Chapter 2,5-7 Body Fluids

1. A routine urinalysis test can be used to diagnose what type of disease process?

A. Prerenal

B. Renal

C. Postrenal

D. All of the above

ANS: D

Urine is an ultrafiltrate of the plasma and is useful in monitoring body homeostasis and metabolic disease processes, as well as kidney disease and pathologic conditions associated with the ureters, bladder, and urethra.

Cognitive Level: 2

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2. Which factor will not affect urinalysis results?

A. Time of collection

B. Preservation method

C. Collection method

D. B and C

E. None of the above

ANS: E

The time of collection, preservation method, and collection method all affect urinalysis results, depending on the test ordered (e.g., diurnal variation, midstream clean catch collection, refrigeration, and so on).

Cognitive Level: 2

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3. First morning specimens provide the ideal specimen for all of the following reasons except:

A. Concentrated specimen

B. Incubated 8 hours

C. Acidic

D. Reduced number of epithelial cells

ANS: D

The first morning specimen is the most concentrated, providing an ideal specimen for detection of constituents that might not be detectable in more dilute specimens collected at other times of the day due to various hydration levels. Formed elements are more stable in acidic urine. In addition, 8-hour incubation in the bladder is ideal for testing substances that require incubation for detection (e.g., nitrites). Epithelial cells may be more numerous in the first morning specimen, providing a preferred specimen for cytology studies.

Cognitive Level: 2

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4. Acidic urine specimens provide a stable environment for which of the following urine constituents?

A. Cellular elements

B. Chemical substances

C. Glucose

D. Nitrites

ANS: A

Formed elements, such as RBCs, WBCs, and casts, are more stable in acidic urine.

Cognitive Level: 1

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5. A random clean catch urine specimen for cytology studies requires:

A. Drinking 24 to 32 ounces of water each hour 2 hours before urine collection

B. Fasting for 12 hours before urine collection

C. Urine collection on 3 different days 1 week apart

D. Refraining from any exercise activity 5 days before each collection

ANS: A

Collection of urine specimens for cytology studies requires the patient to drink 24 to 32 ounces of water each hour for 2 hours before a clean-catch collection. Most cytologic protocols require specimens to be collected on 3 to 5 consecutive days. Exercising 5 minutes before collection by skipping or jumping up and down helps increase the cellularity of the urine specimen.

Cognitive Level: 1

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6. Which statement is not true about cellular morphology in urine specimens?

A. It is enhanced by the high osmolality of the first morning specimen.

B. It can be evaluated in a random urine collection.

C. It degenerates as pH decreases.

D. All of the above

ANS: C

Cellular elements are more stable in an acidic urine. As pH increases, cellular elements begin to disintegrate.

Cognitive Level: 2

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7. Timed urine collections are useful in measuring the excretion of urine substances affected by diurnal variation, which include all of the following except:

A. Albumin

B. Hormones

C. Glomerular filtration rate

D. Renal cells

ANS: D

The excretion of many substances is affected by diurnal or circadian variation, such as hormones, proteins, and GFR, and require a timed collection during their peak excretion times.

Cognitive Level: 2

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8. Timed urine collections can be categorized into all of the following types except:

A. Predetermined length of time

B. Specific time of day

C. Predetermined length plus specific time of day

D. All are correct

ANS: D

Timed collections include predetermined length of time (e.g., 24-hour creatinine), specific time of day (e.g., hormones), or a combination of the two (e.g., urobilinogen collected for 2 hours between 2 and 4 PM).

Cognitive Level: 2

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9. The patient comes in with an order for a creatinine clearance test. The technician will instruct the patient to collect which specimen type?

A. Random

B. Timed

C. First morning

D. Clean catch midstream

ANS: B

Urine creatinine specimens require a timed collection (e.g., 12-hour, 24-hour). Creatinine, which is produced at a steady rate by the body and is not influenced by diet or normal physical activities, provides an effective means to assess kidney function.

Cognitive Level: 2

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10. Timed urine specimens are used for:

A. Quantitative chemical analysis

B. Fluid depravation studies

C. Routine screening

D. Confirmation of orthostatic proteinuria

ANS: A

Timed urine specimens are useful for quantitative chemical analysis, clearance tests, cytology studies, and evaluation of fistulas.

Cognitive Level: 1

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11. The patient brings in a 24-hour urine collection at 8 AM and states that upon collection of the first morning specimen today, he wasn't quite awake, forgot, and voided a small portion into the toilet but quickly stopped and then properly collected the remainder into the container. You should:

A. Ask the patient to estimate the amount voided into the toilet and note it on the container

B. Process the specimen as usual, because the small amount lost will not significantly alter the test results

C. Give the patient another container and instruct him to recollect a new 24-hour specimen

D. Ask the patient to provide another specimen to be added to the container to make up for the lost volume

ANS: C

A 24-hour urine study requires collection of all urine voided within a 24-hour period. If any portion of the urine produced during the specified time frame is not collected in the provided container, the collection process is invalid and must be started over again. Accurate timing and strict adherence to the collection directions are crucial in ensuring valid results. Missing volume creates error in both volume and analyte concentration.

Cognitive Level: 2

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12. Which of the following specimen types is not suitable for bacterial and fungal cultures?

A. Midstream clean catch

B. Catheterized, urethra

C. Routine void

D. Suprapubic aspiration

ANS: C

A routine or random void is not suitable for bacterial and fungal cultures, because the specimen may be contaminated by skin bacteria or fungal organisms, as well as clothing contaminants. Midstream clean catch specimens require the patient to wash the glans penis or urethral meatus before collection and then collect the middle portion of the urine stream. Any normal flora of the distal urethra is voided into the toilet; the midstream portion reflects elements and analytes from the bladder, ureters, and kidneys. Catheterized specimens collect urine from each ureter, and suprapubic aspirations provide specimens directly from the bladder.

Cognitive Level: 2

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13. Proper collection of a midstream clean catch urine specimen requires the patient to:

A. Cleanse the area, void the first portion into the toilet, and collect the remainder in a container

B. Void the first portion into the toilet, cleanse the area, collect the middle portion in a container, and void the remainder into the toilet

C. Cleanse the area, void into the toilet, stop, collect the middle portion into a container, and void the remainder into toilet

D. Cleanse the area, void into the toilet, stop, and collect the remainder into a container

ANS: C

MSCC specimen collection requires the patient to cleanse the area first, void into the toilet, stop, collect the middle portion in the container, and void the remainder into the toilet.

Cognitive Level: 2

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14. Which urine collection method can be used to determine whether kidney disease affects one or both kidneys?

A. Suprapubic

B. Midstream clean catch

C. Timed, diurnal variation

D. Catheterized ureters

ANS: D

Insertion of a catheter into the ureters allows for urine collection from each kidney. Specimens are labeled left ureter and right ureter and analyzed, and the results are compared to determine whether kidney disease affects one or both kidneys.

Cognitive Level: 1

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15. Collection of urine for anaerobic culture requires which of the following urine collection methods?

A. Suprapubic

B. Catheterized urethra

C. First morning urine

D. Midstream clean catch

ANS: A

Anaerobic urine culture requires collection of urine through the insertion of a needle directly into the bladder and then aspiration of urine into the attached syringe. The syringe is submitted for anaerobic culture. All other collections expose the specimen to air, which may result in the death of obligate anaerobic organisms and false-negative cultures.

Cognitive Level: 2

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16. The patient is a 3-month-old infant with a possible bladder infection. The best method of urine collection for routine urinalysis testing and culture is:

A. Clean catch using a pediatric bag

B. Sterile pediatric bag

C. Catheterization, urethral

D. Random

ANS: C

Urine for culture from an infant is best collected using a catheter or by performing suprapubic aspiration. Pediatric bags are satisfactory for routine screening and quantitative assays but are not appropriate for bacterial culture because of possible contamination from skin and/or fecal matter.

Cognitive Level: 2

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17. A urine specimen is received in the laboratory with the patient's name, the date, and the time of collection on the lid of the container. You should:

A. Mark the specimen as received in the computer system

B. Make a label and attach it to the container

C. Reject the specimen as unlabeled

D. Call the nurse to come down and properly label the specimen

ANS: C

If the lid of the urine specimen container is labeled, the specimen technically is unlabeled and should be rejected as such. Specimen mix-ups are possible once the lid is removed, and reporting errors and misdiagnoses may result.

Cognitive Level: 2

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18. As the only technician on the third shift, you receive a routine urine specimen that was collected at 0300 hours. It is now 0400 hours. You have been called to the emergency department for STAT blood draws on two trauma patients. You decide to:

A. Call the floor and have the staff collect another specimen around 7 AM for the day shift

B. Put the specimen in the refrigerator for later testing

C. Leave the specimen in the drop basket so you do not forget to do it later

D. Perform the UA before going to the ED, because the specimen's viability expires in 1 hour

ANS: B

If any delay of 2 hours or longer in the transportation or testing of urine specimens is anticipated, the specimen should be placed in the refrigerator to preserve the chemical and cellular elements. Changes in unpreserved urine include alteration of urine solutes to a different form, resulting in a color change; bacterial growth, which may increase the pH, decrease chemical components such as glucose, and/or lead to false-negative results; solute precipitation, resulting in a change of clarity, and so on.

Cognitive Level: 2

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19. You arrive in the UA department at 7 AM and find five routine urine samples in the refrigerator awaiting analysis. You pull the specimens out, check the dates and times, and let them warm to room temperature before analysis. You groan because you know that if a microscopic is required, the view may be obscured by:

A. Amorphous crystals

B. Bacteria

C. Epithelial cells

D. Degenerated cells

ANS: A

Refrigeration is the easiest means of preserving most urine specimens that cannot be analyzed within 2 hours of collection. However, it causes precipitation of amorphous urate and phosphate crystals that obscure clarity and complicate microscopic analysis.

Cognitive Level: 2

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20. After an extremely busy night collecting and performing STAT tests, you find a routine urine specimen in the drop basket. You check the collection time and note that the specimen is over 2 hours old. You call the floor and request a new specimen because:

A. Chemical constituents may be altered, producing invalid results.

B. Bacteria may have disintegrated because of an increased ammonia level.

C. Precipitation of crystals as the urine cooled may interfere with analysis.

D. pH levels may be falsely lowered because of bacterial conversion of urea to ammonia.

ANS: A

Urine undergoes physical, chemical, and cellular element changes if it is not analyzed or preserved within 2 hours of collection. Chemical constituents may give erroneously decreased or false-negative results. Color may darken; crystals may precipitate out; pH and nitrites increase; glucose, ketones, bilirubin, and urobilinogen decrease; bacteria proliferate; blood cells and casts disintegrate; and trichomonads lose motility or die.

Cognitive Level: 2

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21. Upon opening a urine specimen container, you are almost knocked over by the smell of ammonia. You check the time of collection and note that it is not within the 2-hour time frame. You expect which of the following results:

A. Decreased pH

B. Positive nitrites

C. Positive RBCs

D. Positive glucose

ANS: B

As previously noted in the rationale for question 20, a urine specimen left unrefrigerated for longer than 2 hours shows an increase in nitrites, a decrease in pH and glucose, and disintegration of RBCs; this results in a discrepancy between the microscope result and the reagent blood test pad result.

Cognitive Level: 3

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22. All of the following chemical changes may occur in unpreserved urine specimens except:

A. Color change

B. Decreased glucose

C. Increased urobilinogen

D. Increased nitrites

ANS: C

Unpreserved urine specimens may show a color change, a decrease in glucose and urobilinogen, and an increase in nitrites.

Cognitive Level: 2

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23. It is important to keep the lids on urine specimens before testing so that volatilization does not occur for which urine constituent?

A. Nitrate

B. Urobilinogen

C. Bilirubin

D. Ketones

ANS: D

Ketones are volatile and will dissipate if the lid is not tightly sealed on the urine specimen. Bilirubin, if suspected in the urine, is light sensitive and must be protected from light by using an amber container or wrapping the container in foil.

Cognitive Level: 1, 2

Reference:

24. A client comes to the outpatient department for a urine drug screen. You follow the protocol for collection but question whether the specimen is truly urine. You then follow the procedure for urine verification and obtain the following results. Which result causes you to reject the specimen?

A. Temperature of 30 C

B. pH of 4.0

C. Specific gravity of 1.002

D. None of the above

ANS: A

Criteria that determine whether a fluid is urine are: pH 4.0 to 8.0; specific gravity 1.002 to 1.035; and temperature 32.5 to 37.5 C. Therefore, the temperature of 30 C indicates that the fluid was not collected on site or is not urine.

Cognitive Level: 1

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25. The single most useful means of identifying a fluid as urine is to test:

A. pH

B. Specific gravity

C. Creatinine

D. Sodium and chloride

ANS: C

The creatinine concentration in urine is approximately 50 times that in plasma; creatinine therefore is the single most useful substance in identifying a fluid as urine.

Cognitive Level: 1

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26. The means of preservation used to preserve urine sediment elements is:

A. Thymol

B. Refrigeration

C. Hydrochloric acid

D. Formalin

ANS: A

Thymol is used to preserve urine sediment. Refrigeration is used as a storage preservative measure before and after testing. Hydrochloric acid is used for quantitative analysis of urine solutes, and formalin is a cytologic preservative.

Cognitive Level: 1

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1. The integrity of reagent strips is best assessed by:

A. Using automated instrumentation

B. Running control materials

C. Keeping the lid tightly closed on the bottle

D. Checking for a color change on the pads

ANS: B

The best means of assessing the integrity of reagent strips and of ensuring accurate test results is running QC on newly opened containers and also performing QC regularly, as determined by the manufacturer and laboratory protocol and in conformity with any applicable regulations. The crucial steps for ensuring the integrity of reagent strips are (1) proper storage; (2) following the manufacturer's directions; (3) keeping the lid closed tightly, along with the desiccants; and (4) protecting the strips from UV rays and sunlight.

Cognitive Level: 1

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2. While performing UAs, the technician ran controls and began testing the specimens. He ran out of reagent strips and needed one more to complete the run. He opened a new bottle and:

A. Continued testing on the remaining specimens

B. Ran controls on the new bottle and then continued the run

C. Aborted the run and started all over with the first specimen

D. Checked for discoloration before continuing the run

ANS: B

To ensure the integrity and accuracy of a new bottle of reagent strips or a new lot number, QC must be run before running patient samples.

Cognitive Level: 2

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3. Interlaboratory testing provides additional quality control checks on all of the following except:

A. QC material

B. Laboratorian skill

C. Chemical analysis

D. Microscopic analysis

ANS: A

Interlaboratory testing involves taking an aliquot of a well-mixed urine specimen from the daily workload and having a different laboratory analyze the specimen. This serves as a check of the entire UA process of laboratorian skill in performing and following procedures and protocols for chemical and microscopic examination of urine. It does not assess QC material.

Cognitive Level: 2

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4. All of the following are improper uses of the reagent strip, which will produce erroneous results, except:

A. Inadequate removal of excess urine from the strip

B. Blotting the edge of the reagent strip after dipping it in the urine

C. Prolonged dipping of the strip in urine

D. Reading the results after all test pads have reached full development

ANS: B

Proper reading of UA reagent strips includes removing excess urine from the strip by blotting the edge after brief immersion into the urine and reading each test pad at the appropriate time required for full color development for each test pad.

Cognitive Level: 2

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5. The technician dips a reagent strip into a urine specimen and then reads it manually, following the manufacturer's specifications. After performing the microscopic examination, he notes that the dipstick color on the edge of the reaction pad for ketones is darker than when he had first read it. The technician:

A. Reports the original result and discards the strip and other disposable items

B. Changes the original result of negative to 2+ and verifies the report

C. Takes a new reagent strip and retests the specimen

D. Asks another technician to look at the strip for verification

ANS: A

Color changes that appear only along the edge of a reaction pad or after 2 minutes are diagnostically insignificant and should be disregarded. The color change at the appropriate read time for each pad should be recorded.

Cognitive Level: 3

Reference:

6. The technician is logging urine color and clarity for four specimens he had running on the Clinitek. He notes an abnormal orange color for specimen #3. All test pads for specimen #3 are positive. Upon microscopic examination, the technician reports a negative result for all cellular and crystal elements. Specimens #1 and #4 test negative for all constituents, and no microscopic examinations are performed. Specimen #2 tests positive for nitrites and leukocytes only; that microscopic examination reveals WBCs and bacteria. The next course of action the technician should take is:

A. Finalize all reports and results and send them to the appropriate departments

B. Rerun all specimens, using reagent strips with a new lot number

C. Manually retest specimen #3

D. Spin down specimen #3 and rerun it on the Clinitek

ANS: C

Some medications can cause highly pigmented urine specimens. This can mask chemical reactions on the test pads, leading to false-positive results, because some instruments are unable to identify and compensate for the pigmentation. These specimens must be tested manually using reagents strips or alternative methods.

Cognitive Level: 3

Reference:

7. End-stage renal failure has which of the following characteristics?

A. Isosthenuria

B. Nocturia

C. Fixed specific gravity (SG) of 1.010

D. A and C

E. A, B, and C

ANS: E

End-stage renal disease leads to isosthenuria, nocturia, and a fixed SG of 1.010 as a result of significant renal tubular dysfunction.

Cognitive Level: 2

Reference:

8. The reagent strip test pad for specific gravity produces a color change by measuring the:

A. Release of protons by ionic solutes, resulting in a decreased pH

B. Ratio of ionic and nonionic solutes, resulting in polar bonds

C. Number of solute molecules in relation to solvent

D. Binding of protons by ionic solutes in solution

ANS: A

The reagent test pad for SG produces a color change by measuring the release of protons by ionic solutes present in urine, resulting in a decreased pH.

Cognitive Level: 1

Reference:

9. The kidneys play a major role in acid-base balance by:

A. Adjusting the pH of the blood as it flows through the glomerulus

B. Reabsorbing buffers from the ultrafiltrate

C. Selectively excreting acid or alkali

D. Filtering out excess hydrogen and hydroxyl ions

ANS: C

Normal daily metabolism generates endogenous acids and bases, which are selectively excreted by the kidneys to maintain homeostasis in the body.

Cognitive Level: 1

Reference:

10. Upon review of the urinalysis printout, the technician notes a urine pH of 9.0 on one specimen. The other test results were negative, except for nitrites, which tested positive. The next step is:

A. Double-check the time of collection, transport, and storage

B. Review the other results and, if normal, finalize the report

C. Use pH test paper to confirm the pH result

D. Rerun the reagent strip to confirm all results

ANS: A

Normal urine pH varies between 4.5 and 8.0. Values below or above this range are physiologically impossible and must be investigated. Typically, urine pH values above 8 are due to improper preservation and storage of the specimen (e.g., the specimen was left out at room temperature for longer than 2 hours, resulting in the proliferation of urease-producing bacteria, or it came from a patient who is taking an alkaline medication or therapeutic agent). Alternatively, an alkaline agent may have been added to the specimen after collection.

Cognitive Level: 3

Reference:

11. A 75-year-old man has excruciating flank pain on the left side. The doctor suspects a kidney stone. UA findings of blood and calcium oxalate crystals, along with a CT scan, confirm the diagnosis. The physician treats the patient and advises him to:

A. Drink cranberry juice

B. Eat a vegetarian diet

C. Include more protein at each meal

D. Increase his carbohydrate intake

ANS: B

Calcium oxalate crystals can develop in acidic urine and precipitate out. Eating a vegetarian diet produces a more alkaline urine, keeping the crystals in solution and possibly preventing the formation of kidney stones.

Cognitive Level: 3

Reference:

12. A 16-year-old boy is brought to the ED unconscious and unresponsive. His blood alcohol level is three times the normal limit. His friends report that the last time they saw him conscious was 8 hours ago, around 5 AM. Later that morning, they saw him on the floor in the family room, but they thought he was just sleeping and left him alone. In the afternoon, unable to rouse him, they called 911. The patient is catheterized, and the urine color is brown. The physician is concerned that the urine contains:

A. Hemoglobin

B. RBCs

C. Myoglobin

D. Porphyrin

ANS: C

Nontraumatic disorders, such as alcohol overdose, toxin ingestion, and certain metabolic disorders, may result in myoglobinuria. Myoglobinuria with acute renal failure is common in patients with alcohol overdose or cocaine or heroin addiction.

Cognitive Level: 3

Reference:

13. The UA results for the patient in question 12 are positive for blood, but no RBCs are seen on the microscopic examination. The next step is perform a(n):

A. Prussian blue staining test

B. Ammonium sulfate precipitation test

C. Watson-Schwartz test

D. Hemolytic differentiation test

ANS: B

The differentiation test between hemoglobin and myoglobin is the ammonium sulfate precipitation test. Prussian blue stains for iron, and the Watson-Schwartz test detects porphyria.

Cognitive Level: 2

Reference:

14. In light of the answers to questions 12 and 13, which of the following is the most likely cause of this patient's condition?

A. Hemolytic episode

B. Hemosiderin excretion

C. Nontraumatic rhabdomyolysis

D. Kidney disease

ANS: C

Nontraumatic rhabdomyolysis can result from alcohol overdose. Hemosiderin in the urine is due to a hemolytic episode.

Cognitive Level: 3

Reference:

15. The reagent pad for blood detection is impregnated with:

A. Methyl red and bromthymol blue

B. Tetramethylbenzidine and peroxide

C. Ester and diazonium salt

D. Copper sulfate and tetramethylbenzidine and peroxide

ANS: B

The reagent pad for blood is impregnated with tetramethylbenzidine and peroxide. Methyl red and bromthymol blue detect the pH; ester and diazonium salt detect leukocytes.

Cognitive Level: 1

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16. Whenever the reagent pad shows a negative result for blood and the microscopic examination reveals RBCs, the technician should suspect the presence of:

A. Ascorbic acid

B. Peroxide

C. Hemosiderin

D. Porphyrin

ANS: A

Blood reagent test strips are susceptible to ascorbic acid interference. If a discrepancy exists between the blood cells in the microscopic examination and a negative reagent strip result for blood, ascorbic acid should be suspected. Ascorbic acid is a strong reducing agent that reacts with the peroxide on the test pad, removing it from the chemical reaction with blood and subsequent oxidation of the chromogen.

Cognitive Level: 2

Reference:

17. A 23-year-old female patient comes in for a urinalysis on a midstream clean catch specimen. The results are as follows:

Physical Examination Chemical Examination Microscopic Examination

Color: Pale yellow

Clarity: Slightly hazy Sp. Gr. 1.004

pH 8.0

Blood: Negative

Protein: Negative

LE: Positive

Nitrite: Positive

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: 1.0 EU

Ascorbic acid: Negative 0-3 WBCs

3+ Bacteria

Which interpretation applies to these test results?

A. The results are accurate and do not indicate a urinary tract infection.

B. The results are inaccurate and indicate improper collection of the midstream clean catch specimen.

C. The results are accurate and indicate that the patient is being treated with an alkaline medication.

D. The results are inaccurate, because a discrepancy exists between the chemical and microscopic results.

ANS: D

The presence of LE does not correlate with the finding of 0 to 3 WBCs. LE detects about 10 to 25 WBCs/mcL, and it also can detect lysed WBCs. The urine SG is 1.004 and the pH of 8 is high; consequently, lysis of WBCs may occur, resulting in a detectable LE despite a clinically insignificant number of WBCs.

Cognitive Level: 3

Reference:

18. The technician performs a microscopic examination on urine sediment from a 35-year-old female. The findings for this specimen are:

Physical Examination Chemical Examination Microscopic Examination

Color: Amber

Clarity: Slightly hazy Sp. Gr. 1.025

pH 6.5

Blood: Negative

Protein: Negative

LE: Negative

Nitrite: Negative

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: 1.0 EU

Ascorbic acid: Negative 3-6 WBCs

0-1 Squamous epithelial cells

The best explanation for these results is:

A. The specimen was not well mixed, resulting in a negative LE result.

B. Vaginal contamination of the specimen masked the LE result.

C. An insufficient amount of leukocyte esterase was produced.

D. The specific gravity was too high, causing a false-negative LE result.

ANS: C

The LE test detects about 10 to 25 WBCs/mcL. The 3 to 6 WBCs/hpf present in this specimen may not produce enough LE for detection, resulting in a negative reading. Normally, a few WBCs are present in urine (i.e., 0 to 8/hpf, or 10 WBCs/mcL). The presence of 20 WBCs/mcL or more indicates a pathologic process.

Cognitive Level: 3

Reference:

19. UA results on a 28-year-old female are as follows:

Physical Examination Chemical Examination Microscopic Examination

Color: Amber

Clarity: Hazy Sp. Gr. 1.035

pH 5.0

Blood: Negative

Protein: 2+

LE: Negative

Nitrite: Positive

Glucose: 500 mg/dL

Ketones: Trace

Bilirubin: Negative

Urobilinogen: 1 IU

Ascorbic acid: Negative 15-20 WBCs

5-10 RBCs

4+ Bacteria

The technician notes the discrepancy between the chemical examination findings for LE and blood (i.e., negative) and the microscopic examination findings (i.e., presence of WBCs and RBCs). Which of the following may explain the discrepancy?

A. Specific gravity, glucose, and protein

B. Glucose and protein

C. Specific gravity

D. Protein

ANS: C

A high specific gravity can result in false-negative readings for blood and leukocyte esterase.

Cognitive Level: 3

Reference:

20. The first morning UA results on a 60-year-old male suspected of having a bladder infection are:

Physical Examination Chemical Examination Microscopic Examination

Color: Reddish

Clarity: Cloudy Sp. Gr. 1.035

pH 6.5

Blood: Trace

Protein: 500 mg/dL

LE: Negative

Nitrite: Negative

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: 1.0

Ascorbic acid: Positive 20-30 WBCs

10-15 RBCs

3+ Bacteria

Which of the following is likely to be questionable?

A. Specific gravity

B. Nitrite and leukocyte esterase

C. Specific gravity and blood

D. Specific gravity, nitrite, and leukocyte esterase

E. Specific gravity, nitrite, leukocyte esterase, and blood

ANS: E

The specific gravity can be falsely elevated as a result of a high protein level; the LE can be falsely negative because of the high SG; and the nitrite and blood results can be falsely negative because of the presence of ascorbic acid.

Cognitive Level: 3

Reference:

21. Postural (orthostatic) proteinuria requires:

A. A random urine specimen

B. A timed urine specimen

C. A first morning urine specimen

D. A 24-hour urine specimen

E. Two urine specimens

ANS: E

If orthostatic proteinuria is suspected, two urine specimens must be collected: a first morning specimen and a second specimen after the patient has been in an upright position for several hours.

Cognitive Level: 2

Reference:

22. Fanconi's syndrome is a proximal tubular dysfunction that produces which of the following urine findings?

A. Aminoaciduria

B. Proteinuria and glycosuria

C. Phosphaturia, proteinuria, and glycosuria

D. Aminoaciduria, proteinuria, phosphaturia, and glycosuria

ANS: D

Fanconi's syndrome produces urine findings of aminoaciduria, proteinuria, glycosuria, and phosphaturia, which are caused by proximal tubular dysfunction associated with inherited or acquired diseases.

Cognitive Level: 1

Reference:

23. Protein error of indicators in the protein reagent test pad may result in false positive readings:

A. In highly buffered or alkaline urine (≥9.0)

B. In the presence of proteins other than albumin

C. If the patient is taking phenazopyridine

D. If an alkaline pH is adjusted down to 5.0

ANS: A

A highly buffered or alkaline urine (i.e., pH ≥ 9.0) overwhelms the buffering capacity of the protein reagent pad, producing a false positive result. Adjusting the pH of the urine down to 5.0 with acid and retesting produces an accurate reading.

Cognitive Level: 1

Reference:

24. The UA of a 70-year-old male who takes an alkaline medication reveals 3+ protein on the reagent test strip and a pH of 9.0. The technician should:

A. Perform the sulfosalicylic acid test and report out both results

B. Adjust the urine pH to 5.0 and retest using a reagent strip

C. Note on the report that the protein result is falsely elevated because of the high pH

D. Report the protein result, because protein error of indicators adjusts for a high pH

ANS: B

A highly buffered or alkaline urine (i.e., pH ≥ 9.0) overwhelms the buffering capacity of the protein reagent pad, producing a false-positive result. Adjusting the pH of the urine down to 5.0 with acid and retesting produces an accurate reading.

Cognitive Level: 2

Reference:

25. The reagent strip for protein can detect which protein(s)?

A. Myoglobin

B. Hemoglobin

C. Albumin

D. Globulins

E. All of the above

ANS: C

The reagent strip for protein is more sensitive to albumin than to any other protein. Negative results occur in the presence of globulins, myoglobin, hemoglobin, Bence Jones proteins, and mucoproteins.

Cognitive Level: 1

Reference:

26. Diabetic patients must routinely have their urine checked to monitor their renal status. For this purpose, the technician performs which test?

A. 24-hour urine protein test

B. Reagent strip for protein test

C. Microalbumin reagent strip test

D. Sulfosalicylic acid test for protein

ANS: C

Detection and monitoring of urine albumin excretion greatly aid the identification and management of patients at risk for kidney disease (e.g., those with diabetes, hypertension, or peripheral vascular disease). Microalbumin reagent strips are used to detect clinically significant low-level albumin excretion, because routine reagent strips cannot detect such low levels.

Cognitive Level: 1

Reference:

27. An 80-year-old female with diabetes presents to the ED with heart failure. You might expect to see which of the following conditions confirmed by blood glucose and UA testing?

A. Hyperglycemia and no glucosuria

B. Normal blood glucose and normal glucosuria

C. Normal blood glucose and hypoglucosuria

D. Hypoglycemia and glucosuria

ANS: A

Hyperglycemia can be present without glycosuria. Any disease or condition that decreases the GFR, such as low cardiac output or renal arteriosclerosis, can produce such a result.

Cognitive Level: 3

Reference:

28. The technician receives the following results on a urine specimen from a 1-month-old patient. What additional testing, if any, is required?

Physical Examination Chemical Examination Microscopic Examination

Color: Pale yellow

Clarity: Clear Sp. Gr. 1.015

pH 6.0

Blood: Negative

Protein: Negative

LE: Negative

Nitrite: Negative

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: 1.0 EU

0-1 WBCs

A. Ictotest

B. Clinitest

C. SSA test

D. Acetest

E. No additional testing is needed.

ANS: B

As a standard practice, laboratories routinely test the urine of children under age 2 years for reducing substances. This can be done by performing a Clinitest analysis.

Cognitive Level: 2

Reference:

29. The technician performs a UA and a copper reduction test on a 19-month-old child. The reagent strip shows a positive result for glucose; the copper reduction test also produces a positive result. Which of the following is most likely present in the urine?

A. Galactose

B. Glucose

C. Lactose

D. Homogentisic acid

ANS: B

The reagent strip for glucose is specific for glucose. Although the Clinitest can detect other reducing sugars, the fact that the reagent strip result was positive indicates that glucose most likely is the substance present in the urine.

Cognitive Level: 2

Reference:

30. The technician records these results on a UA and Clinitest: glucose 4+ on reagent strip and negative for Clinitest. The most likely explanation is:

A. The patient has no other reducing substances.

B. The patient is taking high doses of ascorbic acid.

C. The renal threshold level has been reached for glucose.

D. The Clinitest result indicates that the pass-through effect has occurred.

ANS: D

With a high glucose reading on the reagent strip, the most likely explanation for a negative Clinitest result is the pass-through effect. The test should be repeated using the 2-drop method, which reduces the possibility of a pass-through effect.

Cognitive Level: 2

Reference:

31. Mr. Smith, a regular client at the laboratory, comes in for a UA. The technician comments that she hasn't seen Mr. Smith in quite awhile. He tells her that he has been at the University Hospital, undergoing chemotherapy for cancer. He says that he has had a rough time and has lost a lot of weight, but he feels much better thanks to a new medication, MESNA. His appetite is back, and he has been eating regularly. When she tests Mr. Smith's urine, the technician notes that the ketone pad immediately turns purple. Results from the Clinitek show 4+ ketones. She suspects a false-positive result caused by:

A. Weight loss

B. Cancer

C. Free sulfhydryl groups

D. An improper read time

ANS: C

MENSA is a 2-mercaptoethan sulfonic acid rescue drug used in the treatment of cancer. It contains free sulfhydryl groups, which can produce a false-positive ketone result. The reagent test pad immediately shows a positive result, and the color dramatically fades or disappears by the appropriate read time. True ketone color reactions intensify rather than fade. Because automated reagent strip readers have a shorter time for reading the strip, false-positive results can occur.

Cognitive Level: 3

Reference:

32. Which condition produces a negative urine bilirubin result but also an increased urobilinogen result?

A. Transfusion reaction

B. Hepatitis

C. Common bile duct tumor

D. Liver tumor

ANS: A

A transfusion reaction can produce a negative bilirubin result but also an increased urobilinogen result on urine testing. As the RBCs lyse, the liver is able to process all the excess bilirubin released. Conjugate bilirubin is released into the small intestine and converted back to its unconjugated form, where it is reduced by anaerobic intestinal bacteria to form tetrapyrrole urobilinogen. Normally, about 20% of urobilinogen is reabsorbed into the bloodstream. About 2% to 5% goes to the kidneys and is excreted in the urine; the rest is re-excreted by the liver into the bile. The increased production of bile results in increased production of urobilinogen and therefore increased reabsorption into the blood and excretion in the urine. Liver tumors and common bile duct tumors can cause a blockage and thus a reduction in urobilinogen and an increase in bilirubin. Hepatitis results in an increased bilirubin.

Cognitive Level: 3

Reference:

33. The technician performs an admission UA on a urine specimen that is beer brown in color and that was obtained from a homeless 25-year-old male hospitalized with hepatitis. The results are:

Physical Examination Chemical Examination Microscopic Examination

Color: Beer brown

Clarity: Cloudy Sp. Gr. 1.020

pH 6.5

Blood: Trace

Protein: Trace

LE: Positive

Nitrite: Positive

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: 4 EU

Ascorbic acid: Negative 20-30 WBCs

4+ Bacteria

The technician had not expected to see a negative bilirubin result. Based on the UA results, the most likely explanation is:

A. The patient is now in the recovery phase of his illness.

B. The liver is able to compensate for the bilirubin load.

C. The bilirubin result is a false negative caused by the presence of nitrite.

D. The patient has a biliary obstruction in addition to hepatitis.

ANS: C

False-negative reagent strip bilirubin results can occur if ascorbic acid or increased nitrite concentrations are present in the urine because of UTIs. Also, with improper storage, bilirubin can be photo-oxidized to biliverdin when exposed to artificial light or sunlight, or it can be hydrolyzed to free bilirubin, resulting in false-negative results.

Cognitive Level: 3

Reference:

34. A quantitative assessment of the urobilinogen level is performed on which type of urine specimen?

A. 24-hour collection, because of diurnal variation

B. 2-hour collection obtained between 2 and 4 PM

C. 12-hour collection that started at 7 AM

D. Random specimen, because excretion is constant

ANS: B

Urobilinogen excretion is enhanced in an alkaline urine; therefore, the specimen of choice for quantitative assessment is a 2-hour collection after the midday meal, between 2 and 4 PM, which correlates with the "alkaline tide" observed in urine after meals.

Cognitive Level: 1

Reference:

35. The following MUA results were obtained on a specimen from a sexually active 20-year-old college student who was admitted to the hospital with anxiety, abdominal pain, muscle pain, tingling, numbness, weakness, excessive sweating, and slight disorientation.

Physical Examination Chemical Examination Microscopic Examination

Color: Red

Clarity: Slightly hazy Sp. Gr. 1.020

pH 6.5

Blood: Negative

Protein: Negative

LE: Negative

Nitrite: Negative

Glucose: Negative

Ketones: Small amount

Bilirubin: Negative

Urobilinogen: 1 EU

Ascorbic acid: Negative 0-2 WBCs

0-1 Squamous epithelial cells

The patient reported the onset of symptoms over the past few days and stated that she had not really eaten much of anything for a couple of days. She also reported that her urine had turned red. The next course of action would be to perform which test?

A. Watson-Schwartz test

B. Microalbumin test

C. Homogentisic acid test

D. sulfosalicy

ANS: A

The patient's symptoms, along with the red urine, negative blood result on the reagent strip, and negative blood result on the microscopic examination, correlate with acute porphyria. The Watson-Schwartz test screens for urine porphobilinogen, which is increased in the urine of patients with acute porphyria.

Cognitive Level: 3

Reference:

1. All of the following statements about urine specimen volume are true except:

A. The recommended volume for urinalysis is 12 mL for accurate results.

B. A pediatric volume of 6 mL requires doubling of sediment examination results.

C. Urine volumes less than 3 mL must be rejected as QNS (quantity not sufficient).

D. Variations in volume require notation in the specimen report.

ANS: C

In some cases the urine specimen may be 3 mL or less, such as with infants or patients with severe kidney disease who have oliguria and anuria. These specimens should not be rejected. Some laboratories perform the UA microscopic examination without concentration of the sediment. A notation must always accompany the report documenting that the microscopic examination was performed on a volume less than that routinely required.

Cognitive Level: 1

Reference:

2. Which urine specimen should be rejected?

A. 1 mL specimen from a newborn

B. 4 mL specimen from an adult with a renal condition

C. 12 mL specimen with a small amount of fecal matter

D. 20 mL specimen from a catheterization bag

ANS: C

Urine specimens containing fecal matter are typically rejected and a new specimen is requested. Volumes less than 12 mL (i.e., newborn, patient with a renal condition) are accepted, and the UA microscopic examination is performed without concentration of the sediment. A notation must always accompany the report documenting that the microscopic examination was performed on a volume less than that routinely required.

Cognitive Level: 2

Reference:

3. Centrifugation requirements for urine sediment preparation are:

A. 300 g for 15 minutes

B. 350 g for 10 minutes

C. 400 g for 3 minutes

D. 450 g for 5 minutes

ANS: D

Centrifugation requirements for urine sediment preparation are 400 to 450 g for 5 minutes. The speed is relative to centrifugal force (RCF, g), because the term is not centrifuge dependent. The speed in revolutions per minute (RPM) required to obtain 400 to 450 g is centrifuge dependent (i.e., rotor size).

Cognitive Level: 1

Reference:

4. The stain most commonly used to enhance visualization of urine sediment is:

A. Hansel stain

B. Sudan III

C. Prussian blue

D. Sternheimer-Malbin

ANS: D

Visualization of urine sediment is enhanced with Sternheimer-Malbin stain, a supravital stain consisting of crystal-violet and safranin. Another supravital stain for UA sediment is 0.5% solution of toluidine blue.

Cognitive Level: 1

Reference:

5. The microscopy technique that provides more detailed visualization of translucent or low-refractile components and living cells is:

A. Polarizing microscopy

B. Brightfield microscopy

C. Phase-contrast microscopy

D. Interference contrast microscopy

ANS: C

Phase-contrast microscopy is ideal for visualizing urine sediment. It permits more detailed visualization of translucent or low-refractile components and living cells.

Cognitive Level: 1

Reference

6. In a hypotonic urine, RBCs have what type of appearance?

A. Crenated

B. Ghost cell

C. Acanthocyte

D. Biconcave

ANS: B

Hypotonic urine causes the movement of water into the RBCs, resulting in lysis or the appearance of ghost cells. Ghost cells are RBCs that released their hemoglobin as they swelled while retaining an intact cell membrane. The empty cells appear as colorless, empty circles.

Cognitive Level: 2

Reference:

7. The technician evaluates the following urinalysis results and notes a discrepancy between the reagent test and the microscopic examination for blood:

Physical Examination Chemical Examination Microscopic Examination

Color: Reddish-brown

Clarity: Cloudy Sp. Gr. 1.025

pH 6.5

Blood: Trace

Protein: Negative

LE: Positive

Nitrite: Negative

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: 1.0 EU 20-30 WBCs

15-20 RBCs

The most likely cause of this discrepancy is:

A. High specific gravity

B. Strong oxidizing agents

C. Ascorbic acid

D. Microbial peroxidases

ANS: C

The cloudy, reddish-brown urine color correlates with the presence of RBCs in the microscopic examination. The reagent strip result is most likely a false-negative result due to the presence of ascorbic acid. To confirm this, a reagent strip test for ascorbic acid would need to be performed. Strong oxidizing agents and microbial peroxidases would cause a false-positive result.

Cognitive Level: 1

Reference:

8. The technician is having a difficult time identifying cellular elements that look like RBCs but for which the reagent test pad was negative, as was the test for ascorbic acid. The technician decides to add a drop of Sternheimer-Malbin stain, which will differentiate:

A. Calcium oxalate crystals from yeast

B. Yeast from RBCs

C. RBCs from calcium oxalate crystals

D. A and B

E. B and C

ANS: E

Sternheimer-Malbin stain, when added to urine sediment, characteristically colors RBCs but does not stain yeasts or calcium oxalate; this allows for differentiation of RBCs.

Cognitive Level: 1

Reference:

9. The laboratory receives a random urine specimen obtained from a 17-year-old female teenager, who needs the UA as part of her sports physical examination. The test results are:

Physical Examination Chemical Examination Microscopic Examination

Color: Reddish-brown

Clarity: Cloudy Sp. Gr. 1.020

pH 7.0

Blood: Moderate

Protein: Negative

LE: Negative

Nitrite: Negative

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: 1.0 EU 2-4 WBCs

15-20 RBCs

Which of the following explains these results?

A. Glomerulonephritis

B. Urinary tract infection

C. Menstrual contamination

D. Allergic drug reaction

ANS: C

Given the patient's age and gender and the fact that the UA is for a sports physical examination, the blood detected in the urine most likely is due to menstruation. If the patient had glomerulonephritis, RBC casts would be present. A UTI would be indicated by positive results for nitrites and the presence of bacteria, as well as increased WBCs. An allergic drug reaction may present with acute interstitial nephritis (AIN), depending on the drug reaction. Eosinophiluria and eosinophilic casts would be present if the patient had AIN associated with drug hypersensitivity.

Cognitive Level: 3

Reference:

10. A 32-year-old woman presents to the ED with fever, oliguria, hematuria, and a rash. She reports that she has a sinus infection and is currently taking penicillin. The physician suspects that the patient has acute interstitial nephritis (AIN); she therefore orders which tests to be performed on the patient's urine specimen?

A. Eosinophil count using Hansel stain

B. Total WBC count using acetic acid

C. Lymphocyte count using Giemsa stain

D. RBC count on 10 random fields

ANS: A

Urine sediment in AIN reveals eosinophils and eosinophil casts. Hansel stain is preferred over Wright's stain or Giemsa stain for distinguishing eosinophils in urine.

Cognitive Level: 3

Reference:

11. A 45-year-old patient who received a kidney transplant 2 months ago presents to the ED with a temperature of 100 F, chills, aches, headache, dizziness, oliguria, and a weight gain of 6 lb since yesterday. The technician notes that the predominant WBC in the microscopic examination is:

A. Eosinophils

B. Neutrophils

C. Glitter cells

D. Lymphocytes

ANS: D

Lymphocytes are the predominate WBC in urine sediment with renal allograft rejection. Eosinophils predominate in AIN. Neutrophils predominate in UTIs, pyelonephritis, and other conditions. The term glitter cell describes the appearance of large, swollen WBCs in hypotonic urine.

Cognitive Level: 3

Reference:

12. A technician performing a microscopic examination on a urine sediment is trying to determine whether he is looking at a large white cell or a renal tubular cell. He reports 2 to 4 renal tubular cells based on which criterion?

A. The cell is spherical.

B. The cell has refractile inclusions.

C. The cell is polygonal with one flat edge.

D. The cell has a flagstone appearance.

ANS: C

Renal tubular epithelial cells have dense nuclei and are polygonal with at least one flat side. WBCs are spherical. Squamous epithelial cells have a flagstone shape.

Cognitive Level: 2

Reference:

13. Cells found in urine sediment that contain highly refractile droplets are:

A. Glitter cells

B. Ghost cells

C. Oval fat bodies

D. Clue cells

ANS: C

Cells containing many large, highly refractile droplets or glistening granules are called oval fat bodies. Glitter cells are swollen WBCs; ghost cells are RBCs that have released their hemoglobin but retain the cell membrane in hypotonic urine; and clue cells are squamous epithelial cells with bacteria adhering to the edges and beyond in bacterial vaginosis.

Cognitive Level: 1

Reference:

14. The presence of which type of cell indicates vaginal contamination in a random urine specimen or an improperly collected midstream clean catch urine specimen?

A. Clue cell

B. Glitter cell

C. Columnar cell

D. Squamous cell

ANS: D

Squamous epithelial cells line the entire urethra and vagina in the female and the distal portion of the urethra in males. In specimens from females, the presence of large numbers of squamous epithelial cells in the urine sediment indicates vaginal or perineal contamination. In specimens from uncircumcised males, large numbers of squamous epithelial cells also suggest urine contamination.

Cognitive Level: 2

Reference:

15. An 80-year-old woman is admitted to the hospital with disorientation, a temperature of 102 F, cough, congestion, and a preliminary diagnosis of pneumonia. She is catheterized, and a urine specimen is sent down for UA. The technician notes sheets of transitional epithelial cells in the urine sediment. The presence of these cells is most likely due to:

A. An iatrogenic process

B. Transitional cell carcinoma

C. Renal tubular disease

D. Normal desquamation

ANS: A

Urinary catheterization or other types of instrumentation procedures can result in iatrogenic presentation of clusters or sheets of transitional epithelium in the urine sediment.

Cognitive Level: 2

Reference:

16. Healthy individuals may have which of the following in their urine, as a normal finding, after strenuous exercise?

A. WBC and RBC casts

B. Hyaline and finely granular casts

C. RBC and waxy casts

D. Nonpathologic pseudocasts

ANS: B

Strenuous physical exercise can result in increased excretion of casts, partly as a result of increased albuminuria caused by exercise-induced glomerular permeability changes; this does not indicate renal disease. As many as 30 to 50 hyaline or finely granular casts per low-power field may be seen. Within 24 to 48 hours, the proteinuria and casts disappear. WBC casts are seen with pyelonephritis; RBC casts are seen with glomerulonephritis; and waxy casts are seen with chronic renal failure.

Cognitive Level: 2

Reference:

17. Which type of cast indicates significant urinary stasis and a poor prognosis?

A. Broad, waxy casts

B. Coarsely granular casts

C. Hyaline casts

D. Bilirubin casts

ANS: A

Broad casts indicate cast formation in the dilated tubules or large collecting ducts; this type of case is indicative of significant urinary stasis caused by obstruction or disease (e.g., chronic renal diseases). It also indicates a poor prognosis. Coarsely granular casts result from degeneration of tubular cells, which releases intracellular components into the tubular lumen; the coarsely granular casts then become embedded in a cast, or they result from the degeneration of cellular casts. Hyaline casts are simply solidified uromodulin, and the presence of a few is considered normal. Bilirubin casts are composed of a hyaline matrix and bilirubin pigment.

Cognitive Level: 1

Reference:

18. A finding of increased numbers of casts and/or the presence of abnormal casts must be accompanied by a finding of:

A. Leukocyturia

B. Hematuria

C. Proteinuria

D. A and B

E. A, B, and C

ANS: C

The physical and chemical examination findings must correlate with the presence of casts in the urine sediment. An increased number of casts must correlate with the presence of proteinuria. However, proteinuria can occur without the presence of casts.

Cognitive Level: 2

Reference:

19. A 45-year-old woman is seen in the clinic for her annual physical examination. Her general health is good, she is taking no medications, and she notes no physical complaints other than that her weight is creeping up and she has little time for exercise. A new technician, fresh out of college, performs the UA. She then asks another technician to double-check her results, because the chemical analysis does not correlate with the microscopic examination. A repeat UA confirms the chemical analysis results. A repeat microscopic examination is performed as well:

Physical Examination Chemical Examination Microscopic Examination

Color: Amber

Clarity: Slightly hazy Sp. Gr. 1.025

pH 6.5

Blood: Negative

Protein: Negative

LE: Negative

Nitrite: Negative

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: 1.0 EU 2-4 WBCs

0-2 RBCs

20-30 Hyaline casts

Repeat microscopic:

2-4 WBCs

0-2 RBCs

No casts were repo

ANS: A

Casts must be accompanied by protein. The protein test result was negative, so the first report of casts was the result of misidentification. Mucous threads can be misidentified by novice microscopists as hyaline casts. Mucous threads have a low refractive index, as do hyaline casts, but they appear ribbonlike and the ends are serrated, not rounded.

Cognitive Level: 3

Reference:

20. A 50-year-old female is admitted to the hospital. She states that she has not been feeling well for the past week and that she started running a fever several days ago. Examination and testing reveal bacterial endocarditis and renal insufficiency. The UA results are:

Physical Examination Chemical Examination Microscopic Examination

Color: Reddish

Clarity: Cloudy Sp. Gr. 1.010

pH 5.0

Blood: Moderate

Protein: Trace

LE: Negative

Nitrite: Negative

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: Normal 2-4 WBCs

30-60 RBCs

Casts/lpf:

0-2 Hyaline

1-3 RBC

3-5 RBCs

0-2 Granular

Based on these results, what is the most likely renal diagnosis secondary to bacterial endocarditis?

A. Glomerulonephritis

B. Urinary tract infection

C. Renal tubular disease

D. Pyelonephritis

ANS: A

Bacterial endocarditis is associated with glomerulonephritis. RBC casts are diagnostic of intrinsic renal disease with the RBCs being of glomerular origin. Thus, RBCs in the presence of RBC casts is indicative of glomerulonephritis. Pyelonephritis is indicated by WBCs and WBC casts. Renal tubular disease would exhibit RTE casts. UTIs would evidence WBCs, possibly some RBCs, and bacterial. Casts are typically not present in UTIs.

Cognitive Level: 3

Reference:

21. As the technician is scanning for casts, she notes several hyaline-looking casts with a few yellowish cells that appear to be embedded in the matrix. She also notes several muddy brown casts. After closer inspection, the technician reports out which of the following?

A. Bilirubin cast

B. Renal epithelial cast

C. RBC cast

D. WBC cast

ANS: C

RBC casts may appear to resemble hyaline casts but have a few clearly defined RBCs embedded in their matrix. In unstained urine sediments, a yellow or red-brown color indicates degenerating of the RBCs with hemoglobin oxidation. RBC casts can degenerate into pigmented, granular casts referred to as blood cases or muddy brown casts. WBC casts are easily identified by the refractility of the WBCs embedded in the matrix. Renal epithelia casts become damaged and may under degenerative changes making identification difficult; size is similar to WBCs and may require enhanced visualization with stains or other microscopy techniques. Bilirubin colors all urine sediment constituents and casts appear yellow or golden-brown in color.

Cognitive Level: 3

Reference:

22. A 45-year-old man with polycystic disease is admitted to the hospital. The technician scans for casts and notes very large, colorless, hyaline-like casts that appear to have sharp, well-defined edges, some lateral fissures, and uneven ends. She checks the UA chemical analysis:

Physical Examination Chemical Examination

Color: Reddish pink

Clarity: Cloudy Sp. Gr. 1.010

pH 5.0

Blood: Small

Protein: 2000 mg/dL

LE: Negative

Nitrite: Negative

Glucose: 250 mg/dL

Ketones: Negative

Bilirubin: Negative

Urobilinogen: Normal

The technician concludes that what she saw were:

A. Cotton fibers

B. Broad, waxy casts

C. Mucous threads

D. Degenerate casts

ANS: B

Broad waxy casts have a high refractive index with well-defined edges and sharp, blunt, or uneven ends. Cracks or fissures may be present form the lateral margins or along the axes. High level of protein in the urine correlates with the presence of casts. Polycystic kidney disease is a hereditary disease that leads to the formation of cysts on the kidney causing the kidneys to swell and disrupts normal kidney function. Cotton fibers resemble waxy casts but they tend to be flatter in the middle and thicker at their margins whereas casts are thicker in the middle. Mucous threads may be misidentified as hyaline casts but they have serrated ends versus rounded ends. They are irregular, whereas hyaline casts are more formed.

Cognitive Level: 3

Reference:

23. A 36-year-old female presents to the ED with shaking, chills, fever, and nausea, as well as abdominal, flank, and low and mid-back pain. A CAT scan and UA are ordered, along with other blood work. The CAT scan shows numerous kidney stones in the renal pelvis. The UA results reveal pathologic changes:

Physical Examination Chemical Examination Microscopic Examination

Color: Amber

Clarity: Cloudy Sp. Gr. 1.025

pH 7.0

Blood: Trace

Protein: 100 mg/dL

LE: Negative

Nitrite: Positive

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: Normal 30-50 WBCs, clumps

5-10 RBCs

Casts/lpf:

0-2 Hyaline

3-5 WBC

0-2 Granular

Bacteria 2+

The patient is most likely suffering from which of the following?

1. Kidney stone

2. Urinary tract infection

3. Pyelonephritis

4. Renal failure

5. Glomerulonephritis

A. Only 1 is correct

B. 3 is correct

C. 1, 3 and 5 are correct

D. 1, 2 and 5 are correct

E. 1, 4 and 5 are corr

ANS: B

The obstruction of urine flow by the presence of kidney stones increases the chances for the development of pyelonephritis. The kidney stones are confined to the renal pelvis so the UA results are not indicative of a stone moving down the ureter. The presence of a large number of WBCs along with WBC casts, and bacteria further indicates pyelonephritis. In the absence of WBCs, a UTI would most likely be the diagnosis.

Cognitive Level: 3

Reference:

24. A urine crystal that is not considered clinically significant is:

A. Cystine

B. Cholesterol

C. Tyrosine

D. Leucine

ANS: B

Clinically significant urine crystals include cystine, tyrosine, and leucine

Cognitive Level: 1

Reference:

25. Which type of crystal is found in an acetic urine?

A. Calcium oxalate

B. Amorphous phosphates

C. Triple phosphates

D. Ammonium biurate

ANS: A

Crystals that may be present in acid urine include calcium oxalate, bilirubin, cholesterol, cystine, and hemosiderin.

Cognitive Level: 4

Reference:

26. Iatrogenic crystals include which of the following?

A. Tyrosine

B. Leucine

C. Cystine

D. Sulfonamides

E. A, B, and C

ANS: D

Iatrogenic crystals are induced in a patient as a result of a treatment i.e., a prescribed drug. Of the choices, only sulfonamides are a drug. Tyrosine, leucine, and cystine are clinically significant crystals resulting from metabolic disorders.

Cognitive Level: 1

Reference:

27. The presence of ammonium biurate crystals in a fresh urine specimen must be investigated to determine whether:

A. The patient has a metabolic condition arising from a genetic defect.

B. The urine was improperly stored before delivery to the laboratory.

C. The crystals are the result of iatrogenically induced alkalinization.

D. A and B

E. B and C

ANS: E

Ammonium biurate crystals are a normal urine solute occurring most frequently in urines that have undergone prolonged storage. However, when they precipitate out of fresh urine they are clinically significant because in vivo precipitation can cause renal tubular damage. Their presence indicates inadequate hydration of the patient. Investigation must be done to determine if the specimen has been compromised due to improper storage or if in vivo formation is taking place.

Cognitive Level: 1

Reference:

28. The technician reports the following results on a routine UA for an 89-year-old female being given her annual physical examination:

Physical Examination Chemical Examination Microscopic Examination

Color: Pale yellow

Clarity: Hazy

Sp. Gr. 1.010

pH 7.0

Blood: Negative

Protein: Negative

LE: Negative

Nitrite: Positive

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: 1.0 IU

Ascorbic acid: Negative 0-3 WBCs

0-2 RBCs

Many bacteria/hpf

Casts: 0-1 hyaline/lpf

The patient collected a CCMS specimen on site at 2 PM, and the urine was tested at 3 PM. The results indicate which of the following?

A. Urinary tract infection with possible kidney involvement

B. Improper collection of the midstream clean catch specimen

C. Improper storage of the specimen between the time of collection and testing

D. False-negative reagent strip results because of overhydration of the patient

ANS: B

When significant bacteruria is present without leukocytes, the specimen collection and handling should be investigated. In this case, the elderly woman most likely had difficulty performing the cleansing procedure for a CCMS or she did not understand the instructions. It may be necessary to catheterize an elderly patient who is unable to perform the procedure properly.

Cognitive Level: 3

Reference:

29. While performing the microscopic examination of the urine of a 20-year-old college student, the technician notes flagellar movement on several large cells with undulating membranes. She reports:

A. Enterobius vermicularis

B. Schistosoma haematobium

C. Trichomonas vaginalis

D. Torulopsis glabrata

ANS: C

Trichomonads are protozoan flagellates that can be observed in the urine sediment. They appear as turnip-shaped flagellates with four anterior flagella, a single posterior axostyle, and an undulating membrane that extends halfway down the body of the organism. The beating flagella create a characteristic flitting or jerky motility in wet preparations. Trichomonas vaginalis is the most common cause of parasitic gynecological infections in female patients.

Cognitive Level: 1

Reference:

30. While examining a microscopic sediment specimen, the technician sees 1 to 3 squamous epithelial cells that appear soft and finely granular with shaggy edges. He reports:

A. Amorphous urates

B. 1 to 3 epithelial cells

C. Clue cells

D. Bacterial vaginosis

ANS: C

Squamous epithelial cells from vaginal mucosa with large numbers of bacteria adhering to them are called clue cells. The cells appear soft and finely granula with indistinct cell borders i.e., shaggy edges. To be considered a clue cell, the bacteria do not need to cover the entire cell; however, the bacterial organisms must extend beyond the cell's cytoplasmic borders. Clue cells are indicative of bacterial vaginosis a synergistic infection that most often involves Gardnerella vaginalis and Mobiluncus sp.

Cognitive Level: 2

Reference:

31. In a random urine sample from a 50-year-old woman, the technician notes large, free-floating, homogenous fat globules with no intracellular presence. The globules stain orange with Sudan III. The urinalysis results are unremarkable thus far:

Physical Examination Chemical Examination Microscopic Examination

Color: Amber

Clarity: Hazy

Sp. Gr. 1.025

pH 6.0

Blood: Negative

Protein: Negative

LE: Negative

Nitrite: Negative

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: Normal 3-5 WBCs

Bacteria: Few

Which of the following correctly describes what the technician has seen?

A. Triglycerides present

B. Specimen contaminated

C. Cholesterol present

D. Lipiduria

ANS: B

Lipiduria is always accompanied by some degree of proteinuria. The level of proteinuria in a random specimen can be disguised by hydration. However, the SG of the specimen indicates a concentration specimen so the negative protein reading is most likely correct. Other entities in the urine can resemble fact such as starch granules. Oils and fat from lubricants, ointments, creams, and lotions can also contaminate urine. Thus, in the absence of proteinuria in a concentrated urine specimen, the globule is most likely a contaminant.

Cognitive Level: 2

Reference:

32. A 60-year-old man diagnosed with paroxysmal nocturnal hemoglobinuria can tell from the color of his urine when he needs a transfusion. When the urine gets really dark and stays dark, he knows it is time for a transfusion. He drops off a random urine sample at the laboratory at 0730, indicating that he had collected it 30 minutes earlier.

Physical Examination Chemical Examination Microscopic Examination

Color: Brown

Clarity: Slightly hazy Sp. Gr. 1.025

pH 6.0

Blood: Large

Protein: Trace

LE: Negative

Nitrite: Negative

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Urobilinogen: Normal 0-3 WBCs

0-2 RBCs

The technician notes coarse, yellow-brown granules in the specimen. To distinguish them from amorphous granules, she performs which of the following?

A. Hansel stain

B. Prussian blue stain

C. Glacial acetic acid

D. Acetic acid

ANS: B

Hemosiderin granules can be found in urine sediment 2 to 3 days following a severe hemolytic episode such as a transfusion reaction or PNH. The Prussian blue reaction or Rous test is used to identify hemosiderin in urine sediment or in tissues.

Cognitive Level: 3

Reference:

1. Urochrome is a lipid-soluble pigment that:

A. Is excreted in urine, imparting the characteristic amber color

B. May be deposited in subcutaneous fat tissue in renal failure

C. Darkens on exposure to light

D. A and B

E. A, B, and C

ANS: E

The characteristic yellow color of normal urine is principally due to the pigment urochrome. A product of endogenous metabolism, urochrome is a lipid-soluble pigment present in plasma and excreted in urine. Patients in chronic renal failure, with a decreased excretion of urochrome, may exhibit a characteristic yellow pigmentation of their skin because of deposition of urochrome in their subcutaneous fat. Urochrome, like other lipid-soluble pigments, also darkens on exposure to light. This characteristic darkening is often observed in urine specimens that are improperly stored.

Cognitive Level: 1

Reference:

2. Urine color is derived from which of the following?

A. Urobilin

B. Urochrome

C. Uroerythrin

D. A, B, and C

ANS: D

The characteristic yellow color of normal urine is principally due to the pigment urochrome. Small amounts of urobilin (an orange-brown pigment) and uroerythrin (a pink pigment) also contribute to urine color. Urobilin and uroerythrin are normal urine constituents; uroerythrin is most evident when it deposits on urate crystals, producing a precipitate often described as brick dust.

Cognitive Level: 1

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3. Which factor contributes to urine color?

A. Added preservative

B. Urine pH

C. Collection method

D. Patient's age

ANS: B

Many substances are capable of modifying the normal color of urine. The same substance can impart a different color to urine depending on (1) the amount of the substance present, (2) the urine pH, and (3) the structural form of the substance, which can change over time.

Cognitive Level: 1

Reference:

4. Urine color may be indicative of which of the following?

A. Body hydration

B. Urine concentration

C. Pathologic disease

D. A and B

E. A, B, and C

ANS: E

Pale urine indicates fluid ingestion or polyuria due to diabetes insipidus or diabetes mellitus; dark urine indicates a limited fluid intake, dehydration, or a first morning specimen; a red color indicates blood, hemoglobin, or beet ingestion. Other colors also may be indicative of pathologic conditions or drug ingestion.

Cognitive Level: 2

Reference:

5. A reddish brown urine specimen is received in the laboratory. The technician most likely will expect which reagent strip results?

A. Acidic pH, positive blood

B. Neutral pH, negative blood

C. Alkaline pH, positive blood

D. Acidic pH, negative blood

ANS: C

Alkaline urine with RBCs present appears red-brown. The alkaline pH enhances RBC disintegration; this releases hemoglobin, which undergoes oxidation, resulting in the brownish appearance.

Cognitive Level: 2

Reference:

6. A fresh brown urine may indicate the presence of:

A. Urobilinogen

B. Bilirubin

C. Myoglobin

D. Melanin

ANS: C

A fresh brown urine indicates the presence of blood, hemoglobin, or myoglobin in the urine.

Cognitive Level: 1

Reference:

7. Oxidation of bilirubin to biliverdin in urine results in which of the following urine colors?

A. Blue

B. Green

C. Dark amber

D. Orange

ANS: B

If left standing or improperly stored, urine containing bilirubin may change from the characteristic yellow color to green because of the oxidation of bilirubin to biliverdin.

Cognitive Level: 1

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