes. This left shift is
characteristic of a bacterial infection.
14. Chapter 26-14

The abnormal granules seen in Alder-Reilly anomaly could be confused
for:
NURSINGTB.COM
*a. toxic granulation.
b. intracellular bacteria.
c. Döhle bodies.
d. intracellular yeasts.
General Feedback:
The abnormal granules in Alder-Reilly anomaly are deep-purple
to lilac granules that can be mistaken for toxic granulation.
15. Chapter 26-15

What are the abnormal cytoplasmic inclusions in Chédiak-Higashi?
a. Nuclear fragments that prevent cell division

b. Ribosomal material that looks like Döhle bodies
*c. Fused granules that inhibit bactericidal functions
d. Mucopolysaccharide lipids that disrupt cell function
General Feedback:
Abnormally large fused granules that are peroxidase positive
are seen in Chédiak-Higashi syndrome. Uncontrolled activity of the
granular membrane creates large primary, secondary, and mixed
primary/secondary granules. These inhibit the normal bactericidal
function of these granules so that patients are susceptible to
bacterial infection.
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16. Chapter 26-16

What abnormal findings are found in May-Hegglin anomaly?
a. Toxic granulation and vacuoles

b. Fused primary and secondary granules
c. Hypersegmented neutrophils and twinning
*d. Döhle body–like cytoplasmic inclusions
General Feedback:
Döhle body–like cytoplasmic inclusions and thrombocytopenia
are characteristic of May-Hegglin anomaly.
17. Chapter 26-17

Toxic granulation, Döhle bodies, and vacuolization in neutrophils are
often found together in:
a. May-Hegglin anomaly.
*b. Bacterial infection.
c. Chédiak-Higashi syndrome.
d. Alder-Reilly anomaly.
General Feedback:
Neutrophils can exhibit toxic granulation, Döhle bodies, and
vacuolization in a severe bacterial infection.
18. Chapter 26-18

NURSINGTB.COM
Partially digested glycoaminoglycans can lead to which condition?
*a. Neurologic problems

b. Cardiac disorders
c. Gastrointestinal disease
d. Skin rashes
General Feedback:
The mucopolysaccharidoses are associated with a specific
defect in an enzyme necessary for the degradation of GAG
(glycoaminoglycan). Partially digested GAGs buildup and disrupt
cellular functions leading to serious physical and neurologic problems.
19. Chapter 26-19

Congenital deficiencies of lysosomal enzymes, impaired digestion of
macromolecules which accumulate and impair cellular functions is
called:
a. chronic granulomatous disease.

b. congenital C3 deficiencies.
*c. storage cell diseases.
d. familial hyperlipidemia disorders.
General Feedback:
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Lysosomal storage disorders are congenital deficiencies of

lysosomal enzymes, impaired digestion of macromolecules which
accumulate and impair cellular functions.
20. Chapter 26-20

Gaucher cells and Niemann-Pick cells are found in:
a. peripheral blood.
b. bone marrow only.
c. spleen only.
*d. bone marrow and spleen.
General Feedback:
Gaucher cells and Niemann-Pick cells are macrophages with
accumulated glucocerebroside or sphingomyelin and are found in both the
bone marrow and many other organs but are not seen in the peripheral
blood.
21. Chapter 26-21

A college student seeks medical care for extreme fatigue and swollen
lymph nodes in the neck. The WBC count is 11.3 × 109/L. The
differential shows a relative and absolute lymphocytosis. Many of the
lymphocytes are larger than normal, with a basophilic cytoplasm
indented by the red blood cells (RBCs). The nuclei are less clumped
than normal and some have nucleoli. The rest of the complete blood
count (CBC) is normal. WhatNis
URthe
SINmost
GTB.likely
COM diagnosis?
a. Infectious lymphocytosis
*b. Infectious mononucleosis
c. Lymphoma
d. Lymphocytic leukemia
General Feedback:
The description of these cells is that of a reactive
lymphocyte. They are a normal response to viral infection. Infectious
mononucleosis characteristically shows a lymphocytosis with many
reactive T lymphocytes. The age, symptoms, and physical findings also
support infectious mononucleosis.
22. Chapter 26-22

The lymphocytes in the student in Question 21 are most likely:
*a. differentiated T cells.

b. lymphoblasts.
c. plasma cells.
d. B cells.
General Feedback:
The reactive lymphocytes seen in infectious mononucleosis are
differentiated T cells.
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23. Chapter 26-23

A clinical laboratory scientist sees segmenting nuclei and unusual
cytoplasmic borders in monocytes. Which additional finding should the
scientist expect?
a. Toxic vacuoles
b. Increased cytoplasm
c. Indented nuclei
*d. Changes in granule color
General Feedback:
Reactive morphology in monocytes includes segmenting nuclei,
changes in granule color and size, and irregular cytoplasmic borders.
24. Chapter 26-24

The Epstein-Barr virus is the causative agent for:
*a. infectious mononucleosis.

b. infectious lymphocytosis.
c. lymphocytic leukemia.
d. monocytic leukemia.
General Feedback:
The Epstein-Barr virus is the causative agent for infectious
mononucleosis. It is found in body fluids, especially saliva, in
infected individuals.
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25. Chapter 26-25
Most often the clinician makes a diagnosis of infectious mononucleosis
by which finding?
a. Significant lymphocytosis, with reactive lymphocytes

predominating
b. Presence of mild thrombocytopenia, with a significant
lymphocytosis
*c. Demonstration of the presence of the heterophil antibody
d. Demonstration of the presence of cytomegalovirus antibody
General Feedback:
A test for the presence of the heterophil antibody is used to
diagnose infectious mononucleosis. If this test is negative and the
clinician is highly suspicious of the diagnosis, tests for more
specific Epstein-Barr virus antibodies may be necessary.
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1. Chapter 27-01
Which statement about hematologic malignancies is correct?
a. They are localized.

b. Treatment is localized.
c. Diagnosis includes genetic typing.
*d. They include leukemias.
General Feedback:
Specific hematologic malignancies include acute leukemias,
lymphoblastic and myeloid, myeloproliferative neoplasms,
myelodysplastic syndromes, and mature lymphoid neoplasms. Most
hematologic malignancies are not localized but rather are systemic at
initiation of the malignant process. With rare exceptions, most
treatments for hematologic malignancies given with curative intent are
not localized, such as radiation or surgery, but must by nature be
systemic-type treatments.
2. Chapter 27-02
The type of protooncogenes involved in hematologic malignancies is:
a. growth factor receptors.

b. signal transducers.
c. transcription factors.
*d. all of the options.
General Feedback:
NURSINGTthe
In hematologic malignancies B.Ctype
OM of protooncogenes usually
involved are signal transducers (such as tyrosine kinases), growth
factor receptors, or transcription factors.
3. Chapter 27-03
Which type of virus has been associated with hematologic malignancies?
a. DNA virus
*b. Retrovirus
c. Cytomegalovirus
d. Both DNA virus and Retrovirus
General Feedback:
Some viruses have been implicated in hematologic malignancies,
such as retroviruses and DNA viruses.
4. Chapter 27-04
Which is true of acute leukemia?
a. Onset is of slow progression.

b. Progression is delayed.
c. Onset is insidious.
*d. If left untreated, death occurs in weeks.
General Feedback:
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Leukemias are divided into lymphoid and myeloid lineages, and

further into acute (precursor cell) and chronic (mature cell)
categories. In acute leukemias, onset is sudden, progression is rapid,
and the outcome is fatal in weeks or months if left untreated.
5. Chapter 27-05
Which is true regarding chronic leukemia?
*a. White blood cell count is variable.

b. Onset is sudden.
c. Progression is fast.
d. If left untreated, death occurs in weeks.
General Feedback:
In chronic leukemias, onset is insidious, and progression is
slower with a longer survival compared to acute leukemia. The WBC count
is usually elevated and there is a proliferation and accumulation of
mature and maturing cells of a specific lineage.
6. Chapter 27-06
When leukemia is left untreated:
*a. bone marrow function is altered.

b. the associated fatigue is due to decreased hematocrit.
c. symptoms become very specific.
d. the bands shift right.
NURSINGTB.COM
General Feedback:
In all untreated leukemias, most normal hematopoietic cells in
bone marrow are eventually replaced by leukemia cells thus affecting
normal bone marrow function. Due to the rapid expansion of blasts in
bone marrow in acute leukemia, bleeding due to thrombocytopenia, fever
due to neutropenia-induced infection, and fatigue due to decreased
hemoglobin are often found at presentation. Symptoms of chronic
leukemias at presentation are generally non-specific and variable; some
patients may be asymptomatic and diagnosed after an incidental finding
of an elevated white blood cell count or abnormal peripheral blood
film. Bands shift left in leukemia.
7. Chapter 27-07
Exposure to which environmental factor can lead to hematopoietic
malignancies?
a. Chromium
*b. Benzene
c. Hydrochloric acid
d. Ethanol
General Feedback:
Environmental exposures known to lead to hematopoietic
malignancies include radiation exposure, as experienced by survivors of
atomic explosions, and exposure to organic solvents, such as benzene.
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8. Chapter 27-08
The World Health Organization (WHO), Society for Hematopathology, and
the European Association for Haematopathology classifies neoplasms
according to:
a. clinical features.
*b. molecular genetics.
c. cytogenetics.
d. all of the options.
General Feedback:
The World Health Organization in collaboration with the
Society for Hematopathology and the European Association for
Haematopathology, the classification considers clinical features,
morphology, immunophenotyping, cytogenetics, and molecular genetics.
9. Chapter 27-09
Which statement describes the process of leukemogenesis?
a. A hematopoietic cell is engulfed by a macrophage and is

replaced by a malignant cell.
b. Two genetic mutations are required to change healthy
hematopoietic cells into malignant cells.
*c. A hematopoietic cell accumulates multi-hits that turn healthy
cells into malignant clones.
d. The membrane of a hematopoietic cell dissolves making it
NURto
easier for the cytoplasm SIN GTB.C
attach toOM
a malignant cell.
General Feedback:
Leukemogenesis (initiation and maintenance of leukemia) is a
stepwise process in which a hematopoietic cell accumulates multiple,
independent mutations or “multi-hits” that affect various cellular
pathways, which eventually transforms it into a malignant clone. There
are exceptions in which only one genetic mutation is required for
initiation of the leukemia.
10. Chapter 27-10

Which action causes quantitative mutations in a hematopoietic cell?
a. Tumor suppressor gene action on an oncogene

b. Gene amplification of an oncogene
*c. Overexpression of a normal protooncogene
d. DNA repair genes stop protooncogenes
General Feedback:
In quantitative mutations, there is an overexpression of a
normal protooncogene in a hematopoietic cell. An example of this type
of mechanism is found in B-lymphoid malignancies in which a
protooncogene becomes oncogenic by translocation next to the promoter
of the immunoglobulin heavy chain (IGH) locus on chromosome 14.
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11. Chapter 27-11

Why are patients diagnosed with hematologic malignancies living longer
than in past decades?
a. FDA standards for cancer medications have decreased.

b. Radiation is used in all cases of cancer.
c. Chemotherapy is no longer an accepted treatment.
*d. There is an increased availability of less toxic therapies.
General Feedback:
In contrast to many solid tumors, numerous hematologic
malignancies now have cure rates that are substantially higher than
they were two or three decades ago. Many new and exciting therapies
that are less toxic are now under development or are already employed
in patient settings.
12. Chapter 27-12

How does imatinib mesylate work in treating hematologic malignancies?
a. Regulates kinase activity.

b. Increases massive cell proliferation.
c. Suppresses apoptosis of cancer cells.
*d. Blocks tyrosine kinase activity.
General Feedback:
In 2001, FDA cleared imatinib mesylate for treatment of
chronic phase CML as the first rationally designed molecular targeted
NURSIN
therapy for a cancer. The t(9;22) GTB.COM in CML results in
translocation
production of the BCR-ABL1 fusion protein with constitutive and
unregulated tyrosine kinase activity. Imatinib is an orally-
administrated, small, tyrosine kinase inhibitor (TKI) molecule that
binds to the ABL1 domain of the BCR-ABL1 fusion protein and selectively
blocks its tyrosine kinase activity.
13. Chapter 27-13

In promyelocytic leukemia, which gene is fused with the retinoid acid
receptor gene (RARA)?
a. ATRA
*b. PML
c. BCR
d. ABL1
General Feedback:
In acute promyelocytic leukemia (APL), the t(15;17)
translocation results in fusion of the retinoic acid receptor gene,
RARA, with the PML gene.
14. Chapter 27-14

What is the function of chimeric antigen receptor T (CAR-T) cells in
patients with high-risk hematologic malignancies?
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a. Upregulates expression of target genes required for myeloid

differentiation.
*b. Target leukemia cells for destruction.
c. Reverse epigenetic silencing of gene transcription.
d. Binds to the CD-20 antigen on B lymphoid cells.
General Feedback:
CD19-specific chimeric antigen receptor T (CAR-T) cells work
by collecting patient T cells via pheresis that are genetically
engineered ex vivo using lentiviral or retroviral vectors to express
protein complexes that recognize only the patient’s leukemia cells.
Engineered CAR-T cells then specifically bind to patient’s leukemia
cells and target them for destruction.
15. Chapter 27-15

Which are the types of mutations found in hematologic malignancies?
a. Chromosomal rearrangement
b. Aneuploidy
c. Gene deletion
General Feedback:
Types of mutations found in hematologic malignancies include
chromosomal rearrangement (such as translocation or inversion), gain or
loss of chromosomes (aneuploidy), total or partial gene deletion, point
mutation, or gene duplication/amplification.
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16. Chapter 27-16
Which statement describes how hematopoietic stem cell transplantation
(HSCT) is performed?
*a. Bone marrow is harvested from the posterior iliac crests

using sterile technique under general anesthesia.
b. Bone marrow is aspirated from the long bones of the leg using
regional anesthesia.
c. Embryonic stem cells are harvested from the fetus’s umbilical
cord in utero.
d. Adult stem cells are aspirated from patients aged 50 and older
with no history of chronic disease.
General Feedback:
Bone marrow is harvested through multiple needle aspirations
typically from the posterior iliac crests, and it is done in a sterile
surgical environment usually under general or regional anesthesia.
17. Chapter 27-17

Tumor suppressor genes contribute to the malignant process only if:
*a. both alleles have been lost.

b. one allele has been lost.
c. one allele is inactivated.
d. both alleles are active.
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General Feedback:
In contrast to oncogenes, tumor suppressor genes contribute to
the malignant process only if both alleles have been lost or otherwise
inactivated.
18. Chapter 27-18

A patient is diagnosed with Epstein-Barr virus. For which condition is
the patient at risk?
a. Hemophilia A
*b. Burkitt lymphoma
c. Dietary anemia
d. Sickle cell disease
General Feedback:
Epstein-Barr virus, a DNA virus that invades mainly B
lymphocytes and has been implicated as a contributing etiologic factor
in Burkitt and other non-Hodgkin lymphomas, and in a subset of classic
Hodgkin lymphoma.
19. Chapter 27-19

How do miRNAs inhibit gene expression in hematopoietic malignancies?
a. Bind to targeted DNA transcripts.

*b. Block mRNA translation to protein.
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c. Reinforce mRNA in the nucleus.
d. Degrade DNA replication.
General Feedback:
miRNAs (small 22 nucleotide RNA segments) inhibit gene
expression by specifically binding to targeted mRNA transcripts,
blocking their translation to protein, and causing their
destabilization and degradation.
20. Chapter 27-20

Which condition is a patient diagnosed with acute leukemia likely to
experience?
a. Neutropenia
b. Thrombocytopenia
c. Anemia
General Feedback:
Patients diagnosed with acute leukemia are likely to
experience neutropenia, which causes fever due to infection;
thrombocytopenia, which causes bleeding; and anemia, which causes
fatigue.
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1. Chapter 28-01
Hydrodynamic focusing in flow cytometry is important because it:
a. directs the laser light.

b. intensifies the laser light with mirrors.
c. collects the scattered light.
*d. creates a core of individually aligned cells.
General Feedback:
Hydrodynamic focusing creates a central stream of individually
aligned cells surrounded by sheath fluid. This is essential for
consistent illumination of each cell as it passes in front of the gas
laser light source.
2. Chapter 28-02
Forward scatter is related to what cellular feature?
a. Density
*b. Size
c. Granularity
d. Complexity
General Feedback:
Information gathered from the detector situated directly in
line with the illuminating source is called forward scatter and
provides data on particle size.
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3. Chapter 28-03
Which is evaluated using fluorochrome dyes that are bound to monoclonal
antibodies?
*a. Membrane antigens

b. Nuclear complexity
c. Number of lymphocytes
d. Cell size
General Feedback:
The presence or absence of specific membrane antigens is
detected using monoclonal antibodies to which fluorochrome dyes are
bound.
5. Chapter 28-05
What cell type expresses CD20 and contains immunoglobulin light chains
on the surface but not in the cytoplasm?
a. Helper T cells (TH)

b. T suppressor cells
c. Immature B cells
*d. Mature B cells
General Feedback:
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Mature B cells express CD20 and immunoglobulin light chains,

either ê or ë but not both, on their surface.
6. Chapter 28-06
Myeloid stem cells and blasts express which factor on their surface?
a. CD4
b. CD8
*c. CD34
d. Terminal deoxynucleotidyl transferase (TdT)
General Feedback:
CD34 is expressed on the surface of myeloid stem cells and
blasts. CD4, CD8, and TdT are all markers of lymphoid lineage. In
addition, TdT is not a membrane antigen but rather is found in the
nucleus.
7. Chapter 28-07
What marker is most closely related to monocytes leukemia?
a. CD3
*b. CD4
c. CD8
d. CD10
General Feedback:
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Acute monoblastic and monocytic leukemias express myeloid
markers and antigens associated with monocytic lineage, such as CD14,
CD4, CD11b, and CD64.
9. Chapter 28-09
All are true concerning hematopoietic stem cells except:
a. they express both CD34 and CD117 (c-kit).

b. they lose some antigens as they mature.
*c. they express both CD4 and CD34.
d. they gain lineage-specific antigens as they mature.
General Feedback:
CD4 is a marker of T cells, not hematopoietic stem cells
(HSCs). HSCs express both CD34 and CD117 (c-kit). As they mature, some
antigens are lost while lineage-specific antigens are gained.
10. Chapter 28-10

What is an early marker of erythroid precursors?
a. CD45
*b. CD71
c. CD34
d. CD8
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General Feedback:
CD71 identifies the presence of the transferrin receptor and
is found on early erythroid precursors.
11. Chapter 28-11

The presence of TdT is characteristic of progenitors of which lineage?
a. Megakaryocytes and platelets

b. Monocytes
c. Erythrocytes
*d. Lymphocytes
General Feedback:
TdT is found in lymphoid precursors and is useful for
identifying their presence.
12. Chapter 28-12

A patient has a white cell count of 12.6 × 109/L, hematocrit of 28%,
and platelet count of 27 × 109/L. Examination of a Wright-stained blood
film reveals that almost all of the white cells in peripheral blood are
blasts; the bone marrow is hypercellular with very little fat and is
packed with blasts. Flow cytometry is performed on the peripheral blood
cells, and a large cluster of cells is present that mark with CD20 and
have monoclonal ê light chains present on their surface. This patient
has:
NURSINGTB.COM
a. myeloid leukemia.
*b. a mature B cell malignancy.
c. a reactive B cell hyperplasia.
d. a mature T cell malignancy.
General Feedback:
Mature B lymphocytes express CD20 and either ê or ë light
chains on their surface. In a B cell reactive process, a mixture of ê
and ë light chain positivity will be observed. The expression of only
one light chain on the surface of a population of B cells is called
monoclonality and is indicative of a phenotypically mature B cell
malignancy.
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1. Chapter 29-01
Molecular testing is useful for all of the following except:
*a. evaluating clinical severity of anemia.

b. finding chromosomal translocations in malignancies.
c. detecting inherited disorders.
d. identifying blood pathogens.
General Feedback:
Molecular testing is not useful for evaluating the clinical
severity of anemia; that is done using the patient’s physical and
clinical history, as well as evaluating various red cell parameters
(e.g., hematocrit, hemoglobin, red cell morphology). However, it can be
useful for the diagnosis of the cause of an inherited anemia (e.g.,
thalassemia), finding chromosomal translocations in malignancies,
detecting inherited disorders, and identifying blood pathogens.
2. Chapter 29-02
How does ribonucleic acid (RNA) differ from deoxyribonucleic acid
(DNA)?
a. RNA does not contain nucleotides.

*b. RNA has uracil-replacing thymine.
c. DNA is found primarily in the cytoplasm, and RNA is in the
nucleus.
d. DNA has a messenger, whereas RNA does not.

RNA differs from DNA in that it has uracil-replacing thymine.
3. Chapter 29-03
What is the preferred specimen for molecular techniques for diagnosis
of inherited mutations?
a. RNA extracted from peripheral mature red cells.

b. RNA extracted from fresh serum.
*c. DNA extracted from peripheral blood white cells.
d. DNA extracted from peripheral blood mature red cells.
General Feedback:
DNA extracted from peripheral blood (or bone marrow) white
cells is the preferred specimen for molecular techniques when they are
used to diagnose inherited disorders. In inherited disorders, the DNA
from any cell could theoretically be used because the DNA at the
molecular level will be identical regardless of cell origin. However,
DNA from peripheral blood white cells is the easiest tissue to obtain.
Mature red blood cells (RBCs) cannot be used because they do not have a
nucleus and therefore do not have any DNA.
4. Chapter 29-04
Before molecular methods are performed, the DNA must be:
a. primed.
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b. flanked.
c. elongated.
*d. amplified.
General Feedback:
DNA must be amplified before molecular methods are performed
on it. This improves the sensitivity and thus the ability to detect the
abnormality.
5. Chapter 29-05
Gel electrophoresis, restriction endonucleases, and hybridization
techniques are methods to:
*a. detect DNA amplification.

b. detect DNA extraction.
c. measure concentration of DNA.
d. identify BCR gene in chronic myelogenous leukemia.
General Feedback:
These are all methods used to detect DNA amplification and
thus identify the possible presence of a DNA abnormality.
6. Chapter 29-06
Why is the helical configuration of DNA important?
a. Permits purines and pyrimidines to bond.

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b. Permits transcription of DNA by RNA polymerase.
*c. Stabilizes the molecular structure.
d. Prevents occurrence of protein structural abnormalities (e.g.,
point mutations, translocations).
General Feedback:
The helical configuration of DNA, where the strands twist,
stabilizes the DNA molecule and protects the bases from the
environmental damage.
7. Chapter 29-07
Where is messenger RNA formed?
a. Mitochondria
b. Golgi organelle
c. Ribosomes
*d. Nucleus
General Feedback:
Messenger RNA is formed in the nucleus and then leaves it to
enter the cytoplasm, where it is translated. It is found within the
nucleolus of the nucleus.
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8. Chapter 29-08
What is the cell type and tissue of choice for molecular techniques
used to detect acquired DNA mutations leading to malignancy?
a. Peripheral blood mature lymphocytes

b. Bone marrow hematopoietic stem cells
*c. The malignant tissue
d. Peripheral blood mature neutrophils
General Feedback:
Cells from the malignant tissue should be evaluated for the
acquired DNA mutation. Many malignancies, both hematopoietic and solid
tumors, have acquired DNA mutations, some of which are characteristic
for certain malignancies. Because these are acquired mutations, they
will not be found in all cells but only those affected by the mutation
or mutations.
9. Chapter 29-09
DNA has been isolated from appropriate cells and placed in an aqueous
buffer. If molecular testing cannot be immediately performed, what
should be done?
a. Reprecipitate the DNA using isopropanol alcohol and then store

at 4°C.
b. Reprecipitate the DNA using isopropanol alcohol and then store
at ?2-80°C.
c. Store prepared DNA at 4°C.
NUat
*d. Store prepared DNA RS?2-80°C.
INGTB.COM
General Feedback:
If isolated DNA cannot be immediately evaluated for molecular
testing, it should be stored at ?-80° C. The prepared DNA can be stored
for an indefinite period of time and still give valid results.
10. Chapter 29-10

Why is a “no-DNA” control used when performing molecular tests using
the polymerase chain reaction (PCR)?
a. To ensure that the targeted DNA is amplified

b. To ensure that nontargeted DNA is negative
c. To ensure that the targeted DNA containing the mutation is
positive
*d. To ensure that no DNA cross-contamination of the samples,
controls, or reagents occurs
General Feedback:
Contamination of reagents, controls, and samples with
extraneous DNA from the environment is possible when performing
molecular testing. Thus a no DNA control must be run along with the
controls and samples to validate the analysis.
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11. Chapter 29-11

Which is the gold standard method for the detection of point mutations
and single nucleotide polymorphisms?
*a. Sanger DNA sequencing

b. Next-generation sequencing (NGS)
c. Pyrosequencing
d. Real-time PCR
General Feedback:
Sanger DNA sequencing is based on the principle that synthesis
of a DNA polymer is terminated upon incorporation of a
dideoxynucleotide. DNA fragments are produced and identified through
fluorescent labeling. The Sanger method is considered the gold standard
for detection of point mutations and single nucleotide polymorphisms.
12. Chapter 29-12

Areas of hematopathologic molecular testing include all except:
a. detection of mutation.
b. gene rearrangement.
c. chromosomal abnormalities.
*d. gene splicing.
General Feedback:
Detection of mutation, gene rearrangement, and chromosomal
abnormalities that result in hematopathologic disorders can all be
NUtesting
identified through molecular RSINGTmethods.
B.COM Gene splicing is not a
method for molecular identification of hematopathologic disorders.
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1. Chapter 30-01
The congenital gain or loss of an entire chromosome in a developing
fetus usually results in what type of clinical condition?
a. Sexual ambiguity
b. Myeloid leukemia
c. Mental retardation
*d. Usually incompatible with life
General Feedback:
The congenital gain or loss of an entire chromosome other than
sex is usually incompatible with life and ends in a first-trimester
spontaneous abortion.
2. Chapter 30-02
What happens to nuclear chromatin at mitosis?
a. Opens
*b. Condenses
c. Disappears
d. Develops nucleoli
General Feedback:
Nuclear chromatin condenses approximately 10,000-fold at
mitosis; this results in the formation of chromosomes.
3. Chapter 30-03
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What is the best method for detecting chromosomal material that has
been structurally altered?
*a. Fluorescence in situ hybridization (FISH)

b. G banding
c. Q banding
d. Ag-NOR banding
General Feedback:
The best method for detecting structurally altered chromosomes
is FISH.
4. Chapter 30-04
Which is true regarding the number of chromosomes of different species?
a. All mammals have the same number.

*b. Numbers vary greatly among mammals unrelated to
characteristics.
c. Primates have more than lower mammals.
d. Primates have fewer than lower mammals.
General Feedback:
Different species have different numbers of chromosomes that
vary unrelated to characteristics.
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5. Chapter 30-05
Where is a gene designated t(9;22)(q34;q11.2 located)?
a. Short arm of chromosome 23, region 9

b. Long arm of chromosome 3, region 2, band 9
*c. Between long arms of chromosomes 9 and 22
d. On the translocated part of chromosome 9 on chromosome 23
General Feedback:
A gene designated t(9;23) is located between the long arms of
chromosomes 9 and 22.
6. Chapter 30-06
All samples are commonly analyzed for chromosomes except:
a. bone marrow.
b. amniotic fluid.
c. peripheral lymphocytes.
*d. tissue with a low mitotic rate.
General Feedback:
Tissue with a low mitotic rate is not suitable for chromosome
analysis. Tissues with a high mitotic rate, or those that can be
stimulated to divide in culture, can be used.
7. Chapter 30-07
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A chromosome number that is not a multiple of the haploid number is:
*a. aneuploidy.
b. mosaic.
c. polyploidy.
d. incompatible with life.
General Feedback:
Aneuploidy is the term used to describe a chromosome number
that is not a multiple of the haploid number for that species.
8. Chapter 30-08
Cell division to produce daughter cells identical to the parent cell is
an example of:
a. nondisjunction.
b. meiosis.
*c. mitosis.
d. gamete production.
General Feedback:
Mitosis results in the production of daughter cells that are
identical to the parent cell.
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9. Chapter 30-09
How many chromosomes does a human with triploidy have?
a. 3
b. 23
c. 47
*d. 69
General Feedback:
The normal haploid number of chromosomes for humans is 23. A
patient who has triploidy has three times that number (i.e., tri-), or
69.
10. Chapter 30-10

A break in two chromosomes with each piece uniting with different
chromosomes is called:
a. deletion.
b. duplication.
c. insertion.
*d. translocation.
General Feedback:
Translocation occurs when two chromosomes break and each of
the broken pieces reunites with another chromosome. If chromatin is
neither lost nor gained in the process, the exchange is called a
balanced reciprocal translocation.
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11. Chapter 30-11
What tissue is most often studied for hematologic malignancies?
a. Peripheral blood
*b. Bone marrow
c. Spleen
d. Lymph node sections
General Feedback:
Bone marrow is most often studied for hematologic
malignancies.
12. Chapter 30-12

What chromosome abnormality was the first to be identified and
associated with a specific malignancy?
a. Trisomy 8
b. Deletion 7
*c. Philadelphia
d. Isocentric chromosome 16
General Feedback:
The first chromosome abnormality to be identified and
associated with a specific malignancy was the Philadelphia chromosome.
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It initially was associated with chronic myelogenous leukemia, although

clinicians now know it to be found in other hematologic malignancies.
13. Chapter 30-13

All disorders are associated with acquired chromosome abnormalities
except:
*a. megaloblastic anemia.

b. chronic myelogenous leukemia.
c. acute myeloid leukemia.
d. acute lymphoblastic leukemia.
General Feedback:
Megaloblastic anemia results from a deficiency of either folic
acid or vitamin B12. No associated chromosome abnormality exists.
14. Chapter 30-14

Nonrandom chromosomal abnormalities are:
a. congenital chromosome abnormalities that are consistently

found in all tissues of an affected individual.
*b. acquired chromosome abnormalities that are found in the
abnormal or malignant tissue of an affected individual.
c. acquired chromosome abnormalities that are found in all
tissues of an affected individual.
d. congenital chromosome
NURabnormalities
SINGTB.COMthat are found in only one
type of tissue of an affected individual.
General Feedback:
Cancer cytogenetics is a field that is built on the finding of
nonrandom chromosome abnormalities in many types of cancer. Cytogenetic
analysis of malignant cells can help determine the diagnosis and
probable prognosis of a hematologic malignancy.
15. Chapter 30-15

The period in the cell cycle when deoxyribonucleic acid (DNA) is
synthesized is:
a. G1.
*b. S.
c. G2.
d. M.
General Feedback:
DNA is synthesized during the S phase of the cell cycle.
16. Chapter 30-16

Cytogenetics is performed on the bone marrow of a patient, and 20 cells
are examined. The patient’s karyotype is reported as 47, XX, +7(14),
indicating that:
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*a. this is a female patient with trisomy chromosome 7 found in

14 of the cells examined.
b. this is a female patient with monosomy chromosome 7 found in 1
of 4 cells examined.
c. this is a male patient with trisomy 7 found in 1 of 4 cells
examined.
d. this is a male patient with monosomy 7 found in 14 of the
cells examined.
General Feedback:
This is a female patient (XX). She has an additional
chromosome 7 (+7) found in 14 of the 20 cells that were examined.
17. Chapter 30-17

A patient has a hematologic malignancy. Karyotyping is performed for
all of the following reasons except:
*a. to provide unique cytogenetic profile to confirm the

patient’s identification.
b. to provide diagnostic information.
c. to identify whether the patient will respond to appropriate
therapy.
d. to provide prognostic information.
General Feedback:
Patients with various forms of cancers, including hematologic
forms, may exhibit a nonrandom abnormal karyotype. This karyotype can
NURSINGTBidentify
provide useful diagnostic information, .COM whether the patient
will respond to appropriate therapy, and provide prognostic information
for the patient. It does not confirm the patient’s identification.
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1. Chapter 31-01
What is the most common leukemia in children between the ages of 2 and
5 years?
a. Acute myeloid
b. Acute monocytic
c. Acute myelomonocytic
*d. Acute lymphoblastic
General Feedback:
The most common leukemia in this age-group is acute
lymphoblastic leukemia.
2. Chapter 31-02
A 15-year-old boy is complaining of severe headaches; he has a white
count of 76.0 × 109/L, platelet count of 55 × 109/L, and a hematocrit
of 33%. When a white cell differential is performed, most of the
nucleated cells are blasts. They are CD2, CD4, and CD8 positive. The
TdT marker is expressed. What is the most likely diagnosis?
a. Immature-B cell acute lymphoblastic leukemia

*b. T cell acute lymphoblastic leukemia
c. Acute myeloid leukemia without maturation
d. Acute myeloid leukemia with maturation
General Feedback:
T cell acute lymphoblastic leukemia is most often seen in
NURSmass,
teenage boys with a mediastinal INGTelevated
B.COM peripheral blast counts,
meningeal involvement, and infiltration of extra marrow sites. The
blasts commonly mark as CD2, CD4, CD5, and CD8 positive.
3. Chapter 31-03
Which form of acute myeloid leukemia is most often associated with
disseminated intravascular coagulation (DIC)?
a. Acute myeloid leukemia minimally differentiated

b. Acute myeloid leukemia with t(8;21)(q33:q22)
*c. Acute myeloid leukemia with t(15;17)(q22:q12)
d. Acute myeloid leukemia with maturation
General Feedback:
Acute myeloid leukemia with t(15;17)(q22:q12), also known as
acute promyelocytic leukemia, is associated with DIC. Treatment of this
disorder must therefore involve resolution of the DIC.
5. Chapter 31-05
A 27-year-old woman arrives at the emergency department with acute
bleeding and is found to have a white count of 25.7 × 109L with
pancytopenia: hematocrit 27%, platelet count 35 × 109/L, and absolute
neutrophil count 0.8 × 109/L. She has a combination of 97% blasts and
abnormal promyelocytes in her peripheral blood; some of these cells
contain Auer rods. What form of leukemia does she most likely have?
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*a. Acute myeloid leukemia with t(15;17)(q22:q12)

b. Chronic myeloid leukemia
c. Acute monoblastic leukemia
d. Acute myeloid leukemia with t(8;21)(q33:q22)
General Feedback:
Acute myeloid leukemia with t(15;17)(q22:q12) is characterized
by abnormal promyelocytes, which may have Auer rods. Patients are most
often young adults.
6. Chapter 31-06
Acute myelomonocytic leukemia is positive for which factor?
a. CD10
b. periodic acid–Schiff (PAS)
c. HLA-DR1a
*d. CD13 and CD14
General Feedback:
The cells in acute myelomonocytic leukemia are positive for
CD13 (a myeloid antigen) and CD14 (a monocytic antigen).
7. Chapter 31-07
What leukemia is most likely in a patient whose bone marrow is composed
of predominantly large, multinucleated, vacuolated, dysplastic
erythroid precursors?
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a. Acute myelomonocytic leukemia
b. Acute megakaryocytic leukemia
*c. Acute erythroleukemia
d. Acute myeloid leukemia with minimal maturation
General Feedback:
The bone marrow erythroid precursors display significant
dysplastic features, including multinucleation, megaloblastoid
asynchrony, and vacuolization, in acute erythroleukemia. Abnormal
megakaryocytes may also be present.
9. Chapter 31-09
Which form of acute leukemia has megakaryoblasts and antibodies to
platelet glycoprotein IIb/IIIa?
a. Acute myeloid leukemia with minimal differentiation

b. Acute monoblastic leukemia
c. Acute erythroleukemia
*d. Acute megakaryoblastic leukemia
General Feedback:
Acute megakaryoblastic leukemia has blasts that are positive
for the platelet antigens glycoprotein IIb/IIIa. They may also be
positive for glycoprotein Ib or factor VIII–related antigen.
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10. Chapter 31-10

Which would stain most strongly for myeloperoxidase?
a. Lymphoblasts
*b. Auer rods
c. Monocytes
d. Normal myeloblasts
General Feedback:
Auer rods are strongly positive for myeloperoxidase. Sometimes
Auer rods that cannot be seen with Wright stain are visible after
staining for myeloperoxidase. Monocytes are only very weakly positive
for this enzyme, whereas normal myeloblasts and lymphoblasts (both
normal and malignant) are negative.
11. Chapter 31-11

Sudan black is used to distinguish which types of leukemia?
*a. Acute myeloid leukemia from acute lymphoblastic leukemia

b. Acute myeloid leukemia from chronic myelogenous leukemia
c. Acute myeloid leukemia from acute promyelocytic leukemia
d. Acute promyelocytic leukemia from acute monocytic leukemia
General Feedback:
Lymphoid cells are generally negative, whereas myeloblasts are
positive. Thus a positive result with this stain can be used to
differentiate acute myeloidNleukemia
URSINGTfrom
B.Cacute
OM lymphoblastic leukemia.
The entire myeloid series through neutrophils is positive, so it is not
useful in differentiating different types of myeloid leukemia.
Monocytes are negative to weakly positive.
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1. Chapter 32-01
All are included in the chronic myeloproliferative disorders except:
*a. acute myeloid leukemia.

c. polycythemia vera.
d. essential thrombocythemia.
General Feedback:
Acute myeloid leukemia is not included in the chronic
myeloproliferative disorders. All the other conditions listed are part
of this classification.
2. Chapter 32-02
What do all chronic myeloproliferative disorders share?
a. Philadelphia chromosome
b. Increased red cell mass
*c. Increased blood cells; overlapping clinical and laboratory
features
d. Serious thromboembolic complications
General Feedback:
The chronic myeloproliferative disorders all have increased
blood cells, although which one (or ones) varies depending on the
condition. They also all have overlapping clinical features. The
Philadelphia chromosome is found only in chronic myelogenous leukemia
within this classification.NPolycythemia
URSINGTB.C OM uniquely has an increased
vera
red cell mass, and serious thromboembolic complications are primarily
seen in essential thrombocythemia, although they also can be a
complication of polycythemia vera when the patient is treated with
phlebotomy only.
3. Chapter 32-03
Which is an unexpected finding in chronic myelogenous leukemia?
a. Increased eosinophils (EOs) and basophils in the peripheral

blood
*b. 20% blasts in the peripheral blood
c. Hypercellular bone marrow with granulopoiesis
d. White blood count of 100 × 109/L
General Feedback:
Myeloblasts plus promyelocytes are usually present between 1%
and 5% in chronic myelogenous leukemia. A total of 20% blasts plus
promyelocytes is proposed for the classification of chronic myelogenous
leukemia accelerated phase. All the other findings listed are
characteristic of chronic myelogenous leukemia.
4. Chapter 32-04
Which is the most specific laboratory test to diagnose chronic
myelogenous leukemia?
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a. Increased bone marrow fibrosis and reticulin fibers

b. Increased EOs and basophils in peripheral blood
c. 5% blasts in the bone marrow
*d. Leukocyte alkaline phosphatase
General Feedback:
Of the laboratory tests listed, the leukocyte alkaline
phosphatase score is most specific for the diagnosis of chronic
myelogenous leukemia (where it is below normal in most cases). None of
the other findings are specific for chronic myelogenous leukemia.
5. Chapter 32-05
Chronic myelogenous leukemia often progresses to:
a. chronic neutrophilic leukemia.

b. chronic lymphocytic leukemia.
*c. acute leukemia, either myeloid or lymphoblastic.
d. chronic idiopathic myelofibrosis.
General Feedback:
Chronic myelogenous leukemia often progresses to acute
leukemia, which may be either myeloid or lymphoblastic.
6. Chapter 32-06
Which chronic myeloproliferative disorder is treated with imatinib
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mesylate, a drug that inhibits tyrosine kinase?
a. Polycythemia vera
*b. Chronic myelogenous leukemia
c. Essential thrombocythemia
d. Primary myelofibrosis
General Feedback:
Chronic myelogenous leukemia is effectively treated with
imatinib mesylate. This drug inhibits most of the transforming
capability stemming from the tyrosine kinase (P210) activity of the
bcr/abl fusion gene. This P210 fusion protein is not found in the other
myeloproliferative disorders, so the drug is ineffective in these
disorders.
7. Chapter 32-07
Which is an expected finding in polycythemia vera?
*a. Thrombocytosis
b. Anemia
c. Low leukocyte alkaline phosphatase
d. Normal white count
General Feedback:
Thrombocytosis, or an elevated platelet count, is
characteristically present in polycythemia vera. Polycythemia vera has
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an elevated red cell mass, so anemia is not present. The leukocyte

alkaline phosphatase score and the white count are both elevated.
8. Chapter 32-08
A high red count, hemoglobin, and hematocrit are found in all except:
a. polycythemia vera.
*b. bone marrow aplasia.
c. blood hyperviscosity.
d. erythrocytosis secondary to hypoxia.
General Feedback:
A high red count is not found in bone marrow aplasia. It is
characteristic of all the other disorders listed.
9. Chapter 32-09
A patient has an increased red count, hemoglobin, and hematocrit. Which
feature points to secondary polycythemia over polycythemia vera?
a. Increased white count

*d. Decreased arterial oxygen saturation
General Feedback:
Decreased arterial oxygen saturation is characteristic of
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secondary polycythemia. Arterial oxygen saturation is normal in
polycythemia vera. Decreased arterial oxygen saturation leads to
hypoxia, resulting in increased production of erythropoietin. This
stimulates the bone marrow to increase red cell production (erythroid
hyperplasia), also found in polycythemia vera. This results in an
increase in red cell mass, again also found in polycythemia vera, as is
an increased white count.
10. Chapter 32-10

A patient has a platelet count of 1200 × 109/L. Many platelets are
giant and have abnormal shapes. A mild anemia is present. The bone
marrow has increased megakaryocytes in clusters; iron stores are
present. Which is most likely?
*a. Essential thrombocythemia

b. Chronic myelogenous leukemia
c. Thrombocytosis secondary to blood loss
d. Polycythemia vera
General Feedback:
Platelet counts are often over 1000 × 109/L in essential
thrombocythemia. Polycythemia vera also has an elevated platelet count
but usually not in this range. In addition, a mild anemia is present in
the presence of iron stores; this rules out polycythemia vera. Although
the platelet count is usually elevated in the chronic phase of chronic
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myelogenous leukemia, it is not this high, nor would it be this

elevated in thrombocytosis secondary to blood loss.
11. Chapter 32-11

What clinical feature is more often associated with essential
thrombocytosis than with the other chronic myeloproliferative
disorders?
a. Splenomegaly
*b. Bleeding and thrombosis
c. Fatigue
d. Infections
General Feedback:
Bleeding and thromboembolic complications are characteristic
of essential thrombocytosis. Patients with polycythemia vera who are
treated only with phlebotomy are at increased risk for bleeding and
thrombosis, but it is otherwise not characteristic of polycythemia
vera. Splenomegaly is seen in all the myeloproliferative disorders, as
are fatigue and infections.
12. Chapter 32-12

Although found in most chronic myeloproliferative disorders, increased
fibrosis detected by the silver techniques and trichrome stain is the
key feature of:
NURSINGTB.COM
a. secondary polycythemia.
c. essential thrombocythemia.
*d. primary myelofibrosis.
General Feedback:
This is a key feature of primary myelofibrosis.
13. Chapter 32-13

A patient has a normal white blood count, a moderately high platelet
count, and mild anemia. The differential shows immature granulocytes,
nucleated red cells, and teardrop-shaped red cells. Which is most
likely?
*c. Primary myelofibrosis
d. Essential thrombocythemia
General Feedback:
These findings would all be characteristic of primary
myelofibrosis. Polycythemia vera and chronic myelogenous leukemia would
both be expected to have an elevated white count. The platelet count is
markedly increased in essential thrombocythemia.
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15. Chapter 32-15

The Philadelphia chromosome:
a. is a balanced reciprocal translocation between chromosomes 7

and 19.
*b. results in a chimeric gene (bcr/abl).
c. is diagnostic for polycythemia vera.
d. manifests as a tyrosine kinase that blocks cell maturation.
General Feedback:
The Philadelphia chromosome results in the chimeric gene
bcr/abl. It is a balanced reciprocal translocation between chromosomes
22 and 9. This chimeric gene manifests as a tyrosine kinase (P210),
which appears to induce clonal cell proliferation. Although it affects
maturation, as well as proliferation, it results in increased numbers
of mature granulocytes in peripheral blood, so it does not block cell
maturation.
16. Chapter 32-16

Which is true for chronic myelogenous leukemia?
*a. It is a clonal process arising from the pluripotent stem

cell.
b. It is most commonly found in children 5 to 10 years old.
c. Common symptoms include an elevated red cell mass.
d. Lymphadenopathy is common.

Chronic myelogenous leukemia is a clonal process arising from
the pluripotent stem cell. It is most commonly found in middle-aged
adults. A mild anemia that progresses is common, not an elevated red
cell mass; enlarged lymph nodes are not characteristic.
17. Chapter 32-17

Bone marrow or stem cell transplantation is the therapy of choice for
patients younger than 55 years old with:
a. essential thrombocytosis.
b. polycythemia vera.
*c. chronic myelogenous leukemia.
General Feedback:
Bone marrow or stem cell transplantation is the therapy of
choice for patients younger than 55 years old with chronic myelogenous
leukemia if an HLA-matched donor can be found. It is not a therapeutic
choice for either essential thrombocytosis or polycythemia vera.
18. Chapter 32-18

Which is true for the mutated erythroid progenitors in polycythemia
vera?
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a. They require extremely high levels of erythropoietin for

growth in vitro.
*b. They are more resistant to apoptosis than normal erythroid
progenitors.
c. They mature abnormally, giving rise to a marked increase in
poikilocytosis in peripheral blood.
d. They are Philadelphia chromosome positive.
General Feedback:
The mutated erythroid progenitors in polycythemia vera are
more resistant to apoptosis than normal erythroid progenitors. Thus
they do not divide more rapidly (as once believed) but accumulate
abnormally because they do not die normally. This results in an
increased red cell mass in peripheral blood. Maturation is normal,
giving rise to essentially morphologically normal red cells. They grow
in vitro with trace concentrations of erythropoietin and are
Philadelphia chromosome negative.
19. Chapter 32-19

The bone marrow fibrosis observed in primary myelofibrosis is due to:
a. malignant proliferation of fibroblasts.

b. increased erythropoietin, which stimulates fibroblast
proliferation.
*c. increased release of fibroblastic growth factors such as
platelet-derived growth factor.
d. decreased apoptosis of normal fibroblasts.
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General Feedback:
An increased release of fibroblastic growth factors occurs,
including platelet-derived growth factor, in primary myelofibrosis;
this results in fibrosis. The fibroblasts in primary myelofibrosis are
normal, not malignant.
20. Chapter 32-20

The Janus kinase (JAK) mutation is seen in more than 90% of cases of
what disease?
a. Chronic myelogenous leukemia

b. Primary myelofibrosis
c. Plasma cell myeloma
*d. Polycythemia vera
General Feedback:
The diagnosis of polycythemia vera requires the presence of
two major criteria and one minor criteria, or it requires the first
major criteria and two minor criteria. The JAK mutation is the second
of the major criteria.
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1. Chapter 32-01
All are included in the chronic myeloproliferative disorders except:
*a. acute myeloid leukemia.

c. polycythemia vera.
d. essential thrombocythemia.
General Feedback:
Acute myeloid leukemia is not included in the chronic
myeloproliferative disorders. All the other conditions listed are part
of this classification.
2. Chapter 32-02
What do all chronic myeloproliferative disorders share?
a. Philadelphia chromosome
*c. Increased blood cells; overlapping clinical and laboratory
features
d. Serious thromboembolic complications
General Feedback:
The chronic myeloproliferative disorders all have increased
blood cells, although which one (or ones) varies depending on the
condition. They also all have overlapping clinical features. The
Philadelphia chromosome is found only in chronic myelogenous leukemia
within this classification.NPolycythemia
URSINGTB.C OM uniquely has an increased
vera
red cell mass, and serious thromboembolic complications are primarily
seen in essential thrombocythemia, although they also can be a
complication of polycythemia vera when the patient is treated with
phlebotomy only.
3. Chapter 32-03
Which is an unexpected finding in chronic myelogenous leukemia?
a. Increased eosinophils (EOs) and basophils in the peripheral

blood
*b. 20% blasts in the peripheral blood
c. Hypercellular bone marrow with granulopoiesis
d. White blood count of 100 × 109/L
General Feedback:
Myeloblasts plus promyelocytes are usually present between 1%
and 5% in chronic myelogenous leukemia. A total of 20% blasts plus
promyelocytes is proposed for the classification of chronic myelogenous
leukemia accelerated phase. All the other findings listed are
characteristic of chronic myelogenous leukemia.
4. Chapter 32-04
Which is the most specific laboratory test to diagnose chronic
myelogenous leukemia?
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a. Increased bone marrow fibrosis and reticulin fibers

b. Increased EOs and basophils in peripheral blood
c. 5% blasts in the bone marrow
*d. Leukocyte alkaline phosphatase
General Feedback:
Of the laboratory tests listed, the leukocyte alkaline
phosphatase score is most specific for the diagnosis of chronic
myelogenous leukemia (where it is below normal in most cases). None of
the other findings are specific for chronic myelogenous leukemia.
5. Chapter 32-05
Chronic myelogenous leukemia often progresses to:
a. chronic neutrophilic leukemia.

b. chronic lymphocytic leukemia.
*c. acute leukemia, either myeloid or lymphoblastic.
d. chronic idiopathic myelofibrosis.
General Feedback:
Chronic myelogenous leukemia often progresses to acute
leukemia, which may be either myeloid or lymphoblastic.
6. Chapter 32-06
Which chronic myeloproliferative disorder is treated with imatinib
NURSINGTB.COM
mesylate, a drug that inhibits tyrosine kinase?
*b. Chronic myelogenous leukemia
c. Essential thrombocythemia
d. Primary myelofibrosis
General Feedback:
Chronic myelogenous leukemia is effectively treated with
imatinib mesylate. This drug inhibits most of the transforming
capability stemming from the tyrosine kinase (P210) activity of the
bcr/abl fusion gene. This P210 fusion protein is not found in the other
myeloproliferative disorders, so the drug is ineffective in these
disorders.
7. Chapter 32-07
Which is an expected finding in polycythemia vera?
*a. Thrombocytosis
b. Anemia
c. Low leukocyte alkaline phosphatase
d. Normal white count
General Feedback:
Thrombocytosis, or an elevated platelet count, is
characteristically present in polycythemia vera. Polycythemia vera has
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an elevated red cell mass, so anemia is not present. The leukocyte

alkaline phosphatase score and the white count are both elevated.
8. Chapter 32-08
A high red count, hemoglobin, and hematocrit are found in all except:
a. polycythemia vera.
*b. bone marrow aplasia.
c. blood hyperviscosity.
d. erythrocytosis secondary to hypoxia.
General Feedback:
A high red count is not found in bone marrow aplasia. It is
characteristic of all the other disorders listed.
9. Chapter 32-09
A patient has an increased red count, hemoglobin, and hematocrit. Which
feature points to secondary polycythemia over polycythemia vera?
a. Increased white count

*d. Decreased arterial oxygen saturation
General Feedback:
Decreased arterial oxygen saturation is characteristic of
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secondary polycythemia. Arterial oxygen saturation is normal in
polycythemia vera. Decreased arterial oxygen saturation leads to
hypoxia, resulting in increased production of erythropoietin. This
stimulates the bone marrow to increase red cell production (erythroid
hyperplasia), also found in polycythemia vera. This results in an
increase in red cell mass, again also found in polycythemia vera, as is
an increased white count.
10. Chapter 32-10

A patient has a platelet count of 1200 × 109/L. Many platelets are
giant and have abnormal shapes. A mild anemia is present. The bone
marrow has increased megakaryocytes in clusters; iron stores are
present. Which is most likely?
*a. Essential thrombocythemia

c. Thrombocytosis secondary to blood loss
General Feedback:
Platelet counts are often over 1000 × 109/L in essential
thrombocythemia. Polycythemia vera also has an elevated platelet count
but usually not in this range. In addition, a mild anemia is present in
the presence of iron stores; this rules out polycythemia vera. Although
the platelet count is usually elevated in the chronic phase of chronic
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myelogenous leukemia, it is not this high, nor would it be this

elevated in thrombocytosis secondary to blood loss.
11. Chapter 32-11

What clinical feature is more often associated with essential
thrombocytosis than with the other chronic myeloproliferative
disorders?
a. Splenomegaly
*b. Bleeding and thrombosis
c. Fatigue
d. Infections
General Feedback:
Bleeding and thromboembolic complications are characteristic
of essential thrombocytosis. Patients with polycythemia vera who are
treated only with phlebotomy are at increased risk for bleeding and
thrombosis, but it is otherwise not characteristic of polycythemia
vera. Splenomegaly is seen in all the myeloproliferative disorders, as
are fatigue and infections.
12. Chapter 32-12

Although found in most chronic myeloproliferative disorders, increased
fibrosis detected by the silver techniques and trichrome stain is the
key feature of:
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a. secondary polycythemia.
c. essential thrombocythemia.
*d. primary myelofibrosis.
General Feedback:
This is a key feature of primary myelofibrosis.
13. Chapter 32-13

A patient has a normal white blood count, a moderately high platelet
count, and mild anemia. The differential shows immature granulocytes,
nucleated red cells, and teardrop-shaped red cells. Which is most
likely?
*c. Primary myelofibrosis
General Feedback:
These findings would all be characteristic of primary
myelofibrosis. Polycythemia vera and chronic myelogenous leukemia would
both be expected to have an elevated white count. The platelet count is
markedly increased in essential thrombocythemia.
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14. Chapter 32-14

Which is an unexpected finding in primary myelofibrosis?
*a. 80% blasts in the peripheral blood

b. Micromegakaryocytes in the peripheral blood
c. Autoantibodies
d. Extramedullary hematopoiesis
General Feedback:
Eighty percent blasts in the peripheral blood is acute
leukemia, not primary myelofibrosis. All the other findings can be
present in primary myelofibrosis.
15. Chapter 32-15

The Philadelphia chromosome:
a. is a balanced reciprocal translocation between chromosomes 7

and 19.
*b. results in a chimeric gene (bcr/abl).
c. is diagnostic for polycythemia vera.
d. manifests as a tyrosine kinase that blocks cell maturation.
General Feedback:
The Philadelphia chromosome results in the chimeric gene
bcr/abl. It is a balanced reciprocal translocation between chromosomes
22 and 9. This chimeric gene manifests as a tyrosine kinase (P210),
which appears to induce clonal cell proliferation. Although it affects
NURSINGTit
maturation, as well as proliferation, B.C OM
results in increased numbers
of mature granulocytes in peripheral blood, so it does not block cell
maturation.
16. Chapter 32-16

Which is true for chronic myelogenous leukemia?
*a. It is a clonal process arising from the pluripotent stem

cell.
b. It is most commonly found in children 5 to 10 years old.
c. Common symptoms include an elevated red cell mass.
d. Lymphadenopathy is common.
General Feedback:
Chronic myelogenous leukemia is a clonal process arising from
the pluripotent stem cell. It is most commonly found in middle-aged
adults. A mild anemia that progresses is common, not an elevated red
cell mass; enlarged lymph nodes are not characteristic.
17. Chapter 32-17

Bone marrow or stem cell transplantation is the therapy of choice for
patients younger than 55 years old with:
a. essential thrombocytosis.
b. polycythemia vera.
*c. chronic myelogenous leukemia.
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General Feedback:
Bone marrow or stem cell transplantation is the therapy of
choice for patients younger than 55 years old with chronic myelogenous
leukemia if an HLA-matched donor can be found. It is not a therapeutic
choice for either essential thrombocytosis or polycythemia vera.
19. Chapter 32-19

The bone marrow fibrosis observed in primary myelofibrosis is due to:
a. malignant proliferation of fibroblasts.

b. increased erythropoietin, which stimulates fibroblast
proliferation.
*c. increased release of fibroblastic growth factors such as
platelet-derived growth factor.
d. decreased apoptosis of normal fibroblasts.
General Feedback:
An increased release of fibroblastic growth factors occurs,
including platelet-derived growth factor, in primary myelofibrosis;
this results in fibrosis. The fibroblasts in primary myelofibrosis are
normal, not malignant.
20. Chapter 32-20

The Janus kinase (JAK) mutation is seen in more than 90% of cases of
what disease?
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a. Chronic myelogenous leukemia
b. Primary myelofibrosis
c. Plasma cell myeloma
*d. Polycythemia vera
General Feedback:
The diagnosis of polycythemia vera requires the presence of
two major criteria and one minor criteria, or it requires the first
major criteria and two minor criteria. The JAK mutation is the second
of the major criteria.
21. Chapter 33-01

Which is a common feature of the myelodysplastic syndromes?
a. Peripheral blasts between 5% and 20%

*b. Progressive cytopenias
c. Macrocytic red cells and leukocytosis
d. Low mean cell volume (MCV) and thrombocytopenia
General Feedback:
Progressive cytopenias is characteristic of myelodysplastic
syndromes. Although blasts may be increased in the peripheral blood,
they are generally less than 5%. Macrocytic red cells may be present,
so the MCV may be elevated; however, the white count is usually normal
or decreased (depends on type), and platelets are normal to decreased.
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23. Chapter 33-03

What is the cause of myelodysplastic syndromes?
a. Decreased apoptosis
b. Are inherited disorders
*c. Proliferation of mutated myeloid cells
d. Epstein-Barr virus
General Feedback:
Proliferation of mutated myeloid stem cells is the cause for
myelodysplastic syndromes. Apoptosis is increased in early
myelodysplastic syndrome, giving rise to the cytopenia (or cytopenias);
however, later, if the disease progresses and acute leukemia appears,
apoptosis decreases. They are not inherited, and no association exists
with the Epstein-Barr virus.
24. Chapter 33-04

What red cell morphology is expected in the myelodysplastic syndromes?
a. Oval macrocytes
b. Dimorphic
c. Hypochromic, microcytic
*d. Any of the above
General Feedback:
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Red cell morphology is usually abnormal, and all of the
findings listed can be found.
25. Chapter 33-05

Myelodysplastic syndromes sometimes share similar peripheral and bone
marrow cellularity with all except:
a. vitamin B12 deficiency.

*b. aplastic anemia.
c. acute leukemia.
d. folate deficiency.
General Feedback:
The bone marrow in aplastic anemia is hypocellular, containing
primarily fat cells, lymphocytes, and plasma cells. Cytopenias exist in
the peripheral blood, but cell morphology is normal and no immature
cells are present. The myelodysplastic syndromes in general have a
hyperplastic bone marrow but cytopenia (or cytopenias) in peripheral
blood. These two findings can also be seen in acute leukemia and both
vitamin B12 and folate deficiencies.
27. Chapter 33-07

Which is typical in the peripheral blood in patients with
myelodysplastic syndrome?
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a. Lymphocytosis
b. Plasma cells
*c. Hypogranular or agranular neutrophils
d. Low levels of vitamin B12 or folate
General Feedback:
Maturation of granulocytes is abnormal in several of
myelodysplastic syndromes, and as a result hypogranular or agranular
neutrophils may be seen.
28. Chapter 33-08

What test is most important in distinguishing one myelodysplastic
syndrome from another?
a. White blood count

*b. Percentage of blasts in the bone marrow
c. Red cell morphology and MCV
d. Presence of ringed sideroblasts in the peripheral blood
General Feedback:
The primary distinguishing feature of the various
myelodysplastic syndromes is the percentage of blasts in the bone
marrow.
29. Chapter 33-09

Which is a typical finding N
inUR
chronic
SINGTmyelomonocytic
B.COM leukemia?
a. Thrombocytosis
b. Leukopenia
c. 10% to 15% blasts in the peripheral blood
*d. Persistent monocytosis
General Feedback:
Chronic myelomonocytic leukemia is characterized by persistent
monocytosis greater than 1.0 × 109/L in peripheral blood.
30. Chapter 33-10

On what does the World Health Organization (WHO) base its
classification for the myelodysplastic syndromes?
a. Cell morphology
b. Molecular analysis
c. Immunologic similarities
General Feedback:
The 2016 WHO classification system described in this chapter
identifies types of MDS based on similarities in morphology, molecular,
genetic, immunologic, and clinical characteristics, but it has limited
ability to provide a prognosis.
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31. Chapter 33-11

The observed heterogeneity in MDS is driven by:
a. allele burden.
*b. cytokine concentrations.
c. karyotype abnormalities.
General Feedback:
The observed heterogeneity in MDS is driven by allele burden,
karyotype abnormalities, cytokine concentrations, bone marrow
microenvironment, clinical context, and numerous other factors.
32. Chapter 33-12

Which type of mutation are scientists trying to integrate into models
to enhance the accuracy of prognoses for patients?
*a. Somatic
b. Advanced
c. Long-term
d. Stem
General Feedback:
Researchers are trying to integrate somatic mutations into
existing or novel prognostic models to enhance the accuracy of
prognoses for patients.
NURSINGTB.COM
33. Chapter 33-13
What treatment for the myelodysplastic syndromes has the best chance
for cure in these patients?
a. Corticosteroid agents
b. Chemotherapy
*c. Bone marrow transplant
d. Vitamins and hormones
General Feedback:
Bone marrow transplantation with an HLA-matched donor has the
greatest chance for cure in patients with myelodysplastic syndrome.
34. Chapter 33-14

Which is an unexpected finding in myelodysplastic syndrome with a
deletion of 5q?
a. Refractory anemia
b. Thrombocytosis
c. Less than 1% blasts in peripheral blood
*d. Auer rods
General Feedback:
5q syndrome predominantly affects older women. Typical
findings are anemia, thrombocytosis, and hypolobulated megakaryocytes.
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Less than 1% blasts are seen on peripheral blood. Auer rods are not
seen.
35. Chapter 33-15

Cell dysfunction in the myelodysplastic syndromes may be present in:
a. red cells.
b. granulocytes.
c. platelets.
General Feedback:
All blood cells produced in the bone marrow (i.e., red cells,
granulocytes, platelets) may exhibit abnormal cell function.
36. Chapter 33-16

Which are useful for determining prognosis for patients with the
myelodysplastic syndromes?
*a. Bone marrow blasts

b. Karyotypic abnormalities
c. Depth of cytopenias
d. All of the options.
General Feedback:
Prognosis in MDS depends on several factors, including
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percentage of bone marrow blasts, depth of cytopenias, and karyotypic
abnormalities.
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1. Chapter 34-01
Which are common examples of chromosomal translocated genes associated
with lymphomas?
a. MYC
b. BCL2
c. BCL6
General Feedback:
Common examples of translocated genes are MYC which stimulates
entry into the cell cycle, BCL2 which suppresses apoptosis, and BCL6
which can suppress the transcription of other genes necessary for cell
growth. These mutations are found in a number of lymphomas.
2. Chapter 34-02
In which population is acute lymphoid leukemia (ALL) with a stem cell
phenotype most common?
*a. Children
b. Adults
c. Older adults
d. Pregnant women
General Feedback:
Acute lymphoid leukemia (ALL), with a stem cell or precursor
phenotype, is more commonly found in the pediatric population.
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3. Chapter 34-03
Which primary laboratory test is ordered for a patient with
lymphadenopathy?
a. Biochemical analysis
b. Immunophenotyping
c. Flow cytometry
*d. Complete blood cell count
General Feedback:
The CBC is one of the first laboratory tests ordered to
investigate patient symptoms in which a quantitative abnormality may be
the first indication of underlying pathology. Biochemical analysis may
be useful for three purposes: (1) evaluating organ systems for
compromise due to tumor involvement, (2) as an indirect measure of
tumor burden and (3) assessing prognosis. Immunophenotyping is
undertaken with standard consensus panels and the pattern of staining
with a series of monoclonal antibodies (MoAbs) associated with lineages
and degree of maturation establishes an immunologic (CD) profile. Flow
cytometry is often used to document clonality associated with lymphoid
malignancies.
4. Chapter 34-04
What is the clinical significance of an enlarged lymph node?
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a. Usually benign related to an infection

b. Usually indicates lymphoma
*c. Can be benign or malignant depending on the microscopic
evaluation
d. Diagnostic for an autoimmune disorder
General Feedback:
Lymphadenopathy can occur in either benign or malignant
conditions.
5. Chapter 34-05
Which is true regarding the staging process of chronic lymphocytic
leukemia?
a. It pinpoints genetic mutations.

b. It divides patient into healthy and unhealthy groups.
c. It offers a solid prognosis.
*d. It guides clinical management.
General Feedback:
Staging systems are important prognostic determinants for CLL
and are used to guide clinical management.
6. Chapter 34-06
A middle-aged man has a white blood cell (WBC) count of 80 × 109/L with
90% lymphocytes and many smudge
NURScells.
INGTBWhich
.COMis most likely?
*a. Chronic lymphocytic leukemia
b. Hairy cell leukemia
c. T cell lymphoma
d. Sézary syndrome
General Feedback:
Chronic lymphocytic leukemia is characterized by the
accumulation of small lymphoid cells in the peripheral blood with
condensed chromatin pattern without a defined nucleolus. Smudge cells,
representing disintegrated lymphoid cells, are also present. They are
of diagnostic significance.
7. Chapter 34-07
Which are characteristics of monoclonal B cell lymphocytosis?
a. Less than 5x109/L circulating B lymphocytes

b. Absence of cytopenia
c. No organomegaly
General Feedback:
Patients who are asymptomatic, without any lymphadenopathy,
organomegaly, cytopenias or systemic symptoms with less than 5x109/L
circulating B lymphocytes are referred to as having monoclonal B cell
lymphocytosis (MBL)(19).
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8. Chapter 34-08
Where are malignant plasma cells found in multiple myeloma?
*a. Bone marrow

b. Lymph nodes
c. Liver
d. Spleen
General Feedback:
The malignant plasma cells in multiple myeloma are found in
the bone marrow.
9. Chapter 34-09
Cells that are medium to large in size and have accentuated, convoluted
nuclei, coarsely clumped chromatin and deeply basophilic cytoplasm are
associated with:
a. Reed-Sternberg lymphoma.
b. mantle cell lymphoma.
c. small-cell lymphoma.
*d. adult cell leukemia lymphoma.
General Feedback:
The prototypical ATLL cells are medium to large in size and
have accentuated, convoluted nuclei, coarsely clumped chromatin and
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deeply basophilic cytoplasm. The term “flower cell” has been coined for
this morphology.
10. Chapter 34-10

Which is true regarding classic Hodgkin lymphoma?
*a. It is seen in young adults.

b. It is seen in young children.
c. It is seen in middle-aged adults.
d. It is seen in older adults.
General Feedback:
Hodgkin lymphoma occurs preferentially in young adults. It is
one of the first tumor types cured with combination chemotherapy and
therefore serves as a model for the evolution of therapeutics in modern
oncology.
11. Chapter 34-11

What is the diagnostic cell, found in involved lymph nodes, for Hodgkin
lymphoma?
a. Small B lymphocyte
b. Plasma cell
c. Small T lymphocyte
*d. Reed-Sternberg cell
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General Feedback:
Presence of the Reed-Sternberg cell is highly diagnostic of
Hodgkin lymphoma when it is encountered in the appropriate background.
12. Chapter 34-12

Malignant proliferation of plasma cells in the bone marrow with
osteolytic lesions describes:
a. Waldenström macroglobulinemia.
b. marginal zone B cell lymphoma.
c. follicle center lymphoma.
*d. multiple myeloma.
General Feedback:
MM is a bone marrow-based disease with extramedullary
extension to bone or soft tissue. Strict criteria are followed to
establish the diagnosis of MM based on the overall tumor burden as
reflected by percent of plasma cells in the bone marrow as well as the
extent of systemic manifestations of disease such as such as
hypercalcemia, renal failure, anemia and osteolytic lesions.
13. Chapter 34-13

Which are some of the B cell markers in chronic lymphocytic leukemia?
a. CD4 and CD8

b. CD33 and CD45
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*c. CD19 and CD20
d. CD33 and CD59
General Feedback:
On immunophenotyping, CLL lymphocytes exhibit B cell markers
CD19, CD20. and CD23 but also aberrantly co-express the T cell antigen
CD5.
14. Chapter 34-14

Which is true of chronic lymphocytic leukemia cells?
a. They are post-thymic T cells.

b. They are large and pleomorphic.
*c. They demonstrate surface immunoglobulin.
d. They are CD4+ T cells
General Feedback:
Although CLL cells demonstrate surface immunoglobulin, the
level of expression may be dim and the ability to discern light chain
restriction indicating B cell clonality may be difficult. Antigen
expression may be variable, not all cases fit into a classical CLL
immunophenotypic profile.
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15. Chapter 34-15

Mycosis fungoides is a disorder of which kind of cell?
*a. T cell
b. B cell
c. Hairy cell
d. Small cell
General Feedback:
Mycosis fungicides is a disorder of CD4+ T cells.
16. Chapter 34-16

The strongest risk factor for development of a lymphoproliferative
disorder is:
a. age 15 to 34 years.
*b. altered immune function.
c. female sex.
d. cytomegalovirus infection in childhood.
General Feedback:
Patients with altered immune function have the strongest risk
factor for development of a lymphoproliferative disorder. This includes
patients who are immunocompromised and those with autoimmune disease.
17. Chapter 34-17

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Serum protein electrophoresis on an elderly patient reveals a
monoclonal protein spike. Increased plasma cells are present in the
bone marrow. They are CD19 and CD20 negative but demonstrate high-
density CD38 and monoclonal cytoplasmic immunoglobulin. What is the
most likely diagnosis?
*a. Multiple myeloma

b. Hodgkin lymphoma
c. Burkitt lymphoma
d. Chronic lymphocytic leukemia
General Feedback:
Increased bone marrow plasma cells that are CD19 and CD20
negative but have high-density CD38 and monoclonal cytoplasmic
immunoglobulin are characteristic of multiple myeloma. A monoclonal
protein spike is present when serum electrophoresis is performed.
18. Chapter 34-18

Why are patients with multiple myeloma susceptible to infection?
a. Decreased lymphocytes
b. Neutropenia
c. Suppressed normal immunoglobulin levels
*d. Both Neutropenia and Suppressed normal immunoglobulin levels
General Feedback:
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As plasma cells multiply in the bone marrow, normal

hematopoiesis, including granulopoiesis, is suppressed. This leads to
neutropenia. In addition, normal immunoglobulin (antibodies) is
suppressed. Together these contribute to the increased susceptibility
to infection seen in these patients.
19. Chapter 34-19

What are the subtypes of Burkitt lymphoma?
a. Endemic
b. Sporadic
c. HIV associated
General Feedback:
Burkitt lymphoma has three subtypes—endemic, sporadic, and HIV
associated. The endemic form is found primarily in childhood in
equatorial Africa along a geographic distribution similar to malaria.
20. Chapter 34-20

What lymphoproliferative disorder has a very favorable response to
highly aggressive chemotherapy with no radiotherapy?
a. Chronic lymphocytic leukemia

b. Mycosis fungoides
c. Hodgkin lymphoma
*d. Burkitt lymphoma
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General Feedback:
Burkitt lymphoma has a very favorable response rate to
aggressive chemotherapy, primarily because most of the cells are in an
active phase of the cell cycle at any one time. Cure rates are 60% to
90%, depending on the stage of the disease.
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1. Chapter 35-01
Which is part of primary hemostasis?
a. Fibrinolysis
*b. Blood vessels
c. Intrinsic system
d. Inhibitors
General Feedback:
Blood vessels and platelets are important in primary
hemostasis, where they play roles in forming the primary hemostatic
plug.
2. Chapter 35-02
What are the primary procoagulant roles of the blood vessel?
*a. Constrict and provide collagen and other compounds to

activate clotting.
b. Prevent the blood from escaping and promote fibrinolysis.
c. Secrete platelet growth factors and manufacture calcium.
d. Constrict and synthesize most plasma coagulation factors.
General Feedback:
Blood vessels play a role in constriction of the vessel once
it has been damaged. Collagen is located in the subendothelial tissue
and is exposed once a vessel is damaged. They also provide other
compounds, such as von Willebrand factor (VWF), which is necessary for
platelet adhesion. NURSINGTB.COM
3. Chapter 35-03
Which aids in preventing excess clotting?
a. Thrombin
b. Factor VII
c. Nitric oxide
*d. Protein C
General Feedback:
The protein C pathway helps regulate the coagulation mechanism
by digesting activated coagulation factors V and VIII. Thrombin is the
activated form of prothrombin; it plays a number of roles in promoting
coagulation, including the splitting of fibrinogen to form fibrin.
Nitric oxide counteracts vasoconstriction.
4. Chapter 35-04
Which is necessary for platelet aggregation?
a. Protein S
b. Kallikrein
c. Vitamin K
*d. Fibrinogen
General Feedback:
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Platelet aggregation, the binding of platelets to one another,

requires fibrinogen.
5. Chapter 35-05
Where are most of the plasma procoagulant proteins produced?
*a. Liver
b. Megakaryocytes
c. Endothelial cells
d. Spleen
General Feedback:
Most of the procoagulant proteins found in plasma are
synthesized in the liver.
6. Chapter 35-06
Which is true regarding the plasma coagulation zymogens?
a. Circulate normally in their active form.

*b. Are serine proteases that form complexes to activate other
zymogens to ultimately generate thrombin.
c. Activation normally occurs throughout the body when vascular
injury occurs.
d. Are cofactors that induce peptide bonding to make larger
active molecules.
General Feedback:
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Zymogens are the inactive forms of the procoagulant enzymes.
They are serine proteases that form complexes to activate other
zymogens. The end result of this process is to generate thrombin.
7. Chapter 35-07
What happens to the fibrin monomers created when thrombin cleaves
fibrinopeptides A and B from fibrinogen?
a. Immediately inactivated to prevent excess clotting

b. Converted to plasminogen
c. Digested quickly by tissue plasminogen activator (TPA)
*d. Polymerized and are stabilized by factor XIIIa
General Feedback:
Once thrombin splits fibrinopeptides A and B from fibrinogen,
the fibrin monomers are formed. These spontaneously polymerize to form
the initial soluble fibrin polymer, which is cross-linked by XIIIa and
then becomes insoluble. Fibrin monomers spontaneously polymerize to
form the fibrin clot, which is then stabilized by factor XIIIa. TPA
activates plasminogen to plasmin, which lyses the clot.
8. Chapter 35-08
On what does factor VIII depend for stability?
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*a. VWF
b. Platelets
c. Thrombin
d. Protein S
General Feedback:
Factor VIII circulates bound to VWF. Free factor VIII is
unstable in plasma, so much so that it cannot even be detected.
9. Chapter 35-09
Patients who have a deficiency of protein C or protein S have which
type of disorder?
a. Bleeding disorder
*b. Thrombotic disorder
c. Bruising disorder
d. Hypercalcemia
General Feedback:
Patients with a deficiency of either protein C or protein S
have a thrombotic disorder. These two proteins are important in
regulating, by downgrading, thrombin generation and thus clotting.
Activated protein C binds free protein S to form a complex that
inactivates factors Va and VIIIa.
10. Chapter 35-10

NURSINGTB.COM
Oral anticoagulation is based on:
a. increasing plasminogen.
b. activating plasmin.
c. combining with antithrombin.
*d. vitamin K antagonism.
General Feedback:
Vitamin K antagonism is the basis for oral anticoagulation.
11. Chapter 35-11

Which are components of the contact group of factors?
a. Fibrinogen and thrombin

b. VIII and VWF
*c. XII and prekallikrein
d. Calcium and IX
General Feedback:
The contact factors include factor XII, prekallikrein
(Fletcher factor), and high-molecular-weight kininogen (Fitzgerald
factor).
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12. Chapter 35-12

Which is the most important protease of the coagulation pathway because
of its role in so many different catalytic functions?
*a. Thrombin
b. Factor XIa
c. Plasmin
d. Factor VIIa
General Feedback:
Thrombin is considered the most important protease of the
coagulation pathway because of its multiple functions. These include
splitting fibrinogen to form fibrin monomers; activating the cofactors
V and VIII; activating factor XIII; binding to thrombomodulin to
activate protein C; and aggregating platelets, to name just a few.
13. Chapter 35-13

What is the role of the thrombin-thrombomodulin complex?
a. Initiates vasoconstriction.
b. Activates thrombin.
c. Inhibits factor Xa.
*d. Activates protein C.
General Feedback:
Thrombin binds the endothelial cell membrane protein
thrombomodulin, and the complex then activates protein C. Activated
NURSIS,
protein C complexes with protein NGand
TB.the
COMcomplex degrades factors Va
and VIIIa, which downregulates thrombin generation.
14. Chapter 35-14

What protein does heparin work with to inhibit coagulation?
a. Protein S
*b. Antithrombin
c. Vitamin K
d. Factor VII
General Feedback:
Heparin binds to antithrombin, thus bringing thrombin in close
proximity to antithrombin. It also changes the configuration of
antithrombin so that it can effectively bind thrombin. The thrombin-
antithrombin complex renders thrombin inactive; the complex is taken to
the liver and cleared.
15. Chapter 35-15

What substance digests the fibrin clot after healing?
*a. Plasmin
b. Activated protein C
c. TPA
d. alpha2-antiplasmin
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General Feedback:
Plasmin is the active form of the zymogen plasminogen. Plasmin
systematically digests (i.e., degrades, lyses) the fibrin clot after
healing.
16. Chapter 35-16

Which therapy actually lyses the clot rather than prevents future
clots?
a. Aspirin
b. Heparin
*c. TPA
d. Coumadin
General Feedback:
TPA is normally released from endothelial cells and activates
plasminogen, which then gradually lyses the fibrin clot. TPA is used
therapeutically to lyse pathologic clots in thrombotic disease. Aspirin
inhibits platelet function, heparin binds to antithrombin to inhibit
thrombin, and Coumadin interferes with normal synthesis of the vitamin
K–dependent proteins.
17. Chapter 35-17

Absence of D dimers is useful for ruling out:
*a. thromboembolism.
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b. von Willebrand disease (vWD).
c. protein C deficiency.
d. factor VII deficiency.
General Feedback:
The D dimer is a specific marker for thrombosis; when the
assay is negative, it is useful for ruling out thromboembolism.
18. Chapter 35-18

All are functions of thrombin except:
a. activates factors V and VIII.

*b. activates plasminogen.
c. activates factor XIII.
d. initiates platelet aggregation.
General Feedback:
Thrombin does not activate plasminogen. It does perform all of
the other functions listed.
19. Chapter 35-19

What role do cofactors play in the procoagulant process?
a. Bind fibrinolytic factors to slow down lysis of the clot.
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b. Bind Ca2+ to form a bridge with platelet phospholipids.

*c. Bind to their specific activated serine protease to stabilize
the protease and increase its activity.
d. Bind to collagen to aid in platelet adhesion.
General Feedback:
Cofactors bind to their specific activated serine protease to
stabilize the protease and increase its activity. One example is the
binding of the cofactor Va to factor Xa, which then magnifies the
activity of factor Xa to activate prothrombin.
20. Chapter 35-20

What plasma protein is important for normal wound healing and
stabilization of the fibrin clot?
a. Tissue factor
b. Prothrombin
c. Factor Xa
*d. Factor XIIIa
General Feedback:
Factor XIIIa stabilizes the fibrin polymer and is essential
for normal wound healing, as well as tissue integrity.
21. Chapter 35-21

What vitamin is essential for
NURnormal
SINGTsynthesis
B.COM of prothrombin group
proteins, thus enabling them to bind Ca2+?
*a. Vitamin K
b. Vitamin B12
c. Vitamin C
d. Vitamin D
General Feedback:
Vitamin K is necessary for carboxylation of glutamic acid
residues on the precursor prothrombin group proteins. This
carboxylation enables these proteins to bind Ca2+.
22. Chapter 35-22

What substance is known to inactivate arachidonic acid, causing
impairment of platelet function?
*a. Aspirin
b. Calcium
c. Tylenol
d. Vitamin K
General Feedback:
Aspirin inactivates the enzyme cyclooxygenase, blocking
thromboxane A2 production and causing impairment of platelet function
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(called aspirin effect). Thromboxane A2 causes Ca+2 to be released and

promotes platelet aggregation and vasoconstriction.
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1. Chapter 36-01
Two children in the same family have recurrent, chronic bruising in
multiple sites, repeated long-lasting epistaxis, and minor bleeding
after dental work. Which type of disorder is most likely?
a. Localized, acquired, anatomic

b. Localized, congenital, anatomic
*c. Generalized, congenital, systemic
d. Generalized, acquired, systemic
General Feedback:
Because the two affected children are in the same family, this
is most likely congenital. Recurrent, chronic bruising in multiple
sites, along with long-lasting epistaxis and minor bleeding after
dental work, make this generalized and systemic rather than localized
and anatomic.
2. Chapter 36-02
Which is appropriate initial testing for the siblings in Question 1?
a. Fibrinogen, D-dimer, and platelet aggregation studies

b. Factor VIII assay, liver function tests, and vitamin K level
c. von Willebrand factor (VWF) antigen, Bethesda titer, and
reptilase time
*d. Prothrombin time (PT), partial thromboplastin time (PTT), and
platelet count

The initial hemostasis profile should consist of the PT, PTT,
and platelet count.
3. Chapter 36-03
What is the possible mechanism for bleeding in patients with severe
liver disease?
a. Thrombocytopenia
b. Inadequate production of procoagulants
c. Disseminated intravascular coagulation (DIC)
General Feedback:
All of the findings listed are possible causes for bleeding in
patients with severe liver disease.
4. Chapter 36-04
Which is decreased in DIC?
*a. Fibrinogen
b. PT
c. PTT
d. Fibrin degradation products
General Feedback:
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Fibrinogen is decreased in DIC. The PT and PTT are both

increased (prolonged), whereas fibrin degradation products are
increased.
5. Chapter 36-05
The bleeding associated with renal disease is related most to
defective:
a. blood vessels.
b. plasma procoagulants.
*c. platelets.
d. inhibitors.
General Feedback:
Platelet dysfunction is the primary cause for prolonged
bleeding in patients with renal failure.
6. Chapter 36-06
Which patient group is most susceptible to bleeding because of a
deficiency of vitamin K–dependent proteins?
a. Those with poor diets

b. Those on antibiotic agents
c. Pregnant women
*d. Newborns
General Feedback:
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Newborns are the most susceptible to vitamin K protein
deficiency because the levels of the vitamin K–dependent proteins at
birth are significantly lower than those for adults, and they drop even
further the first few days of life. Breastfeeding prolongs the
deficiency because passively acquired maternal antibodies delay
establishment of the gut flora.
7. Chapter 36-07
Clot-based mixing studies and Bethesda titers are used to test for:
a. vitamin K deficiency.
*b. inhibitors (antibodies) against coagulation factors.
c. DIC.
d. hemophilia.
General Feedback:
An inhibitor against a coagulation protein is confirmed using
clot-based mixing studies. The Bethesda titer is then performed to
determine the concentration of the inhibitor.
8. Chapter 36-08
What are the primary roles of VWF?
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*a. Mediates platelet adhesion and carrier molecule for factor

VIII.
b. Mediates platelet aggregation and carrier molecule for factor
IX.
c. Inhibits excess coagulation and activates protein C.
d. Activates plasmin and enhances vitamin K factors.
General Feedback:
VWF is required for normal platelet adhesion; it is also the
carrier protein for factor VIII, protecting it from proteolysis and
thus prolonging the in vivo half-life from just a few minutes (in the
absence of VWF) to 8 to 12 hours.
9. Chapter 36-09
Which is the most common form of von Willebrand disease (VWD)?
*a. Type 1
b. Type 2A
c. Type 3
d. Acquired
General Feedback:
Type 1 VWD is seen in more than 70% of patients with VWD.
10. Chapter 36-10

A 21-year-old woman has a primary complaint of menorrhagia. Her
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coagulation screen gives the following results.
Test Test Result Reference range
Prothrombin time 12.0 seconds 11–15 seconds
(PT)
Partial 40 seconds 25–37 seconds
thromboplastin
time (PTT)
Factor VIII 35% 50%–150%
activity
Platelet count 225 × 109/L 150–400 × 109/L
What disorder is most likely?
a. Hemophilia A
b. Hemophilia B
*c. VWD, type 1
d. Factor X deficiency
General Feedback:
VWD is the most prevalent of the congenital bleeding
disorders, affecting both female and male subjects; hemophilia A and B
both affect primarily male subjects. Female patients with VWD often
complain of menorrhagia. Most patients with VWD have factor VIII levels
in the range of 35% to 50%.
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11. Chapter 36-11

Desmopressin acetate (DDAVP) is used to treat:
a. dysfibrinogenemia.
b. warfarin overdose.
c. vitamin K deficiency.
*d. VWD, type 1.
General Feedback:
DDAVP, which triggers the release of VWF from storage
organelles, is used to treat type 1 VWD. It is also useful in type 2A,
but it is contraindicated in type 2B.
12. Chapter 36-12

Which single-factor inherited deficiencies are most common as the cause
for hemophilia?
a. Factor V
*b. Factor VIII
c. Factor IX
d. Factor XI
General Feedback:
Eighty-five percent of congenital single-factor deficiencies
are of factor VIII. This results in hemophilia A.
13. Chapter 36-13

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What is common in patients with severe hemophilia A?
a. Generalized bleeding after trauma or dental work

b. Generalized hemorrhage
c. Major bruising on extremities and chronic nosebleeds
*d. Serious anatomic bleeds into joints
General Feedback:
Hemophilia A causes anatomic bleeds, including deep muscle and
joint bleeds. Major bruising is associated with platelet abnormalities.
14. Chapter 36-14

Which test is increased in a patient with severe hemophilia A?
*a. PTT
b. Thrombin time (TT)
c. PT
d. Factor VIII assay
General Feedback:
The PTT is increased (prolonged) in patients with severe
hemophilia A because of a significant decrease in factor VIII. The PT
and TT are both normal.
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15. Chapter 36-15

What test is useful for detection of a female carrier of hemophilia A?
a. PTT
b. PT
*c. Factor VIII to VWF ratio
d. VWF antigen test
General Feedback:
Approximately 90% of female carriers of hemophilia A are
detected using the ratio of factor VIII activity to VWF antigen. This
is because VWF production is unaffected by factor VIII deficiency, so
it should be normal in a female hemophilia A carrier, whereas the
factor VIII activity will be less than that of VWF. Thus a discrepancy
exists in the concentration of these two proteins.
16. Chapter 36-16

What is the purest form of factor VIII that is available for treating a
bleeding patient with hemophilia A?
a. Cryoprecipitate
*b. Recombinant factor VIII concentrate
c. Fresh frozen plasma
d. Factor VIII concentrate prepared by chemical concentration
General Feedback:
Recombinant deoxyribonucleic acid (DNA) technology provides a
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high-purity factor VIII concentrate.
17. Chapter 36-17

What is the best test to distinguish hemophilia A from B or C?
*a. Specific factor assays

b. PTT
c. TT
d. Bleeding time
General Feedback:
Hemophilia A (factor VIII deficiency), hemophilia B (factor IX
deficiency), and hemophilia C (factor XI deficiency) are differentiated
from one another using specific factor assays.
18. Chapter 36-18

In which substance is a patient with the following coagulation test
results most likely deficient?
Test Test Result Reference
Range
Prothrombin time 17 seconds 11–15 seconds
(PT)
Partial 31 seconds 25–37 seconds
thromboplastin time
(PTT)
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Thrombin time (TT) 16 seconds 15–21 seconds
a. Fibrinogen
*b. Factor VII
c. Factor VIII
d. Factor X
General Feedback:
Factor VII deficiency shows a prolonged PT with a normal PTT
result. A deficiency of fibrinogen ideally should prolong the PT, PTT,
and TT. Factor VIII deficiency prolongs the PTT but not the PT and TT,
whereas a factor X deficiency should prolong both the PT and PTT but
not the TT.
19. Chapter 36-19

The urea solubility test is used to detect deficiencies in which
factor?
a. Fibrinogen
b. Factor V
c. Factor XII
*d. Factor XIII
General Feedback:
The plasma from patients with a factor XIII deficiency forms
NURS2IN
weak clots that dissolve within GTB.when
hours COMsuspended in a 5M urea
solution because the clot has not been cross-linked by XIIIa.
20. Chapter 36-20

What coagulation screening test is the most sensitive for detecting
mild liver disease?
a. Fibrinogen
b. PTT
*c. PT
d. TT
General Feedback:
Liver disease particularly affects production of the vitamin
K–dependent proteins. Because the PT is sensitive to factor VII
activity and it (factor VII) has a short half-life of 3 to 5 hours, the
PT is the most sensitive for detecting mild liver disease.
21. Chapter 36-21

Which protein is the best test to distinguish moderate to severe liver
disease from vitamin K deficiency?
*a. Factor V concentration

b. Factor VII concentration
c. Factor VIII concentration
d. Factor IX concentration
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General Feedback:
Factor V is not vitamin K dependent, but it is produced in the
liver, so it is decreased in moderate to severe liver disease. Factors
VII and IX are both vitamin K dependent, so they are decreased in both
liver disease and vitamin K deficiency. Factor VIII is not decreased in
either liver disease or vitamin K deficiency; in fact, because it is an
acute phase reactant, it may actually be elevated in mild to moderate
liver disease.
22. Chapter 36-22

A 67-year-old woman arrives at the emergency department with acute
bleeding into the back of the throat. A coagulation screen is ordered
with the following results:
Test Result Reference 1:1 Mix With
Range Normal
Plasma
Prothrombin 12 11–15
time (PT) seconds seconds
Partial 57 25–37 36 seconds
thromboplastin seconds seconds (immediate)
time (PTT)
Fibrinogen 450 mg/dL 150–400
mg/dL
What would be a reasonable next step to perform?

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a. Perform factor IX assay.
b. Perform factor VII assay.
*c. Incubate the 1:1 mix at 37°C for 1 hour.
d. Perform TT.
General Feedback:
Factor VIII autoantibodies are usually time and temperature
dependent. Thus the 1:1 mix must be incubated at 37°C for 1 to 2 hours
to give the antibody time to react with the factor VIII added by the
normal plasma. Prolongation of the PTT on this incubated 1:1 mix
indicates that an antibody to VIII is present. A factor VIII assay,
when performed, will show a low factor VIII (less than 30%).
23. Chapter 36-23

What procedure is used to quantitate a factor VIII inhibitor?
*a. Bethesda assay

b. Reptilase time
c. Factor VIII concentration
d. VWF assay
General Feedback:
The Bethesda assay is used to quantitate a factor VIII
inhibitor.
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24. Chapter 36-24

All can mask a deficiency of VWF and thus of type 1 VWD except:
*a. fibrinogen levels.

b. pregnancy.
c. acute stress.
d. type ABO blood group.
General Feedback:
The concentration of VWF is low in VWD, type 1. VWF is an
acute-phase reactant and is thus elevated in acute stress. Higher
estrogen levels during pregnancy also elevate VWF. Individuals with
type ABO blood type have higher levels of VWF. All these can thus mask
VWD.
25. Chapter 36-25

Which type of VWD gives a positive response to low-dose ristocetin-
induced platelet aggregation?
a. 1
b. 2A
*c. 2B
d. 2N
General Feedback:
The low-dose ristocetin-induced platelet aggregometry
identifies VWD, subtype 2B.NURSINGTB.COM
26. Chapter 36-26

A 39-year-old male patient shows evidence of poor wound healing and a
history of joint bleeding. What protein deficiency is most likely
present?
a. Factor VIII
b. Factor IX
c. Factor V
*d. Factor XIII
General Feedback:
Patients with a deficiency of factor XIII have evidence of
poor wound healing and anatomic bleeds.
27. Chapter 36-27

Which screening test would be normal when the plasma for the patient in
Question 26 is analyzed?
a. PT
b. PTT
c. TT
General Feedback:
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The PT, PTT, and TT are all normal in a patient with factor
XIII deficiency. Factor XIII deficiency is evaluated by placing the
clot in 5M urea; the uncross-linked clot is weak and dissolves within 2
hours in this solution.
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1. Chapter 37-01
The qualitative platelet disorders and vascular disorders typically
exhibit what type of symptoms?
*a. Superficial bleeding

b. Deep tissue bleeding
c. Hemarthrosis
d. Thrombosis
General Feedback:
Superficial bleeding, including petechiae, epistaxis (nose
bleeds), and gingival (gum) bleeding, is characteristic of qualitative
bleeding disorders.
2. Chapter 37-02
Which is an autosomal recessive disorder in which the GP Ib/IXI/V
complex is missing from the platelet surface?
a. von Willebrand disorder (VWD)

*b. Bernard-Soulier syndrome
c. Glanzmann thrombasthenia
d. Dense granule deficiency
General Feedback:
Bernard-Soulier syndrome is inherited as an autosomal
recessive disorder in which the GP Ib/IX/V complex is missing from the
platelet surface or exhibits abnormal function. Inability to bind to
NURof
VWF accounts for the inability SIN GTB.COMto adhere to exposed
platelets
subendothelium and the resultant bleeding characteristic of this
disorder.
3. Chapter 37-03
Which is the most likely diagnosis for an infant who experiences
bleeding after circumcision with epistaxis and gingival bleeding?
a. Aspirin ingestion
b. Gray platelet syndrome
c. Vitamin C deficiency
*d. Glanzmann thrombasthenia
General Feedback:
Glad Glanzman thombobasthenia is a rare disorder which
manifests itself clinically in the neonatal period or infancy,
occasionally with bleeding after circumcision and frequently with
epistaxis and gingival bleeding. Hemorrhagic manifestations include
petechiae, purpura, menorrhagia, gastrointestinal bleeding, and
hematuria.
4. Chapter 37-04
Which is the most common cause of acquired platelet dysfunction?
a. Myeloproliferative disorders
b. Wiskott-Aldrich syndrome
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*c. Drugs, especially aspirin

d. Afibrinogenemia
General Feedback:
Aspirin and other drugs are the most common causes of acquired
platelet dysfunction.
5. Chapter 37-05
Which is normal in a patient regularly taking aspirin?
a. Platelet aggregation
b. Platelet cyclooxygenase function
c. Synthesis of thromboxane A2
*d. Platelet count
General Feedback:
Only the platelet count, of those evaluations listed, is
normal in a patient who regularly takes aspirin. Aspirin acetylates
cyclooxygenase, which is necessary for the synthesis of thromboxane A2.
6. Chapter 37-06
What types of hemostatic complications are found in patients with
myeloproliferative disorders?
a. Hemorrhagic
b. Thrombotic NURSINGTB.COM
c. Abnormal platelet function
General Feedback:
Patients with one of the chronic myeloproliferative disorders,
such as polycythemia vera and essential thrombocythemia, may have
abnormal platelet function; clinically, they may result in either
abnormal bleeding or abnormal thrombosis. Some patients develop both,
although this is rare.
7. Chapter 37-07
What is the mechanism for the platelet dysfunction in multiple myeloma
and Waldenström macroglobulinemia?
a. Granules become deficient.

*b. Platelets are coated with paraprotein.
c. Nitric oxide is not produced.
d. Cyclooxygenase is acetylated.
General Feedback:
Platelet dysfunction results from coating of the platelet
membranes by paraprotein and does not depend on the type of paraprotein
present. In addition to interacting with platelets, the paraprotein
likely interferes with fibrin polymerization and the function of other
coagulation proteins.
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8. Chapter 37-08
All are common conditions or situations that interfere with platelet
function except:
a. liver disease.
b. uremia.
*c. allergic purpura.
d. cardiopulmonary bypass surgery.
General Feedback:
Allergic purpura does not interfere with platelet function.
All of the other listed conditions or situations can affect platelet
function.
9. Chapter 37-09
Which is true regarding testing for the diagnosis of vascular
disorders?
*a. Most do not have abnormal clinical laboratory tests.

b. The platelet count and aggregometry are useful.
c. The prothrombin time (PT) and partial thromboplastin time
(PTT) are most useful.
d. Evaluation of von Willebrand factor (VWF) is useful.
General Feedback:
Clinical laboratory tests are not available for evaluation and
NURSIRuling
diagnosis of vascular disorders. NGTB.out
COMother sources of bleeding
disorders often makes the diagnosis. The usual clinical signs are easy
bruising and spontaneous bleeding, especially from mucosal surfaces. In
that respect they are similar to platelet dysfunction disorders.
10. Chapter 37-10

A 78-year-old patient recently noticed dark blotches on his forearms
and on the backs of his hands. He seems to bruise even when a
phlebotomy is performed using excellent technique with no problems
encountered. No other symptoms exist, and all laboratory tests are
normal. Which is the most likely diagnosis?
a. Hereditary hemorrhagic telangiectasia

b. Ehlers-Danlos syndrome
c. Paraproteinemia and amyloidosis
*d. Senile purpura
General Feedback:
Senile purpura is the most likely diagnosis for this 78-year-
old man who only recently began to notice abnormal bruising and/or
bleeding. The hereditary abnormalities would have presented earlier in
life. Paraproteinemia and amyloidosis would demonstrate other abnormal
clinical laboratory testing.
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11. Chapter 37-11

Platelet count and function studies are performed on a patient with a
history of easy bruising, and the following results are obtained:
Test Result
Platelet count 295 × 109/L
Platelet function assay Prolonged
Platelet aggregation Primary but no
with epinephrine secondary wave
Platelet aggregation Primary but no
with low-dose adenosine secondary wave
diphosphate (ADP)
Platelet aggregation Normal
with ristocetin
What is the most likely diagnosis for this patient?
a. Bernard-Soulier disease
*b. Dense granule deficiency
c. Glanzmann thrombasthenia
d. Gray platelet syndrome
General Feedback:
The platelet count on this patient is normal; however, the
platelet function assay is abnormal, which suggests platelet
dysfunction. Of the disorders listed, only dense granule deficiency has
the platelet aggregation results that are listed. Patients with
Bernard-Soulier disease have normal aggregation studies with every
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agonist except ristocetin, which is abnormal. The reverse is true for
Glanzmann thrombasthenia—they have normal aggregation with ristocetin
but have no primary wave, as well as no secondary wave with other
agonists. Patients with gray platelet syndrome have a moderate
thrombocytopenia, prolonged bleeding time, and large platelets that
appear gray on a Wright-stained blood film because of the absence of
alpha-granules. Platelet aggregation studies are unremarkable.
12. Chapter 37-12

Clopidogrel (Plavix) is a drug used therapeutically for patients with a
risk of arterial thrombi because it:
a. inhibits thrombin.
b. activates the protein C pathway.
*c. inhibits platelet function.
d. activates plasminogen.
General Feedback:
Clopidogrel is an antiplatelet function drug used for three
reasons: (1) to treat patients with arterial occlusive disease; (2) for
prevention of myocardial infarction; and (3) to decrease the risk of
thrombotic stroke in patients with cerebrovascular disease and in
patients who are intolerant of aspirin.
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1. Chapter 38-01
What is the correct term to describe a platelet count of 550 × 109/L
when all other complete blood count (CBC) results are basically normal?
a. Normal
*b. Thrombocytosis
c. Thrombocytopenia
General Feedback:
This platelet count is elevated, so the correct terminology to
describe it is thrombocytosis; this is most probably a reactive
thrombocytosis. Platelets are also elevated in essential
thrombocythemia, but they usually exceed 1 million/mL (1000 × 109/L),
and other abnormalities would also be seen in the CBC.
2. Chapter 38-02
Chemotherapy results in which condition?
*a. Acquired thrombocytopenia

b. Inherited thrombocytopenia
c. Acquired splenic sequestration
d. Inherited thrombocythemia
General Feedback:
Wide arrays of chemotherapeutic agents used for the treatment
of hematologic and nonhematologic
NURSIN malignancies
GTB.COM suppress bone marrow
megakaryocyte production and the production of other hematopoietic
cells. Drug-induced thrombocytopenia is often the dose-limiting factor
for many chemotherapeutic agents.
3. Chapter 38-03
What is the single most common cause of clinically important bleeding?
a. Hemophilia
b. Fibrinogen deficiency
*c. Thrombocytopenia
d. Qualitative platelet disorders
General Feedback:
The single most common cause of clinically important bleeding
is thrombocytopenia with a platelet count less than 100 × 109/L.
4. Chapter 38-04
Which results in ineffective thrombopoiesis?
a. Immune thrombocytopenic purpura

b. Thrombotic thrombocytopenic purpura
c. Disseminated intravascular coagulation (DIC)
*d. Megaloblastic anemia
General Feedback:
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Thrombocytopenia because of ineffective thrombopoiesis is one

of the usual features of megaloblastic anemias. Vitamin B12 and folic
acid are both required for normal maturation of megakaryocytes in the
bone marrow.
5. Chapter 38-05
A 28-year-old woman sees her family physician complaining of easy
bruising and menorrhagia. She has a platelet count of 60 × 109/L. All
other hematology and routine coagulation tests are normal. She has a
platelet-associated immunoglobulin G (IgG) autoantibody in her serum.
Which is most likely?
*a. Chronic immune thrombocytopenic purpura

c. Acute immune thrombocytopenic purpura
d. Hemolytic uremic syndrome
General Feedback:
Chronic immune thrombocytopenic purpura is most often seen in
women between the ages of 20 and 50 years of age. Patients most often
complain of easy bruising, recurrent epistaxis, and menorrhagia.
Platelet destruction in chronic immune thrombocytopenic purpura is the
result of an IgG autoantibody, with various membrane glycoproteins
being the most frequent targets.
6. Chapter 38-06 NURSINGTB.COM

Which patient group is most commonly diagnosed with acute immune
thrombocytopenic purpura?
a. Older men after an infection

b. Infants born to women who had eclampsia
*c. Children after having an infection
d. Adult patients with enlarged spleens
General Feedback:
Acute immune thrombocytopenic purpura is primarily a disorder
of children. It frequently occurs 1 to 3 weeks after an infection.
7. Chapter 38-07
Which is a commonly used drug that can cause thrombocytopenia?
a. Warfarin
b. Aspirin
c. Ibuprofen
*d. Heparin
General Feedback:
Heparin is associated with drug-induced thrombocytopenia; this
is called heparin-induced thrombocytopenia, and it can have serious
thrombotic complications. Warfarin does not affect the platelet count.
Aspirin and ibuprofen both affect platelet function.
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8. Chapter 38-08
What kind of antibody causes neonatal alloimmune thrombocytopenia?
*a. Maternal antibody against a fetal platelet antigen inherited

from the father
b. Fetal antibody directed against maternal platelet antigen
c. Fetal antibody against a fetal platelet antigen inherited from
the father
d. Maternal autoantibody against a mother’s platelet antigen
General Feedback:
Neonatal alloimmune thrombocytopenia develops when a mother
develops an alloantibody against a platelet antigen inherited by the
fetus from the father. These antibodies cross the placenta, bind to the
antigen-bearing fetal platelets, and cause their premature destruction.
9. Chapter 38-09
A 35-year-old woman with neurologic symptoms presents with a markedly
decreased platelet count. She has moderate anemia with many red cell
fragments on the blood film, as well as polychromasia and nucleated red
blood cells (RBCs). The prothrombin time (PT) and partial
thromboplastin time (PTT) are both normal. Which is the most likely
diagnosis?

*b. Thrombotic thrombocytopenic purpura
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c. Hemolytic uremic syndrome
d. DIC
General Feedback:
Thrombotic thrombocytopenic purpura is characterized by
thrombocytopenia, a microangiopathic hemolytic anemia with schistocytes
(red cell fragments), and neurologic abnormalities. It is most common
in women 30 to 40 years of age.
10. Chapter 38-10

A 4-year-old child becomes very sick after drinking contaminated water.
Kidney function tests are markedly elevated. Thrombocytopenia is mild,
and a few schistocytes are noted on the blood film. Which is most
likely the diagnosis?

*c. Hemolytic uremic syndrome
d. DIC
General Feedback:
Hemolytic uremic syndrome is found primarily in children
between the ages of 6 months to 4 years. In outbreaks of HUS associated
with consumption of E. coli–contaminated water, both children and
adults have developed HUS.
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11. Chapter 38-11

Which is successfully treated with therapeutic plasma exchange?

b. Chronic DIC
c. Acute DIC
*d. Thrombotic thrombocytopenic purpura
General Feedback:
The most effective treatment for thrombotic thrombocytopenic
purpura is therapeutic plasma exchange using fresh frozen plasma.
Dramatic effects may be seen within just a few hours.
12. Chapter 38-12

A patient in the intensive care unit has anemia, schistocytes, and
thrombocytopenia. The PT and PTT are elevated, and the fibrinogen is
low. What diagnostic test should be used?
*a. D dimer to confirm acute DIC

b. Bone marrow to confirm immune thrombocytopenic purpura
c. Platelet antibody against P1A1 to confirm heparin-induced
thrombocytopenia
d. Platelet aggregometry to confirm posttransfusion purpura
General Feedback:
In acute DIC, the D dimer is elevated, along with the other
laboratory findings listed. None of the other conditions listed have
NURfibrinogen,
the prolonged PT and PTT, low SINGTB.CandOM elevated D dimers.
13. Chapter 38-13

Which is an example of a quantitative platelet disorder related to
distribution?
a. Thrombotic cytopenic purpura

b. Essential thrombocythemia
*c. Splenomegaly
d. Hemolytic uremic syndrome
General Feedback:
An abnormal distribution of platelets may cause
thrombocytopenia. The spleen sequesters approximately one-third of the
total platelet mass. When the spleen is enlarged (splenomegaly), most
platelets are sequestered in the enlarged spleen, resulting in a lower
venous blood count.
14. Chapter 38-14

Which factor does the Coppo score consider in thrombotic
thrombocytopenic purpura?
a. Creatinine levels
b. Platelets counts
c. Antinuclear antibodies
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General Feedback:
The score described by Coppo, which considers creatinine
levels, platelet counts, and the presence of antinuclear antibodies,
offers high positive predictive values and specificity, but low
sensitivity in TTP.
15. Chapter 38-15

A patient has a platelet count of 650 × 109/L. The other hematology
tests are normal. No evidence of hemostasis failure exists. Which is
most likely?
*a. Reactive thrombocytosis

c. DIC
General Feedback:
The term reactive thrombocytosis refers to an abnormally high
platelet count, typically more than 450 × 109/L, secondary to
inflammation, trauma, or some other underlying and seemingly unrelated
conditions. The platelet count does not usually exceed 800 × 109/L, and
the elevation is transient.
16. Chapter 38-16 NURSINGTB.COM

All are often associated with thrombocytosis except:
a. hemorrhage.
*b. alcoholic liver disease.
c. iron deficiency.
d. inflammation.
General Feedback:
The only condition listed that is not associated with reactive
thrombocytosis is alcoholic liver disease.
17. Chapter 38-17

A 23-year-old man is brought by helicopter to a major trauma center
after a severe motorcycle accident. He has major abdominal trauma,
including a ruptured spleen, and is taken to surgery, where his spleen
is removed. Two weeks after surgery, his platelet count peaks at 950 ×
109/L. What is the most likely cause for this high platelet count?
a. Reactive thrombocytosis secondary to trauma

*c. Postsplenectomy thrombocytosis
d. Reactive thrombocytosis secondary to acute blood loss
General Feedback:
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Removal of the spleen characteristically results in a

thrombocytosis that can reach or even exceed 1000 × 109/L (1
million/mL). The platelet count usually peaks 1 to 3 weeks after
surgery and generally remains elevated for 1 to 3 months. Platelet
counts generally are not this elevated in reactive thrombocytosis, and
they do not peak 2 to 3 weeks after surgery.
18. Chapter 38-18

The terms petechiae, purpura, and ecchymoses all describe:
a. varying degrees of thrombocytopenia.

b. varying degrees of thrombocythemia.
c. varying qualitative platelet disorders.
*d. varying size hemorrhages into the skin because of small-
vessel bleeding.
General Feedback:
These terms all refer to small-vessel bleeding into the skin
that is caused by thrombocytopenia or many of the qualitative platelet
disorders. Petechiae are small pinpoint hemorrhages, purpura are about
1 cm in diameter, whereas ecchymoses are 3 cm or larger.
19. Chapter 38-19

What is the most common infectious cause of congenital neonatal
megakaryocytic hypoplasia?
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a. Epstein-Barr virus
b. Human immunodeficiency virus (HIV)
*c. Cytomegalovirus
d. Rubella
General Feedback:
Cytomegalovirus is the most common infectious agent causing
congenital neonatal megakaryocytic hypoplasia. Cytomegalovirus appears
to inhibit megakaryocytes and their precursors, resulting in impaired
platelet production.
20. Chapter 38-20

What is believed to be the cause for acute immune thrombocytopenia
purpura in children?
a. Development of a platelet-specific autoantibody

b. Development of a white cell autoantibody that cross-reacts
with platelet membrane antigens
c. Development of an allogeneic antibody after transfusion of
random allogeneic platelets
*d. Nonspecific binding of immune complexes to the platelet
membrane after a viral illness
General Feedback:
Acute immune thrombocytopenia purpura in children often
follows a viral illness. This suggests that some children produce
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antibodies and immune complexes against viral antigens and that

platelet destruction may result from their binding to the platelet
membrane.
21. Chapter 38-21

What is the most serious clinical consequence of heparin-induced
thrombocytopenia?
a. Hemorrhage
*b. Thrombosis
c. Factor XII activation
d. Resistance to aspirin therapy
General Feedback:
Patients with heparin-induced thrombocytopenia develop
thrombotic problems. Patients who develop heparin-induced
thrombocytopenia should be removed from heparin therapy as soon as the
diagnosis is made, because continued heparin therapy can lead to
significant morbidity and mortality. After discontinuation of heparin,
the platelet count begins to rise and should return to normal within a
few days.
22. Chapter 38-22

Binding of therapeutic heparin to platelet factor 4 is used in testing
to confirm:
NURSINGTB.COM
*a. heparin-induced thrombocytopenia.
b. acute immune thrombocytopenic purpura.
c. chronic immune thrombocytopenic purpura.
d. aspirin resistance.
General Feedback:
Heparin-induced thrombocytopenia (HIT) is a good example of
immune complex-induced thrombocytopenia, the fourth mechanism of drug-
induced thrombocytopenia. Binding of therapeutic heparin to platelet
factor 4 (PF4), a protein released by activated platelets, or binding
of PF4 to the platelet membrane causes a conformational change in PF4,
resulting in the exposure of neoepitopes.
23. Chapter 38-23

What is the probable cause for thrombotic thrombocytopenic purpura?
*a. Deficiency of a metalloprotease needed to enzymatically

degrade unusually large von Willebrand factor (VWF) multimers
b. Abnormal synthesis of unusually large VWF multimers by
endothelial cells
c. Abnormal synthesis of unusually large VWF multimers by
megakaryocytes
d. Abnormal complexing of normal VWF multimers to create
unusually large VWF multimers
General Feedback:
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Patients with the more common form of thrombotic

thrombocytopenic purpura are deficient in a metalloprotease (ADAMTS 13)
needed to cleave unusually large VWF into the smaller VWF multimers
normally found in plasma. Both endothelial cells and megakaryocytes
normally make these unusually large VWF multimers.
24. Chapter 38-24

What are the primary clinical manifestations of essential
thrombocythemia?
a. Platelet dysfunction
b. Hemorrhage
c. Thrombosis
General Feedback:
Patients with essential thrombocythemia have platelet
dysfunction and may either bleed or experience thrombosis.
NURSINGTB.COM
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1. Chapter 39-01
Inappropriate formation of platelets or fibrin clots that obstructs
blood vessels is called:
a. thrombophilia.
*b. thrombosis.
c. embolus.
d. factor V Leiden.
General Feedback:
Thrombosis is the inappropriate formation of platelets or
fibrin clots that obstruct blood vessels. Thrombophilia refers to
congenital abnormalities that increase the risk of thrombosis; factor V
Leiden is one such risk factor. An embolus forms when a piece of a
thrombus breaks off and travels to another location via the circulatory
system.
2. Chapter 39-02
Which is the cause for most strokes and heart attacks in the United
States?
a. Hemorrhage
b. Thrombocytopenia
c. Cancer
*d. Consequences of thrombotic events
General Feedback:
About 80% of heartNU RSINGand
attacks TB.85%
COMof strokes in the United
States are caused by thrombi that block coronary or carotid arteries.
3. Chapter 39-03
All are associated with an increased risk of thrombosis except:
*a. high high density lipoprotein (HDL) cholesterol.

b. increased homocysteine.
c. immobilization of extremities.
d. increased high-sensitivity C-reactive protein.
General Feedback:
High HDL cholesterol is actually believed to be protective
(the so-called good cholesterol). All the other listed findings are
risk factors for thrombosis.
5. Chapter 39-05
A thrombosis risk testing profile is ordered on a patient being treated
with warfarin for a blood clot in the leg. Select the best course of
action.
a. Run the tests immediately.

b. Reject the order.
c. Perform only the tests for protein C and protein S.
*d. Recommend the testing be postponed until the warfarin is
discontinued.
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General Feedback:
Testing should be postponed until the warfarin has been
discontinued for 10 to 14 days. Warfarin blocks the normal synthesis of
vitamin K–dependent proteins, which include protein C and protein S.
6. Chapter 39-06
A patient who is not on heparin and has no history of a factor
deficiency has a prolonged partial thromboplastin time (PTT). Select
the test that should be performed next.
a. High-sensitivity C-reactive protein

*b. Mixing studies for lupus anticoagulant
c. Thrombin time (TT)
d. Lipid panel
General Feedback:
The lupus anticoagulant results in a prolonged PTT. It is
characterized by lack of correction when the patient plasma is mixed
1:1 with normal platelet-poor plasma and the PTT repeated. None of the
other listed findings prolong the PTT.
7. Chapter 39-07
Which result puts the patient at an increased risk for thrombosis?
a. Total cholesterol of 180 mg/dL

b. PTT of 25 seconds
NURSINGTB.COM
c. Deficiency of factor V
*d. Chronically elevated fibrinogen
General Feedback:
High fibrinogen levels have a positive correlation to relative
risk of myocardial cardiovascular risk, especially in patients with
angina pectoris. Care must be taken in evaluating patients because
fibrinogen is an acute phase reactant and increases under stress.
8. Chapter 39-08
Select the next best test to run given the following PTT results on a
patient’s plasma:
Initial PTT: 75 seconds
Immediate 1:1 mix with normal plasma: 38 seconds
Incubated 1:1 mix with normal plasma: 36 seconds
a. Dilute Russell’s viper venom time

*b. Factor assays
c. Factor V Leiden
d. Bethesda titer
General Feedback:
Factor assays should be performed on this plasma to determine
the factor deficiency (or deficiencies) present. The PTT corrects on a
1:1 mix. If this were the lupus anticoagulant, the prolonged PTT should
remain prolonged on the 1:1 mix; thus no reason exists to perform the
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dilute Russell’s viper venom time to confirm the presence of the lupus
anticoagulant. If it were a factor VIII inhibitor, which can fully
correct on the immediate 1:1 mix, it would prolong after incubation of
the 1:1 mix. Then it would be appropriate to perform a Bethesda titer.
Factor V Leiden does not result in a prolonged PTT.
9. Chapter 39-09
What is the best test to perform if a patient’s PTT does not rise after
the typical heparin dose?
a. Immunoassay for anticardiolipin antibody

b. Lipoprotein(a) assay
*c. Chromogenic antithrombin
d. Mixing studies
General Feedback:
When a patient has a deficiency of antithrombin, heparin may
be administered in therapeutic or even higher dosages, but it will not
exert an anticoagulant effect in vivo, nor will it be detected by the
PTT. This is called heparin resistance.
10. Chapter 39-10

What is the best method to prevent warfarin-induced skin necrosis
during treatment for thrombosis?
a. Use higher dose of warfarin early in treatment.

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b. Give the patient injections of protein C.
c. Stop warfarin at the first sign of necrosis.
*d. Use heparin for first 5 days in conjunction with warfarin.
General Feedback:
To prevent warfarin-induced skin necrosis, heparin is given
along with the warfarin until a therapeutic and stable international
normalized ratio (INR) is obtained.
12. Chapter 39-12

Which unusual laboratory finding may be present in sepsis-induced DIC?
*a. Fibrinogen may be high because it is an acute phase reactant.

b. Schistocytes are absent because the fever destroys them.
c. D dimer is low because the toxins prevent fibrin lysis.
d. The PT and PTT are low because bacteria interfere with these
tests.
General Feedback:
Fibrinogen levels may drop in DIC, but because fibrinogen is
an acute phase reactant it may actually be increased in the presence of
an inflammatory process such as sepsis.
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13. Chapter 39-13

A patient has a quantitative D dimer of 800 ng/mL. Which can be ruled
out from the following list?
a. DIC
b. Deep vein thrombosis
c. Pulmonary embolus
*d. Patient is normal
General Feedback:
A D dimer of 800 ng/mL is significantly elevated, so that the
patient is not normal. D dimers are elevated in DIC, pulmonary embolus,
and deep vein thrombosis.
14. Chapter 39-14

Which is an expected finding in DIC?
a. Thrombocytosis
*b. Schistocytes on the blood film
c. Normal hemoglobin and hematocrit
d. Macrocytic red cells
General Feedback:
Schistocytes are seen in about 50% of DIC cases.
Thrombocytopenia is expected, along with anemia, because red cells are
being destroyed in circulation. Red cells are not macrocytic.
NURSINGTB.COM
15. Chapter 39-15
Which is used to treat DIC?
a. Prothrombin complex
b. Platelet transfusions
c. Fibrinogen concentrates
General Feedback:
All the products listed, in the appropriate clinical setting,
may be used for therapy of DIC.
16. Chapter 39-16

What tests should be performed on a regular basis on patients receiving
therapeutic heparin?
a. PT and hematocrit
b. PTT and white count
*c. PTT and platelet count
d. Factor assays and platelet count
General Feedback:
Patients on heparin must have platelet counts performed daily.
A significant drop in the platelet count is a signal for heparin-
induced thrombocytopenia. The PTT is also regularly performed to
monitor the heparin dosage.
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17. Chapter 39-17

A 37-year-old female patient has a PTT of 76 seconds (reference range,
25 to 37 seconds). Her plasma is mixed 1:1 with normal plasma. An
immediate PTT performed on the mix is 74 seconds. Which is the most
likely diagnosis?
a. Hemophilia A
b. Factor VIII inhibitor
c. Intrinsic factor deficiency
*d. Lupus anticoagulant
General Feedback:
A prolonged PTT that remains prolonged after an immediate
repeat of the PTT on the 1:1 mix is seen in patients (either male or
female subject) with the lupus anticoagulant. A patient with hemophilia
A would most likely be a male subject (female hemophilia A is rare). In
addition, the immediate 1:1 mix should correct, as it also would with
an intrinsic factor deficiency. The PTT on an immediate 1:1 mix in the
presence of a factor VIII inhibitor would also essentially correct.
18. Chapter 39-18

What is important about the test systems used for detection of the
lupus anticoagulant?
a. The phospholipid concentration should be high.

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b. Ellagic acid should be the PTT activator substance.
*c. The patient plasma and normal plasma used for mixing studies
should be platelet poor.
d. A 1:1 mix should be performed when the initial test is normal
to improve the sensitivity.
General Feedback:
Platelets contain phospholipid in their membrane, and this can
overcome and thus mask the lupus anticoagulant when it is present. Thus
both the patient and the normal plasma used for mixing studies must be
platelet poor. The phospholipid concentration in the reagent used for
detection must also have a low concentration of phospholipid to be
sensitive. The initial test before the 1:1 mix must be prolonged to
even suggest the possible presence of the lupus anticoagulant,
providing a lupus anticoagulant–sensitive reagent is used.
19. Chapter 39-19

Why does the factor V Leiden mutation increase thrombotic risk?
*a. Makes factor Va resistant to degradation by activated protein

C.
b. Makes blood more viscous.
c. Makes factor V more susceptible to activation by thrombin.
d. Decreases the binding of factor Va to the inhibitor
antithrombin.
General Feedback:
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Activated factor V Leiden is resistant to degradation by

activated protein C, which is critical for slowing down thrombin
generation. This results in an increased thrombotic risk for the
patient.
20. Chapter 39-20

Why does prothrombin G20210A increase the risk of thrombosis?
a. Makes prothrombin activation easier.

*b. Elevates prothrombin levels.
c. Decreases binding of thrombin by antithrombin.
d. Decreases binding of plasminogen to prothrombin.
General Feedback:
The prothrombin G20210A mutation results in elevated levels of
prothrombin; this increases the risk of thrombosis, although the reason
why is not clear.
21. Chapter 39-21

When the chromogenic assay for antithrombin is performed, which is
true?
*a. The colored end-product intensity is inversely proportional

to the antithrombin concentration.
b. The chromogenic substrate is bound by antithrombin.
c. Warfarin is added to the patient sample before testing to
improve sensitivity.
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d. Activated protein C competes for the chromogenic substrate, so
it must first be selectively removed.
General Feedback:
Antithrombin concentration is inversely proportional to the
intensity of end-product color. Heparin is added to the patient plasma
before testing to improve sensitivity to antithrombin. A protease,
often Xa, is added in excess to an aliquot of the patient sample. Some
of this Xa will be bound by the heparin-antithrombin complex and thus
inhibited. After this, a chromogenic substrate is added that is
specific for Xa. When the residual Xa hydrolyzes this substrate, color
will be released. The more antithrombin present in the patient sample,
the more Xa will be bound and the less chromogen will be released.
22. Chapter 39-22

What substance is used to activate protein C in the chromogenic assay
to determine its concentration?
a. Partial thromboplastin
*b. A specific snake venom
c. Kaolin
d. Heparin
General Feedback:
A specific snake venom is used to activate protein C in its
chromogenic assay.
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23. Chapter 39-23

A patient arrives at the emergency department complaining of pain in
the calf of his left leg and shortness of breath. A “stat” D dimer is
ordered. Why is this useful information for this patient’s care?
*a. An elevated D dimer supports the possibility of deep vein

thrombosis.
b. An elevated D dimer is diagnostic for deep vein thrombosis.
c. A normal D dimer is diagnostic for deep vein thrombosis.
d. This was not an appropriate test to order on this patient.
General Feedback:
An elevated D dimer supports the possibility of a deep vein
thrombosis, but it is not diagnostic. Many other clinical situations
can lead to elevation of this test. A normal D dimer has negative
predictive value (i.e., a normal D dimer result is useful for ruling
out deep vein thrombosis). With the patient’s presenting symptoms,
pulmonary embolism may also be present, which can be a consequence of
deep vein thrombosis. Thus this was an appropriate requisition for this
patient.
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1. Chapter 40-01
Why is it important to monitor patients who are receiving anticoagulant
therapy?
a. Drugs are expensive.

b. Prophylactic and therapeutic dosage ranges are unknown.
c. Patients commonly abuse these drugs.
*d. Clinical consequences for overdosing are significant.
General Feedback:
The clinical consequences for incorrect dosage of
anticoagulant drugs are significant. Overanticoagulation can lead to
serious bleeding that may even require a visit to the emergency
department.
2. Chapter 40-02
Warfarin skin necrosis occurs within the first 2 to 3 days after
starting warfarin therapy because:
a. the platelet count decreases to fewer than 100 × 109/L, and

significant bleeding occurs.
*b. protein C decreases significantly before full
anticoagulation, and skin thrombosis results.
c. prothrombin decreases rapidly generating less thrombin, and
significant bleeding occurs.
d. plasminogen increases, and rapid clot lysis occurs.

Protein C has a 6-hour half-life, and so it rapidly decreases
when warfarin therapy is begun, along with factor VII (both are vitamin
K–dependent proteins). Full anticoagulation with warfarin is not
obtained until factors X and prothrombin are decreased to less than
50%, requiring 4 to 7 days based on their half-lives. Because protein C
is important in controlling clot formation, its decrease actually puts
the patient in a prethrombotic state until full anticoagulation is
obtained.
3. Chapter 40-03
Once a patient is stabilized on warfarin therapy, how often should he
or she be monitored?
a. Once every 6 months

b. Once every week
c. Once a year
*d. Once a month
General Feedback:
Once a patient is stabilized on warfarin therapy, monitoring
should continue every 4 to 6 weeks until therapy is complete. Changes
in diet, metabolism, renal function, other drugs being taken, as well
as additional factors all change the response to warfarin and may
require making dosage adjustments.
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4. Chapter 40-04
A patient is stabilized on warfarin therapy and being monitored using
the prothrombin time (PT) followed by calculation of the international
normalized ratio (INR). The formula for calculating the INR is:
INR = (PTpatient/PTnormal)ISI (where ISI = international sensitivity
index)
What is used for the PTnormal?
a. arithmetic mean PT for the control.

*b. geometric mean PT for the reference population.
c. arithmetic mean PT as found in a standard reference textbook.
d. geometric mean PT reported by the manufacturer of the PT
reagent being used.
General Feedback:
The PTnormal is the geometric mean for the PT reference
interval determined by the clinical laboratory scientists in the
laboratory where the testing is being performed. Using the wrong value
in this calculation has led to major reporting errors that have
resulted in bad patient outcomes.
5. Chapter 40-05
An INR of 6.5 is obtained on a patient taking warfarin. All quality
control is acceptable. What should be done?
a. Report the result.NURSINGTB.COM

b. Report only the PT in seconds and ignore the INR.
c. Send an e-mail to the health care provider.
*d. Call the clinician immediately.
General Feedback:
INRs greater than 5 are associated with increased risk of
hemorrhage, and require immediate communication with the clinician who
is managing the patient’s case.
6. Chapter 40-06
Unfractionated heparin is commonly monitored by the:
a. PT.
*b. partial thromboplastin time (PTT).
c. thrombin time (TT).
d. kinetic fibrinogen.
General Feedback:
The PTT is the most commonly used test for monitoring heparin
therapy because it responds in a linear fashion over the therapeutic
range. The PT is relatively insensitive to heparin, whereas the TT is
too sensitive. The kinetic fibrinogen is the least sensitive of these
tests to therapeutic heparin.
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7. Chapter 40-07
A patient is admitted through the hospital emergency department with
thrombosis, and heparin is initially begun. Her baseline PTT, before
heparin therapy, is prolonged at 68 seconds. Further laboratory studies
determine that she has the lupus anticoagulant. What test should be
used to monitor her heparin therapy?
a. PTT
b. PTT after first adding antithrombin to her plasma
*c. Chromogenic anti-Xa assay
d. TT after first making a 1:10 dilution of the patient plasma
General Feedback:
The PTT is already prolonged by the lupus anticoagulant, so
the heparin therapeutic range for the PTT reagent becomes meaningless.
In this case a chromogenic anti-Xa assay should be used.
8. Chapter 40-08
A clinical laboratory receives a new lot of PTT reagent, so clinical
laboratory scientists in the laboratory need to establish the heparin
therapeutic range for this new reagent lot. How should this be done?
a. Compare PTT results for patient heparinized samples to those

for the lot of PTT reagent that is presently being used.
*b. Perform chromogenic Xa and PTT assays on patient heparinized
samples, and do a statistical analysis of result comparisons.
c. Add heparin at various therapeutic concentrations to normal
NURonSIeach
plasma, and perform PTT NGTconcentration
B.COM using the new lot
of reagent.
d. Add heparin at high concentration to one normal plasma, make
dilutions of this plasma, and then perform PTT on each diluted
sample using the new lot of reagent.
General Feedback:
Accrediting agencies for clinical laboratories require that
the PTT heparin therapeutic range be determined using samples from
patients who are receiving heparin therapeutically; they cannot be
receiving simultaneous warfarin therapy (thus their PT must be normal).
Both a chromogenic anti-Xa assay and PTT are performed on each patient
sample, and the paired results are plotted in a linear graph. The range
that corresponds to 0.3 to 0.7 chromogenic anti-Xa is the therapeutic
range.
9. Chapter 40-09
Why is the platelet count monitored daily for a patient receiving
heparin therapeutically?
a. Platelets increase when a patient is overheparinized.

b. Platelets decrease when a patient is overheparinized.
*c. A significant decrease in the platelet count is evidence for
heparin-induced thrombocytopenia.
d. A significant increase in the platelet count is early evidence
for heparin-induced thrombocytosis.
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General Feedback:
A decrease of 40% or greater in the platelet count, even if
the platelet count remains in the reference range, is evidence for
heparin-induced thrombocytopenia. This is a serious consequence, and
unfractionated heparin therapy must be immediately stopped and replaced
with a direct thrombin inhibitor.
10. Chapter 40-10

All of the following serine proteases are bound and inhibited by
antithrombin except:
a. Xa.
b. IXa.
*c. VIIa.
d. XIa.
General Feedback:
Antithrombin covalently binds and inhibits XIIa, XIa, Xa, IXa,
and thrombin. It does not bind VIIa.
11. Chapter 40-11

Which is true related to the use of aspirin to prevent cardiovascular
disease?
*a. It is used to prevent arterial thrombosis.

b. New studies show it is not effective.
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c. It works well but must be carefully monitored with monthly
bleeding times.
d. Aspirin monitoring tests such as thromboxane B2 are now easy
to perform and widely available.
General Feedback:
Aspirin, as well as other antiplatelet drugs, have been shown
to be effective for prevention of arterial thrombosis, especially
myocardial infarction, stroke, and peripheral artery occlusion. This
therapy is not monitored. However, some individuals are resistant to
aspirin therapy, and thromboxane B2 tests are available, although they
are not easily performed or widely available.
12. Chapter 40-12

After confirmation of a deep vein thrombosis (DVT) and pulmonary
embolus in a patient, a baseline coagulation screen and platelet count
are obtained. His fibrinogen is 620 mg/dL. When the PTT is performed at
6 hours after initiation of therapy, it is 45 seconds (reference range,
25 to 37 seconds). What should be done?
a. Report the PTT as not responding.

*b. Monitor the patient with the chromogenic anti-Xa assay.
c. Add an additional standard amount of heparin to the patient
plasma to improve the sensitivity.
d. Add a standard amount of antithrombin to the patient plasma to
improve the sensitivity.
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General Feedback:
An elevated fibrinogen tends to shorten the PTT and makes it
less sensitive to the effect of heparin; this is called heparin
resistance. The chromogenic anti-Xa assay should then be used to
monitor this patient.
13. Chapter 40-13

All are true about the activated clotting time (ACT) except:
*a. it is useful for monitoring warfarin therapy.

b. is a popular point-of-care test.
c. blood for the test is collected with negative tube pressure.
d. the median reference interval is 98 seconds.
General Feedback:
The ACT can be used to monitor heparin therapy, not warfarin.
ACT is a popular point-of-care test that has a median reference
interval of 98 seconds. The ACT evacuated blood specimen collection
tubes have no anticoagulant but have a particulate clot activator and a
small magnet. The negative tube pressure collects 2 mL of blood.
14. Chapter 40-14

Low-molecular-weight heparin (LMWH):
*a. is essentially as effective therapeutically as unfractionated

heparin (UFH).
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b. has the same antithrombin effect as UFH.
c. can be monitored using the PTT.
d. has a shorter in vivo half-life than UFH.
General Feedback:
LMWH has essentially the same therapeutic efficacy as UFH.
Because of its lower molecular weight, it does not have the same
bridging effect as UFH, and so the antithrombin effect is reduced (not
the same). For this reason, the PTT cannot be used to monitor LMWH; it
is not responsive. The chromogenic anti-Xa must be used. LMWH has a
longer in vivo half-life than UFH; this is one of the advantages.
16. Chapter 40-16

What anticoagulant therapy is monitored using the ecarin clotting time
(ECT)?
a. Unfractionated heparin
b. Warfarin
c. LMWH
*d. Direct thrombin inhibitors
General Feedback:
The ECT uses an enzyme extracted from Echis carinatus venom.
Direct thrombin inhibitors yield a linear, dose-dependent response to
the ECT. The test is useful for monitoring direct thrombin inhibitors
when the patient has lupus anticoagulant or factor deficiencies.
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17. Chapter 40-17

Elevated urinary levels of 11-dehydrothromboxane B2 identify patients
who are:
a. at risk for heparin-induced thrombocytopenia.

b. overanticoagulated with warfarin.
*c. resistant to aspirin antiplatelet therapy.
d. resistant to direct thrombin inhibitors.
General Feedback:
11-Dehydrothromboxane B2 is a metabolite derived from
thromboxane A2, synthesized by the platelet in the eicosanoid pathway.
This pathway is blocked by aspirin’s effect on cyclooxygenase. When it
is not blocked, and platelet activation occurs, 11-dehydrothromboxane
B2 is secreted and found in urine at an elevated level. Thus its
elevation indicates that platelet activation is occurring and has not
been blocked by aspirin. This is called aspirin resistance.
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1. Chapter 41-01
Which is good practice in regard to phlebotomy on patients with
hemostasis testing ordered?
a. Make sure the patient is fasting.

b. Always draw the sodium citrate tube last.
c. Collect the blood in a glass syringe.
*d. Use a 20- or 21-gauge needle.
General Feedback:
For routine coagulation draws, a 20- or 21-gauge needle is
used. The patient does not need to be fasting, the sodium citrate tube
should be drawn first, and glass (syringe) should never be used for
coagulation specimens because glass activates the contact phase.
2. Chapter 41-02
Which will cause spuriously prolonged clot-based coagulation tests?
*a. An evacuated 3.2% sodium citrate tube filled to 50% capacity

b. An evacuated 3.2% sodium citrate tube filled to 90% capacity
c. Prolonged tourniquet application
d. Plasma collected from a traumatic tap
General Feedback:
Filling an evacuated 3.2% sodium citrate only halfway (50%)
will lead to falsely prolonged clot-based coagulation test results. The
relative excess anticoagulant will bind (some) of the calcium added in
the test system. A 90% fillNgives
URSIN GTB.results
valid COM and can be used.
Prolonged tourniquet application and plasma collected from a traumatic
tap both have the potential of activating coagulation, thus leading to
shortened, not prolonged, results.
3. Chapter 41-03
Which is an acceptable sample for testing on a photo-optical clot-
detecting instrument?
a. Lipemic plasma
b. Hemolyzed plasma
c. Serum
*d. Plasma collected using a 9:1 ratio of whole blood to 3.2%
sodium citrate
General Feedback:
Plasma should be collected at a 9:1 ratio of blood to
anticoagulant (3.2% sodium citrate). Lipemia and hemolysis are possible
interfering substances when using an instrument that uses the photo-
optical principle for end-point detection. Serum cannot be used for
coagulation testing because the sample has already clotted, with
resultant loss of several coagulation proteins.
4. Chapter 41-04
Which practice is necessary when collecting blood specimen from a
heparin or saline lock?
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*a. Flush the IV line with 5-mL saline before collecting the
specimen.
b. The first 5 mL of blood that is collected must be immediately
inserted into the blood tube for testing.
c. Flush the IV line with heparin before collecting the specimen.
d. Collect the blood directly into an evacuated tube.
General Feedback:
Collection of blood from a heparin or saline lock is usually
performed by physicians or nursing staff. The IV line must be flushed
with 5-mL saline before the blood draw to avoid specimen contamination.
The first 5 mL of blood that is collected should be discarded. IV lines
should never be flushed with heparin before collecting blood for
coagulation testing. Blood should be collected into a syringe, and a
transfer device is used to transfer the blood to an evacuated tube.
5. Chapter 41-05
A patient has a hematocrit of 65%. Which is true related to coagulation
testing?
a. Hematocrit does not affect coagulation testing.

b. Tube must be recollected with heparin as the anticoagulant.
*c. Tube must be recollected using 0.34 mL of sodium citrate to
4.5 mL of blood.
d. Tube must be recollected using 0.62 mL of sodium citrate to
4.5 mL of blood.
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General Feedback:
The plasma volume is relatively low in a patient who has a
high hematocrit. This unacceptably raises the anticoagulant-to-plasma
ratio, invalidating test results that become falsely prolonged. When
the hematocrit is greater than 55%, the volume of citrate must be
decreased to optimize the anticoagulant-to-plasma ratio. Blood is not
collected in heparin for coagulation tests.
6. Chapter 41-06
Which is an acceptable sample for a prothrombin time (PT) test?
*a. One that was collected 24 hours before testing.

b. One with a very small clot that was easily removed.
c. 3.2% sodium citrate blood sample immediately collected
following a serum separator tube.
d. Blood anticoagulated with heparin and brought to the
laboratory within 1 hour.
General Feedback:
Specimens collected for PTs may be held uncentrifuged or
centrifuged at 15° to 25°C and tested within 24 hours of the time of
collection. Any clot in a specimen makes the sample useless for
coagulation testing. Serum separator tubes contain a clot activator;
this can contaminate the next tube drawn, and, for coagulation, is the
same as having a clot. Heparinized samples are not used for coagulation
testing.
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7. Chapter 41-07
The platelet function test will be normal and is no value to perform in
patients who have:
a. a qualitative platelet disorder.

b. von Willebrand disease (VWD).
c. Glanzmann thrombasthenia.
*d. factor VIII deficiency.
General Feedback:
The platelet function test will be normal in patients with a
factor VIII deficiency. It ideally will be prolonged in all the other
listed settings. The bleeding time test is being used less often
because it has poor predictive value and leaves scarring.
8. Chapter 41-08
Which is necessary for normal platelet aggregation?
a. Ristocetin
b. von Willebrand factor (VWF)
c. Epinephrine
*d. Fibrinogen
General Feedback:
Normal platelet aggregation requires fibrinogen. Ristocetin is
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a substance added in vitro that causes platelet to clump. VWF is needed
for normal platelet adhesion. Epinephrine is a platelet agonist
stimulating platelet aggregation, but it is not necessary.
9. Chapter 41-09
Which is the purpose ristocetin?
*a. Checks for plasma abnormalities in VWD.

b. Provides info about platelet secretion conditions.
c. Cleaves two protease-activatable receptors.
d. Binds P2Y1 and P2Y12.
General Feedback:
Ristocetin is used to check for abnormalities of plasma VWF in
VWD. Lumiaggregometry provides more definitive information for
conditions where recording platelet secretion, in addition to platelet
aggregation, is an important diagnostic factor. Thrombin (or TRAP)
cleaves two platelet membrane protease-activatable receptors (PARs),
PAR-1 and PAR-2, both members of the seven-transmembrane repeat
receptor family. ADP binds platelet membrane receptors P2Y1 and P2Y12,
also members of the seven-transmembrane repeat receptor family.
10. Chapter 41-10

A prolonged bleed time could signal:
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a. Glanzmann thrombasthenia.
b. von Willebrand disease.
c. scurvy.
General Feedback:
A prolonged bleeding time could theoretically signal von
Willebrand disease (VWD), a functional platelet disorder such as
Glanzmann thrombasthenia, or a vascular disorder such as scurvy or
vasculitis, and was thought to have a predictable result in therapy
using aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).
11. Chapter 41-11

A patient’s platelet count drops 4 days after being placed on heparin.
Select the correct interpretation.
a. The patient has heparin-induced thrombocytopenia.

b. The patient has benign, limited thrombocytopenia related to
heparin.
c. A bleeding time should be performed to evaluate qualitative
platelet disorders.
*d. An immunoassay for heparin-dependent anti–platelet factor 4
(PF4) should be performed to distinguish heparin-induced
thrombocytopenia from benign, limited thrombocytopenia related to
heparin.
General Feedback:
NURin
This pattern, a drop SIthe
NGTplatelet
B.COM count 4 days after being
placed on heparin, suggests heparin-induced thrombocytopenia. It could
also be a benign, limited thrombocytopenia related to heparin. Assays
such as the immunoassay for heparin-dependent anti-PF4 can distinguish
the two.
12. Chapter 41-12

How often must the partial thromboplastin time (PTT) reference interval
be determined?
a. Only when both the normal and abnormal controls are outside
their acceptable limits
b. At least every 6 months
*c. With each new lot of reagent
d. Only when the normal control is outside its acceptable limits
General Feedback:
The PTT reference interval must be determined with each new
lot of reagent and at least once per year.
13. Chapter 41-13

What is the test commonly used to monitor the high heparin doses used
in cardiac bypass surgery?
*a. PTT
b. Prothrombin time
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c. Thrombin clotting time

d. Fibrinogen
General Feedback:
The high heparin doses used in cardiac bypass surgery can be
monitored using the PTT.
14. Chapter 41-14

Patients with which condition would have a normal PT?
a. Liver disease
b. Disseminated intravascular coagulation (DIC)
c. Factor VII deficiency
*d. Factor IX deficiency
General Feedback:
Patients with a deficiency of factor IX will have a normal PT.
The PT does not require this protein.
16. Chapter 41-16

A patient is stabilized on warfarin with an international normalized
ratio (INR) of 2.7. He develops pneumonia and is admitted to the
hospital. His appetite is depressed and he is placed on broad-spectrum
antibiotic agents. At 1 week after the admission, his INR is 5.0. What
is the most likely interpretation?
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a. The patient should be given more warfarin.
b. A PTT should be performed to rule out heparin administration.
c. A new sample should be collected to rule out a clotted
specimen.
*d. Vitamin K is reduced, increasing the effects of warfarin.
General Feedback:
This elevated INR is probably the result of a deficiency of
vitamin K, which increases the effects of warfarin. Vitamin K
deficiency is seen during use of broad-spectrum antibiotic agents that
destroy gut flora and in people with a poor diet, both of which are
present in this patient.
17. Chapter 41-17

Which patient would likely have a normal PT?
a. Patient with a factor VII deficiency

*b. Patient with a factor VIII deficiency
c. Patient on warfarin
d. Clotted blood
General Feedback:
A patient with a factor VIII deficiency would have a normal
PT. All the others listed would have a prolonged PT.
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18. Chapter 41-18

Which condition would have a normal PTT?
a. Lupus anticoagulant
b. Fibrinogen of 50 mg/dL
*c. Factor VII deficiency
d. Heparin therapy
General Feedback:
Factor VII deficiency would have a normal PTT. All the other
listed conditions would have a prolonged PTT.
19. Chapter 41-19

A patient admitted to the hospital with thrombosis is given the
standard heparin dosage. Twenty-four hours after the heparin is
started, the PTT is 38 seconds (reference range, 25 to 37 seconds).
Both normal and abnormal controls are within their limits. Which is
most likely?
a. Laboratory error
*b. Patient has low antithrombin
c. Heparin-induced thrombocytopenia
d. Patient should be switched to low-molecular-weight heparin
(LMWH)
General Feedback:
When a patient has a deficiency of antithrombin, heparin may
NURor
be administered in therapeutic SIN GTBhigher
even .COM dosages, but it will not
exert an anticoagulant effect in vivo or be detected by the PTT. This
is called heparin resistance.
20. Chapter 41-20

A prolonged PTT is corrected when mixed with normal plasma and tested
immediately and after a 2-hour incubation. Which test (or tests) should
be performed next?
a. Bethesda titer
b. High-phospholipid PTT
c. Anti-Xa assay
*d. Factor VIII assays
General Feedback:
This pattern suggests a factor deficiency, and factor VIII
assay should be performed. The Bethesda titer is performed when a
specific factor inhibitor is present; no evidence exists for this
because the PTT on the incubated 1:1 mix did not prolong. High-
phospholipid PTT testing is done to confirm the lupus anticoagulant;
this is not present because the immediate 1:1 mix on this sample
corrected. No reason exists to perform an anti-Xa assay, often used to
monitor LMWH.
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21. Chapter 41-21

A patient has an elevated thrombin time and normal reptilase time.
Which situation is most likely?
*a. Heparin therapy

b. Low fibrinogen
c. Elevated fibrin split products
d. Dysfibrinogenemia
General Feedback:
Heparin prolongs the thrombin time but does not prolong the
reptilase time. A low fibrinogen, elevated fibrin split products, and
dysfibrinogenemia prolong both, although differences exist in
sensitivity to some of these between the two tests.
22. Chapter 41-22

Which condition is associated with an elevated fibrinogen?
a. Acute DIC
*b. Chronic inflammation
c. Severe liver disease
d. Increased plasmin levels
General Feedback:
An elevated fibrinogen is present in chronic inflammation
because fibrinogen is an acute phase protein. It is decreased in all
the other situations listed.
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23. Chapter 41-23
A patient has a factor VIII level of 50% activity. Which is most likely
true regarding what can be expected for this patient’s clinical
situation?
a. Severe bleeding
b. Moderate bleeding
c. Mild bleeding
*d. Normal with respect to factor VIII
General Feedback:
The reference range for factor VIII activity is 50% to 150%.
Thus this patient is normal.
24. Chapter 41-24

A patient undergoing thrombolytic therapy has a plasminogen level of
3.5 mg/dL. Which condition does this patient most likely have?
a. Pregnancy
b. Hemorrhage
c. Acute inflammation
*d. Hepatitis
General Feedback:
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A typical plasminogen reference interval is 5 to 13.5 mg/dL.

Plasminogen levels are decreased in thrombolytic therapy, DIC,
hepatitis, and cancer, or may be hereditary. Decreased plasminogen is
associated with thrombosis. Plasminogen rises in systemic fibrinolysis,
acute inflammation, and during pregnancy, and high levels may be
associated with hemorrhage.
25. Chapter 41-25

Which laboratory test identifies genetic variants in platelet-related
bleeding disorders?
*a. HTS
b. Sanger
c. TEG
d. ROTEM
General Feedback:
High-throughput genetic sequencing (HTS) has become the
reference approach to identifying the genetic variants that underlie
platelet-related and coagulopathy-related bleeding disorders, having
replaced the pioneering but less precise Sanger sequencing.
Thromboelastography (TEG) and modification rotational
thromboelastometry (ROTEM) measure clotting time and the dynamics of
clot formation and dissolution as effected by the kinetics of thrombin
generation, platelet activation, fibrin generation, clot strength, clot
stability, and inhibitory effects on any aspect.
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26. Chapter 41-26
A patient is positive for fibrin degradation products and negative for
D dimers. Which condition is most likely?
*a. Systemic fibrinolysis

b. DIC
c. Hypofibrinogenemia
d. Deep vein thrombosis (DVT)
General Feedback:
Fibrin degradation products are positive and D dimers are
negative in systemic (also called primary) fibrinolysis. Plasmin is
present, which degrades fibrinogen so that it is decreased. However,
thrombin is not present, so no D dimers are formed. They are both
elevated in DIC and DVT. Neither is useful for hypofibrinogenemia,
which is diagnosed using a fibrinogen assay.
27. Chapter 41-27

An elevated tissue plasminogen activator (TPA) is associated with:
*a. abnormal bleeding.

b. aspirin use.
c. DIC.
d. decreased fibrinolysis.
General Feedback:
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An elevated TPA is associated with abnormal bleeding. TPA

activates plasminogen to plasmin, which lyses a clot; when TPA is
elevated, this occurs prematurely and bleeding ensues.
28. Chapter 41-28

Which specimen would be acceptable for platelet aggregation studies?
a. Blood drawn in ethylenediaminetetraacetic acid (EDTA) and kept

at room temperature for 6 hours.
b. Blood drawn in 3.2% sodium citrate and transported to the
laboratory on ice (2° to 4°C).
c. Blood drawn in a serum separator tube.
*d. Blood drawn in 3.2% sodium citrate and kept at room
temperature for 2 hours after drawing.
General Feedback:
Platelet function studies must be performed within 3 hours of
drawing, and the specimen must be kept at room temperature because
chilling damages platelets. The blood sample must be drawn in 3.2%
sodium citrate.
29. Chapter 41-29

A 53-year-old woman arrives at the hospital with bleeding into the back
of the throat and has a coagulation screen performed. She has no
history of abnormal bleeding before this despite major stress to
hemostasis in the past—she was in a major automobile accident at age 37
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and has had impacted wisdom teeth extracted. Her coagulation results
follow:
Patient’s Reference 1:1 Mix
Results Range With
Normal
Plasma
Prothrombin 13.1 11–15
time (PT) seconds seconds
Partial 87 seconds 25–37 35
thromboplastin seconds
time (PTT)
Fibrinogen 380 mg/dL 200–400
mg/dL
Which is the most likely cause for her bleeding?
a. Factor XII deficiency

b. Factor IX deficiency
c. Factor VIII deficiency
*d. Factor VIII inhibitor
General Feedback:
This patient is bleeding abnormally. However, she has had
major trauma in the past with no abnormal bleeding; this suggests the
problem is acquired, not congenital. The PTT is prolonged, so the
common pathway appears to be intact. The prolonged PTT fully corrects
on a 1:1 mix, although at the upper end of the reference range. Putting
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all of this together, the most likely problem is an acquired factor

VIII inhibitor.
30. Chapter 41-30

Which deficiency prolongs the PTT but does not lead to abnormal
bleeding?
a. Factor V
b. Factor VIII
c. Factor XI
*d. Factor XII
General Feedback:
A deficiency of factor XII prolongs the PTT. However, patients
with this deficiency do not have abnormal bleeding.
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1. Chapter 42-01
All are considered routine coagulation tests that are available in most
large and small clinical laboratories except:
a. prothrombin time (PT).

b. fibrinogen assay.
c. partial thromboplastin time (PTT).
*d. antithrombin assay.
General Feedback:
The antithrombin assay traditionally has not been available in
most clinical laboratories, and that is still true today in small
laboratories.
2. Chapter 42-02
Diagnostica Stago coagulation instruments are based on what clot
detection principle?
a. Photo-optical
*b. Mechanical
c. Chromogenic
d. Nephelometric
General Feedback:
Diagnostica Stago coagulation instruments use a mechanical
end-point clot detection principle. These instruments magnetically
monitor the movement of a steel ball within plasma. As the clot forms,
NURof
the sensor detects the slowing SIN GTball.
the B.COM
3. Chapter 42-03
Which is the most common clot detection principle used for coagulation
testing?
*a. Photo-optical
b. Mechanical
c. Chromogenic
d. Immunologic
General Feedback:
The most common clot detection principle used by automated
coagulation instruments is photo-optical.
4. Chapter 42-04
Using which principle does plasma become more opaque as a clot forms
and the amount of light being detected decreases?
*a. Photo-optical
b. Mechanical
c. Chromogenic
d. Immunologic
General Feedback:
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A light source of specified wavelength is made to pass through

plasma; some light normally gets through to the detector. As a fibrin
clot forms, the amount of light detected decreases. When light
decreases to a predetermined deflection from the baseline, the timer
stops, indicating clot formation.
5. Chapter 42-05
Which assay uses indirect measurement using a chromogenic substrate to
quantitate heparin?
a. Protein C
b. Thrombin time (TT)
*c. Anti-Xa assay
d. Fibrinogen assay
General Feedback:
The heparin anti-Xa assay is used to indirectly measure the
concentration of heparin. In this system, heparin has an inhibitory
effect on the enzyme Xa. Xa normally proteolytically cleaves the
chromogenic substrate, releasing the chromogen with a color intensity
that is then measured. Because heparin has inhibited some of the Xa,
less free Xa will be available to cleave the substrate and less color
will be released. Thus the concentration of heparin is inversely
proportional to the activity of Xa. This is classified as an indirect
measurement.
6. Chapter 42-06
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Which principle measures the actual coagulation protein rather than
fibrin formation?
a. Photo-optical
b. Mechanical
c. Chromogenic
*d. Immunologic
General Feedback:
Immunologic methods measure the actual coagulation protein
rather than fibrin formation. These assays are based on antigen-
antibody reactions.
7. Chapter 42-07
Which is true regarding advances in automated coagulation
instrumentation?
a. Less staff training is required to operate and maintain the

equipment than was necessary for earlier semiautomatic
instruments.
*b. Single-sample testing is possible because of increased
precision.
c. Newer instruments are less expensive.
d. Accuracy is so improved that controls do not need to be run.
General Feedback:
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Increased precision on the new automated coagulation

instruments means that single-sample testing is possible. Before this,
every sample had to be tested in duplicate and the duplicates had to
agree within certain preset limits before they could be averaged and
the result reported.
8. Chapter 42-08
Which single instrument development has been the most important
improvement in coagulation instrumentation?
a. Multiple-sample dilutions
b. Improved flagging
*c. Random access testing
d. Graphing of clot formation
General Feedback:
The most significant improvement in automated coagulation
analyzers is the ability to provide random access testing. This means
that a variety of tests can be run in any order on the same plasma
specimen or many specimens within the same testing batch. This vastly
improves the efficiency of the clinical laboratory.
9. Chapter 42-09
Which is most improved safety for laboratory scientists?
*a. Closed tube sampling

b. Random access
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c. Expanded computer capabilities
d. Improved flagging capabilities
General Feedback:
Closed tube sampling has improved the safety and efficiency of
coagulation testing. This reduces the chances of the clinical
laboratory scientist being exposed to the patient specimen through
spillage or aerosol formation.
10. Chapter 42-10

Automatic performance of certain tests based on the results of other
tests is called:
*a. reflex testing.

b. interpretive liberty.
c. programming flexibility.
d. random access.
General Feedback:
Reflex testing is the automatic ordering of tests based on
preset parameters or the results of other tests. These reflex tests
must be clearly indicated to the ordering health care provider at the
time the initial screening test (or tests) is ordered.
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11. Chapter 42-11

What is the greatest disadvantage to photo-optical coagulation
instruments?
a. High cost
b. Complexity of operation
c. Availability is limited
*d. Interference from lipemia, hemolysis, and hyperbilirubinemia
General Feedback:
Possible interference from the presence of lipemia, hemolysis,
or hyperbilirubinemia is the greatest disadvantage for photo-optical
end-point detection methods.
12. Chapter 42-12

Aspirin-induced bleeding and von Willebrand disease (VWD), type 1, are
detected reliably by:
a. platelet count.
b. point-of-care testing (POCT).
*c. PFA 100 Platelet Function Analyzer.
d. nephelometry.
General Feedback:
The PFA 100 Platelet Function Analyzer assesses platelet
dysfunction. Aspirin and VWD both negatively affect platelet function,
although by entirely different mechanisms. Aspirin acetylates
NURSthe
cyclooxygenase, thus preventing INGeventual
TB.COMproduction of thromboxane
A2, an important platelet agonist. In type 1 VWD, von Willebrand factor
(VWF) is decreased and therefore platelet adhesion is abnormal. The
platelet count is not a reliable test for platelet function.
13. Chapter 42-13

Who should select the coagulation instruments for a given laboratory?
*a. Medical staff

b. Patients
c. Vendors
d. Billing department
General Feedback:
The decisions regarding which tests are the most appropriate
for the clinical situations encountered by each laboratory should be
made in conjunction with the medical staff. When that input has been
obtained, the laboratory can determine the availability and cost of
instruments that would meet those requirements.
14. Chapter 42-14

Examples of instrument malfunction flags include all except:
a. temperature error.
b. probe not aspirating.
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c. mechanical movement.
*d. hemolysis.
General Feedback:
The presence of hemolysis is not flagged by the instrument but
must be noted by the clinical laboratory scientist. All the other flags
are instrument generated.
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1. Chapter 43-01
At what age is it normal for bone marrow cellularity to be 80% to 90%
(i.e., has very little fat)?
*a. At birth
b. In an 8-year-old
c. In a 20 to 40-year-old
d. In those older than 70 years
General Feedback:
At the time of birth, the bone marrow is fully active and
extremely cellular with very little fat. It contains all hematopoietic
cell lineages.
2. Chapter 43-02
Which age-group normally has the lowest mean cell volume?
*a. Newborn
b. Young child
c. Adult
d. Older adult
General Feedback:
The erythrocytes of newborn infants are markedly macrocytic at
birth. The average MCV for full-term infants is 119 ± 9.4 fL; however,
a sharp decrease occurs during the first 24 hours of life.1,2 The MCV
continues to decrease to 90N±UR
12
SIfL
NGin
TB3.C 4 months.2,9,17 The more
toOM
premature the infant, the higher the MCV.
3. Chapter 43-03
What is the most likely reason that the red blood cell (RBC) count
remains elevated in a newborn for the first 2 weeks of life?
a. Loss of plasma during the birth process

b. Longer RBC life span
*c. Hypoxia in utero
d. Switch from fetal to adult hemoglobin
General Feedback:
Partial hypoxia occurs in utero, which causes the normal
physiologic response to increase erythropoietin, which stimulates
erythropoiesis. About 2 weeks after birth, as the infant makes the
transition from its placenta-dependent oxygenation to the increased
tissue oxygenation of the lungs, erythropoietin decreases, and the red
cell count begins to decrease.
4. Chapter 43-04
All are normal peripheral blood RBC findings at birth in a full-term
infant except:
a. nucleated RBCs.
*b. mean cell volume (MCV) less than 90 fL.
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c. reticulocytosis of 5%.
d. hemoglobin of 20.2 g/dL.
General Feedback:
An MCV of 90 fL in a newborn is abnormal and cause for a
thalassemia/iron deficiency work-up. The mean MCV in a full-term
newborn is 109 fL; an MCV less than 94 fL is cause for evaluation for
alpha-thalassemia or iron deficiency. All the other results given are
normal for a full-term newborn.
5. Chapter 43-05
A complete blood count (CBC) is requested on a full-term newborn girl,
and the following results are obtained:
RBCs 5.07 × 1012/L
Hemoglobin 14.4
Hematocrit 44.5%
MCV 88 fL
White blood cells 26.8 × 109/L
(WBCs)
Platelets 295 × 109/L
What conclusion can be made regarding these data for this infant?
a. All results are normal.

b. The white count is elevated.
*c. Hemoglobin, hematocrit, and MCV are all decreased.
NURSINGTand
d. Red cell count, hemoglobin, B.C OM
hematocrit are all normal, but
MCV is decreased.
General Feedback:
The hemoglobin, hematocrit, and MCV are all low for a full-
term newborn (the red count is actually in the reference range).
Because the red count is relatively high for the hematocrit and
hemoglobin, with the low MCV, thalassemia should be suspected.
6. Chapter 43-06
Why is the white count in a normal full-term newborn elevated shortly
after birth?
a. A relative loss of plasma occurs.

*b. An absolute increase in neutrophils occurs.
c. An absolute increase in lymphocytes occurs.
d. An absolute increase in both neutrophils and lymphocytes
occurs.
General Feedback:
An absolute increase in neutrophils occurs within hours of
birth; this elevates the white count. Bands and occasionally myelocytes
may also be present. At day 2, the count begins to drop progressively,
primarily because of an absolute decrease in neutrophils.
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7. Chapter 43-07
A normal 3-month-old boy has a hemoglobin of 11.2 g/dL. Which is true
about his hemoglobin? It is:
a. higher than that of a normal full-term newborn.

*b. lower than that of an adult of the same age.
c. higher than that of a 14 year old of the same sex.
d. the same as that of an adult of the same sex.
General Feedback:
Hemoglobin is lower in a 3 month old than in an adult of the
same sex. It is normally higher at birth but quickly begins to decrease
so that by 3 months old this would be a normal hemoglobin (abnormal at
birth). It is lower than that of both a 14 year old and an adult of the
same sex.
8. Chapter 43-08
Why is there a relative lymphocytosis in a 2 year old?
a. An absolute neutropenia occurs.

*b. The absolute number of lymphocytes is increased as the immune
system develops.
c. A greater proportion of neutrophils are marginated.
d. Fewer lymphocytes are marginated.
General Feedback:
An absolute increase in lymphocytes occurs, presumably because
NURSas
the immune system is developing INmore
GTB.antigens
COM are encountered; this
increases the absolute number of lymphocytes, as well as the relative
percent. The number of marginated neutrophils is not increased;
lymphocytes do not marginate.
9. Chapter 43-09
What is the normal bone marrow cellularity in the population older than
65 years?
a. 90%
b. 70%
c. 50%
*d. 30%
General Feedback:
Bone marrow cellularity decreases in the older population and
is approximately 30%. That of a young adult is 50%. This change may be
caused by an increase in the volume of spongy tissue in the bone, as
well as an increase in fat, rather than an actual decrease in
hematopoietic tissue.
10. Chapter 43-10

An 85-year-old woman has a hemoglobin of 10.5 g/dL. This is:
a. high for a woman of this age.
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b. normal for this age regardless of sex (i.e., for both male and
female patients).
*c. a sign of an underlying disease that requires further
evaluation.
d. most likely a myelophthisic anemia.
General Feedback:
The majority of geriatric individuals maintain a normal
hemoglobin for their sex so that this hemoglobin of 10.5 g/dL in an 85-
year-old woman is low and a sign of an underlying disease. This
requires further work-up. Most anemias in older adults are iron
deficiency or the anemia of chronic inflammation (disease).
Myelophthisic anemia, in which the bone marrow is invaded by something
foreign, such as metastatic malignant cells, certainly occurs but is
not the most common cause of anemia in older adults.
11. Chapter 43-11

Iron deficiency anemia in older adults is most often a result of:
a. poor nutritional intake of iron.

b. malabsorption of iron.
c. decreased ability to transport iron because of a decrease in
transferrin.
*d. bleeding in the gastrointestinal tract.
General Feedback:
Bleeding from the gastrointestinal tract is the most common
NURSin
cause of iron deficiency anemia INolder
GTB.C OM
adults.
12. Chapter 43-12

Which is more likely to result from poor absorption than from
inadequate nutritional intake in older adults?
a. Folic acid deficiency

b. Iron deficiency
*c. Vitamin B12 deficiency
d. Lead deficiency
General Feedback:
Vitamin B12 deficiency is most likely to develop from
inadequate intestinal absorption, rather than an inadequate vitamin
intake. This can progressively lead to the development of pernicious
anemia.
13. Chapter 43-13

Which is true concerning age-related changes of hemostasis in older
adults?
a. Decreased factor VIII

b. Decreased platelet activity
*c. Increased fibrinogen
d. Increased fibrinolysis
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General Feedback:
Fibrinogen levels, factor VIII, and platelet activity all
increase during aging. Plasminogen activator inhibitor, the major
inhibitor of fibrinolysis, increases with aging, so fibrinolysis of
clots decreases.
14. Chapter 43-14

Which is most commonly seen in the population older than70 years?
*a. Chronic lymphocytic leukemia

c. Essential thrombocytosis
d. Acute lymphocytic leukemia
General Feedback:
Chronic lymphocytic leukemia is the most common leukemia in
the population older than 70 years of age, although acute myeloid
leukemia and chronic myelogenous leukemia do show increased age-related
incidence. Essential thrombocytosis is rare. Chronic myelogenous
leukemia is seen more often in the middle aged, and acute lymphocytic
leukemia most commonly occurs in children.
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Rodak's Hematology 6th Edition Test Bank

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TEST BANK FOR RODAK'S HEMATOLOGY 6TH EDITION BY WALENGA

Nursylab 1# Nursing Materials Seller of 2021

*a. blood cells.

a. every time a complete blood count (CBC) is requested on a

*a. Medical laboratory professional

a. white cell count.

a. defend the body against bacterial invasion.

a. White blood cell (WBC) count

General Feedback: NURSINGTB.COM

a. Should be derived from reference books

10. Chapter 02-10

a. Ignore the result unless it happens again the next day.

does not appear to need recalibration because one control is acceptable

11. Chapter 02-11

12. Chapter 02-12

13. Chapter 02-13

*a. Chemotherapy patients

14. Chapter 02-14

15. Chapter 02-15

a. purchase high-quality instruments from reputable vendors.

16. Chapter 02-16

*a. Make this a quality assurance project.

17. Chapter 02-17

18. Chapter 02-18

a. between 13.4 and 14.2 g/dL.

19. Chapter 02-19

The SD for this hemoglobin method was calculated in Question 18. A

a. It is within the 95.5% confidence levels for this test.

a. Condensed, darkly stained

The Golgi apparatus directs traffic in the cell, where it is

a. low concentration of lysosomes.

10. Chapter 03-10

11. Chapter 03-11

*a. Cell membrane

12. Chapter 03-12

*a. more nucleoli.

A cell that is active in protein synthesis has more nucleoli,

13. Chapter 03-13

a. Activates cell nucleus to replicate DNA.

14. Chapter 03-14

*a. Bone marrow

15. Chapter 03-15

16. Chapter 03-16

17. Chapter 03-17

a. Lymph node spleen

a. Stem cells escape the bone marrow and mature in peripheral

*a. Adjacent to the outer surfaces of the vascular sinuses

c. Deep in the cords

*b. Low protein

a. Burst-forming unit—erythroid (BFU-E)

10. Chapter 04-10

*a. Failure to thrive

11. Chapter 04-11

12. Chapter 04-12

13. Chapter 04-13

14. Chapter 04-14

15. Chapter 04-15

16. Chapter 04-16

*a. Activating adipose cells

17. Chapter 04-17

18. Chapter 04-18

19. Chapter 04-19