A routine urinalysis is performed on a young child suffering from

diarrhea. The reagent test strip is negative for glucose but positive for
ketones. These results may be explained by which of the following
statements?
A. The child has Type 1 diabetes mellitus.
B. The child is suffering from lactic acidosis, and the lactic
acid has falsely reacted with the impregnated reagent area
for ketones.
C. The child is suffering from increased catabolism of fat
because of decreased intestinal absorption.
D. The reagent area for ketones was read after the maximum
reading time allowed.

Although a positive result on a urine test for ketones is most commonly

associated with increased urinary glucose levels, as in diabetes
mellitus, other conditions may cause the urine ketone test to show
positive results while the urine glucose test shows negative results. In
young children, a negative glucose reaction accompanied by a positive
ketone reaction is sometimes seen. Ketones in the urine may be seen
when a child is suffering from an acute febrile disease or toxic
condition that is accompanied by vomiting or diarrhea. In these cases,
because of either decreased food intake or decreased intestinal
absorption, fat catabolism is increased to such an extent that the
intermediary products, known as ketone bodies, are formed and
excreted in the urine
A reagent test strip impregnated with a diazonium salt such as
diazotized 2,4-dichloroaniline may be used to determine which
analyte?
A. Glucose
B. Ketone
C. Hemoglobin
D. Bilirubin

Bilirubin is a compound that is formed as a result of hemoglobin

breakdown. The majority of bilirubin in the blood is bound to
albumin and is known as unconjugated bilirubin. Because
unconjugated bilirubin is not water soluble, it may not be
excreted in the urine. The remainder of the bilirubin in the blood has
been processed by the liver. In the liver, the bilirubin is conjugated
with glucuronic acid or sulfuric acid. This conjugated bilirubin is
water soluble, and it is this portion that is excreted in increased
amounts in the urine in some hepatic and obstructive biliary tract
diseases. The presence of conjugated bilirubin in a urine specimen
may be detected by use of the reagent test strips.

The test strips are impregnated with a diazonium salt, such as

diazotized 2,4-dichloroaniline, which forms a purplish azobilirubin
compound with bilirubin.
Which of the following will contribute to a specimen's specific gravity if
it is present in a person's urine?
A. 50-100 RBC/hpf
B. 85 mg/dL glucose
C. 3+ amorphous phosphates
D. Moderate bacteria

Only dissolved solutes affect specific gravity (e.g., glucose).

Cells, mucus, crystals, or any other formed elements will have no
effect, regardless of concentration. If the reagent strip method is used,
it should be noted that only dissolved ions will contribute to specific
gravity results. Thus glucose would not affect reagent strip results at
any concentration. In such instances as diabetes mellitus, with urine
glucose levels over 2 g/dL, there may be a discrepancy between
specific gravity results obtained with a reagent strip method versus
using a refractometer, because such glucose levels are known to
increase refractometer results, thus requiring correction
A random urine is collected from a patient and the results obtained are
as follows: urine albumin =16 mg/dL and urine creatinine = 140 mg/dL.
These findings are consistent with:
A. Microalbuminuria
B. Macroalbuminuria
C. Nephrotic syndrome
D. Obstructive jaundice

The ratio of urine albumin to creatinine in a random specimen is

commonly used to evaluate microalbuminuria, especially in patients
with diabetes mellitus. This patient's ratio is 114 mg albumin per gram
creatinine. The American Diabetes Association defines
microalbuminuria as between 30 and 299 mg/g. Values greater
than 299 mg/g would be "macroalbuminuria." Nephrotic
syndrome is characterized by excretion of albumin in excess of 3.5
grams per day. Patients with obstructive jaundice will usually not
experience proteinuria.
A 40-year-old female patient with a history of kidney infection is seen
by her physician because she has felt lethargic for a few weeks. She
has decreased frequency of urination and a bloated feeling. Physical
examination shows periorbital swelling and general edema, including a
swollen abdomen. Significant urinalysis results show the following:
color = yellow; appearance = cloudy/frothy; specific gravity =
1.022;pH = 7.0; protein = 4+; 0-3 WBC/hpf; 0-1 RBC/hpf; 0-2 renal
epithelial cells/hpf; 10-20 hyaline casts/lpf; 0-1 granular casts/lpf; 0-1
fatty casts/lpf; occasional oval fat bodies. Her serum chemistries show
significantly decreased albumin, increased urea nitrogen, and
increased creatinine. These findings suggest which condition?
A. Multiple myeloma
B. Glomerulonephritis
C. Nephrotic syndrome
D. Chronic renal failure
E. COPD

Nephrotic syndrome is suggested by the increased urine protein (with

serum albumin significantly decreased), the hyaline and fatty casts,
and the presence of oval fat bodies. The patient's symptoms of
periorbital swelling and edema reflect the loss of oncotic pressure
because of the excretion of albumin. Its loss from the vascular
compartment will induce plasma water movement into the tissue
spaces. Glomerulonephritis will have many more red blood cells,
including red blood cell casts. Multiple myeloma will not show
increased urine albumin but rather immunoglobulin light chains.
Chronic renal failure will have multiple types of casts present (hyaline,
granular, cellular, waxy, fatty).
Alkaptonuria, a rare hereditary disease, is characterized by the urinary
excretion of:
A. Alkaptone
B. Phenylalanine
C. 5-Hydroxyindole acetic acid
D. Homogentisic acid

Alkaptonuria is a rare hereditary disease that is characterized by

excessive urinary excretion of homogentisic acid. This acid, the
product of phenylalanine and tyrosine metabolism, accumulates
in urine because of a deficiency in the enzyme homogentisic acid
oxidase, which normally catalyzes the oxidation of homogentisic acid
to maleyl acetoacetic acid. Urine containing homogentisic acid turns
black on standing because of an oxidative process; thus the screening
test for alkaptonuria consists of the detection of a black coloration in
urine that is left standing at room temperature for 24 hours
 Some clinical conditions are characterized by unique urinalysis
result patterns. Which of the following shows such a
relationship?
A. Nephrotic syndrome: positive protein on reagent strip,
negative protein with sulfosalicylic acid
B. Intensive dieting: increased ketones, negative glucose
C. Multiple myeloma: positive protein by both reagent strip
and sulfosalicylic acid
D. Cystitis: positive nitrite and protein

Because of increased lipid metabolism in long-term, intensive

dieting, ketone body formation will increase. Blood glucose levels in
such patients will be normal or decreased. In nephrotic syndrome,
the large amounts of albumin excreted will be detectable by both
reagent strip and SSA methods. In multiple myeloma, however, the
increased globulin light chains (Bence Jones proteins) excreted will
only be detectable by SSA because the reagent strip is more
sensitive to albumin. Cystitis is a lower urinary tract infection
affecting the bladder but not the kidney itself.
 Phenylketonuria may be characterized by which of the following
statements?
A. It may cause brain damage if untreated.
B. It is caused by the absence of the enzyme,
phenylalanine oxidase.
C. Phenylpyruvic acid excess appears in the blood.
D. Excess tyrosine accumulates in the blood.

Phenylketonuria is inherited as an autosomal recessive trait that

manifests itself in the homozygous form. The basis for the disease lies
in the fact that the enzyme phenylalanine hydroxylase, which is
needed for the conversion of phenylalanine to tyrosine, is absent.
Because of this enzyme deficiency, phenylalanine levels rise in the
blood, with increased amounts of phenylpyruvic acid and other
derivatives being excreted in the urine. If the disease is detected at an
early stage, mental retardation may be avoided by restricting the
dietary intake of phenylalanine
Which of the following is true about the final concentrating of urine in
the kidney?
A. The distal convoluted tubule, through active transport,
reabsorbs water.
B. Water is reabsorbed under the direct influence of
angiotensin II.
C. Vasopressin controls the collecting duct reabsorption of
water.
D. Water reabsorption is influenced by urine filtrate levels
of potassium.

The distal convoluted tubule and collecting duct provide water

reabsorption through the action of antidiuretic hormone (vasopressin).
The renin-angiotensin-aldosterone system is responsible for sodium
reabsorption by the distal and collecting tubules. Decreased plasma
volume leads to pressure alterations detected by receptors located in
the kidney's juxtaglomerular apparatus and the right atrium of the
heart. These changes trigger the production of renin and antidiuretic
hormone, respectively
Which statement regarding urine pH is true?
A. High-protein diets promote an alkaline urine pH
B. pH tends to decrease as urine is stored
C. Contamination should be suspected if urine pH is less than
4.5
D. Bacteriuria is most often associated with a low urine pH
E. None of the Above

Bacteriuria is usually associated with an alkaline pH caused by the

production of ammonia from urea. Extended storage may result in loss
of volatile acids, causing increased pH. A high-protein diet promotes
excretion of inorganic acids. The tubular maximum for H+ secretion
occurs when urine pH reaches 4.5, the lowest urinary pH that the
kidneys can produce
Which of the following is likely to result in a false-negative dry reagent
strip test for proteinuria?
A. Penicillin
B. Aspirin
C. Amorphous phosphates
D. Bence–Jones protein
E. All of the Above

Dry reagent strip tests using tetrabromophenol blue or

tetrachlorophenol tetrabromosulfophthalein are poorly sensitive to
globulins and may not detect immunoglobulin light chains.
Turbidimetric methods such as 3% SSA will often detect Bence–Jones
protein but may give a false-positive reaction with penicillin,
tolbutamide, salicylates, and x-ray contrast dyes containing iodine.
Amorphous phosphates may precipitate in refrigerated urine, making
interpretation of turbidimetric tests difficult
 The following are renal-associated clinical picture, except:
A. Advanced renal disease
B. Fanconi syndrome
C. Cushing syndrome
D. Osteomalacia

Cushing syndrome is hyperglycemia associated disease. All are

significant for glucose. Advanced renal disease, Fanconi syndrome and
osteomalacia are all renal-associated.
In the reagent strip method, nitrite reacts with an aromatic amine to
form a diazonium salt, which then reacts with a dye to produce a pink
product. It is also used as for the evaluation of UTI, and antibiotic
therapy:
A. Urobilinogen
B. Nitrite
C. Blood
D. Leukocyte Esterase
E. All of the Above

Reagent strip detects the ability of certain bacteria to reduce nitrate

(found in urine normally) to nitrite (abnormal in urine).
 A characteristic of substances normally found dissolved in the
urine is that they are all
A. Water soluble
B. Inorganic
C. Organic
D. Waste product
E. All of the Above

To be found in urine, a solute must be water soluble. Solutes can be

inorganic (e.g., sodium) or organic (e.g., urea). Excreted waste
products, meaning end products of metabolism, are creatinine, urea,
and uric acid. Some excreted solutes, however, are not present as
waste but as overload, such as glucose or sodium
All are true with abnormal crystals, except:
A. Cystine crystal appearance is hexagonal and colorless, it is
associated with cystinuria
B. Cholesterol crystals has notched plates and colorless, it is
associated with nephrotic syndrome
C. Tyrosine crystal appearance is in needles and colorless, it is
associated with infection treatment
D. Leucine crystal has concentric circles, it is associated with
liver disease

Tyrosine is associated with liver disease, not infection treatment.

Infection treatment is associated with ampicillin crystals which are
needles in appearance and are colorless
The presence of renal tubular epithelial cells and casts is an indication
of:
A. Acute interstitial nephritis
B. Chronic glomerulonephritis
C. Minimal change disease
D. Acute tubular necrosis
E. All of the Above

Acute interstitial nephritis – WBC casts present, Inflammation of the

renal interstitium and tubules frequently caused by a reaction to a
Medication.
Chronic glomerulonephritis – finding of blood, protein, and casts in the
urine. Clinical chemistry: markedly decreased glomerular filtration rate
is present in conjunction with increased BUN and creatinine levels and
electrolyte imbalance
Minimal change disease -also known as lipid nephrosis). produces little
cellular change in the Glomerulus - Heavy proteinuria, Transient
hematuria, Fat droplets
Acute tubular necrosis - RTE cells containing large, nonlipid-filled
vacuoles may be seen along with normal renal tubular cells and oval
fat bodies
Which of the following statements regarding urinary casts is correct?
A. Fine granular casts are more significant than coarse
granular casts
B. Cylindruria is always clinically significant
C. The appearance of cylindroids signals the onset of end-
stage renal disease
D. Broad casts are associated with severe renal tubular
obstruction

There is no clinical difference between fine and coarse granular casts.

Granular casts may form by degeneration of cellular casts, but some
show no evidence of cellular origin. Granular casts may form from
inclusion of urinary calculi, but some are of unknown etiology.
Cylindruria refers to the presence of casts in the urine. Hyaline casts
may be seen in small numbers in normal patients and in large numbers
following strenuous exercise and long-distance running. Hyaline casts
may also be increased in patients taking certain drugs such as
diuretics. Broad casts form in dilated or distal tubules and indicate
severe tubular obstruction seen in chronic renal failure. Waxy casts
form when there is prolonged stasis in the tubules and signal end-
stage renal failure. Cylindroids are casts with tails and have no special
clinical significance.
Urine of constant SG ranging from 1.008 to 1.010 most likely indicates:
A. Addison’s disease
B. Renal tubular failure
C. Prerenal failure
D. Diabetes insipidus
The SG of the filtrate in Bowman’s space is approximately 1.010. Urine
produced consistently with a SG of 1.010 has the same osmolality of
the plasma and results from failure of the tubules to modify the filtrate.
Which statement regarding CSF is true?
A. Normal values for mononuclear cells are higher for infants
than adults
B. Absolute neutrophilia is not significant if the total WBC
count is less than 25/μL
C. The first aliquot of CSF should be sent to the microbiology
laboratory
D. Neutrophils compose the majority of WBCs in normal CSF
E. A and B

A. Lymphocytes account for 40%–80% of WBCs in adults; monocytes

and macrophages for 20%–50%. Neutrophils should be less
than 10% of the WBCs.

The reference range for WBCs in adults is 0–5/μL. Disease may be

present when the WBC count is normal, if the majority of WBCs are
PMNs. In infants, monocytes account for 50%–90% of WBCs, and the
upper limit for WBCs is 30/μL. The first aliquot is sent to the chemistry
department because it may be contaminated with blood or skin flora.
SITUATION: What is the most likely cause of the following CSF results?
CSF glucose 20 mg/dL
CSF protein 200 mg/dL
CSF lactate 50 mg/dL (reference range 5–25 mg/dL)

A. Viral meningitis
B. Viral encephalitis
C. Cryptococcal meningitis
D. Acute bacterial meningitis
E. All of the Above

Acute bacterial meningitis causes increased production of

immunoglobulins in CSF. Glucose levels are below normal (35 mg/dL
being correlated with bacterial meningitis). When associated with
increased PMNs and LD, these findings point to bacterial meningitis
Which of the following conditions is most often associated with normal
CSF glucose and protein?
A. Multiple sclerosis
B. Malignancy
C. Subarachnoid hemorrhage
D. Viral meningitis

In viral (aseptic) meningitis, the CSF glucose is usually above 40 mg/dL

and the total protein is normal or slightly increased. Some types of
viral meningitis can cause a low glucose, which makes the
differentiation of bacterial and viral meningitis difficult.

Low CSF glucose and elevated total protein are also seen in
malignancy, subarachnoid hemorrhage, and some persons with
multiple sclerosis. Low glucose in malignancy and multiple sclerosis
results from increased utilization. Glucose is reduced in subarachnoid
hemorrhage due to release of glycolytic enzymes from RBCs. All three
conditions result in high CSF protein, but multiple sclerosis is
associated with an increased IgG index owing to local production of
IgG.
All sentences are correct, except:
A. CSF that is clear and colorless is normal
B. Cloudy: Indicates WBCs, RBCs, protein, or bacteria; seen in
meningitis, hemorrhage, disorders of the blood-brain
barrier, etc.
C. Xanthochromic (yellow): Increased hemoglobin, bilirubin,
protein, immature liver in premature infants
D. In chemistry testing, CSF glucose levels are increased in
bacterial meningitis and fungal infections

CSF glucose is in equilibrium with plasma glucose. Normal values in the

CSF range from 50 to 80 mg/dL or approximately 60% of plasma
glucose levels. Levels are decreased in bacterial meningitis and fungal
infections. Levels are increased in hyperglycemia and in cases of a
traumatic tap.
The following normal values are correct, except:
A. Volume: 2-5mL, pH: 7.2-8.0 is normal
B. Viscosity: Normal is no clumps or strings; must have
specimen that is completely liquefied, which takes about
30-60 minutes.
C. Appearance: Normal is a translucent, gray-white color.
D. None of the above.

- All sentences are correct.