, CHAPTER LIST
Part I: Basic Hematology Principles
Chapter 1: Introduction to Hematology and Basic Laboratory Practice
Chapter 2: From Hematopoiesis to the Complete Blood Count
Chapter 3: Red Blood Cell Production, Function, and Relevant Red Blood Cell Morphology
Chapter 4: Hemoglobin Function and Principles of Hemolysis
Part II: Red Blood Cell Disorders
Chapter 5: The Microcytic Anemias
Chapter 6: The Macrocytic Anemias
Chapter 7: Normochromic Anemias: Biochemical, Membrane, and Miscellaneous Red
Blood Cell Disorders
Chapter 8: The Normochromic Anemias Caused by Hemoglobinopathies
Part III: White Blood Cell Disorders
Chapter 9: Leukopoiesis, Wbc Differential, and Lymphocyte Function
Chapter 10: Abnormalities of White Blood Cells: Quantitative, Qualitative, and the Lipid
Storage Diseases
Chapter 11: Acute Leukemias
Chapter 12: Myeloproliferative Neoplasms
Chapter 13: Lymphoproliferative Disorders and Related Plasma Cell Disorders
Chapter 14: The Myelodysplastic Syndromes
Part IV: Hemostasis and Disorders of Coagulation
Chapter 15: Overview of Hemostasis and Platelet Physiology
Chapter 16: Quantitative and Qualitative Platelet Disorders
Chapter 17: Defects of Plasma Clotting Factors
Chapter 18: Fibrinogen, Thrombin, and the Fibrinolytic System
Chapter 19: Introduction to Thrombosis and Anticoagulant Therapy
Part V: Hematology Automation, Flow Cell Cytometry, and
Laboratory Procedures
Chapter 20: Hematology Automation and Flow Cell Cytometry
Chapter 21: Basic Procedures in a Hematology Laboratory
,Test Bank: Hematology in Practice, 4th Edition
(Betty Ciesla)
Chapter 1: Introduction to Hematology and Basic Laboratory
Practice
1. What is the primary function of the aperture diaphragm in a brightfield light
microscope?
A. To control the contrast and angle of light striking the specimen
B. To raise or lower the condenser lens height
C. To adjust the total magnification power of the objective lens
D. To compensate for refractive index differences in oil immersion
Answer: A
Rationale: The aperture diaphragm (condenser diaphragm) controls the angular aperture
and amount of light passing through the condenser, directly regulating contrast, resolution,
and depth of field during microscopic observation.
2. Name the term used to describe a sudden, persistent shift in Quality Control (QC) data
points that fall consistently on one side of the mean line on a Levey-Jennings chart.
Answer: Shift
Rationale: A shift is defined in quality control as a sudden and sustained change in the mean
of the control values, usually indicating an abrupt systemic failure such as a new lot of
reagent, light source degradation, or recalibration error.
3. What is the standard anticoagulant-to-blood ratio required for sodium citrate tubes
used in routine coagulation testing?
Answer: 1:9
Rationale: Sodium citrate tubes require an exact ratio of 1 part 3.2% sodium citrate
anticoagulant to 9 parts whole blood (or 1:9 ratio) to prevent artificial prolongation of
clotting times due to excess free anticoagulant.
,4. Which Westgard rule is violated when a single control measurement exceeds the mean
by more than three standard deviations?
Answer: 1_3s
Rationale: The 1_3s Westgard rule is a rejection rule triggered when one control result
exceeds the mean +/- 3 standard deviations, serving primarily as an indicator of random
error or severe systemic error.
5. What term refers to a preanalytic laboratory check that automatically compares a
patient's current test result with their previous recent test results?
Answer: Delta check
Rationale: A delta check compares a patient's present laboratory result with a previously
determined result. Significant unexpected variations signal potential preanalytic errors such
as patient misidentification, IV contamination, or sample mislabeling.
6. A hematology analyzer measures a control sample 10 times, obtaining a mean
Hemoglobin value of 14.0 g/dL and a standard deviation (SD) of 0.28 g/dL. Calculate the
coefficient of variation (CV%) for this control assay.
Answer: 2.0%
Rationale: The formula for coefficient of variation is CV% = (Standard Deviation / Mean) x
100. Substituting the given values: CV% = (0.28 g/dL / 14.0 g/dL) x 100 = 0.02 x 100 = 2.0%.
7. A laboratory establishes a normal reference interval for Platelet count using a Gaussian
distribution of healthy donors. The mean platelet count is 260 x 10^3/uL with a standard
deviation of 45 x 10^3/uL. Calculate the 95.5% central reference interval (Mean +/- 2 SD)
for this population.
Answer: 170 to 350 x 10^3/uL
Rationale: The 95.5% confidence/reference range under a normal Gaussian distribution
spans from (Mean - 2 SD) to (Mean + 2 SD). Lower limit = 260 - (2 x 45) = 260 - 90 = 170 x
10^3/uL. Upper limit = 260 + (2 x 45) = 260 + 90 = 350 x 10^3/uL.
8. A phlebotomist collects blood into a 3.2% sodium citrate tube from a patient with a
severe polycythemia whose hematocrit is 65%. Given the total blood volume in a standard
full tube is 4.5 mL (consisting of 0.5 mL anticoagulant and 4.0 mL whole blood), calculate
the corrected amount of sodium citrate anticoagulant required for this tube volume using
,the formula: C = (0.0018) x (100 - Hct) x V, where V is whole blood volume in mL.
Answer: 0.25 mL
Rationale: The formula for corrected anticoagulant volume is C = (0.0018) x (100 - Hct) x V.
Inserting the values: C = (0.0018) x (100 - 65) x 4.0 mL = 0.0018 x 35 x 4.0 = 0.252 mL (rounds
to 0.25 mL).
9. During quality control validation, a automated cell counter run shows an observed WBC
count of 10.8 x 10^3/uL. The manufacturer's assigned target mean value for the control is
10.0 x 10^3/uL. Calculate the percent error of this measurement.
Answer: 8.0%
Rationale: Percent error is calculated as: |(Observed Value - Target Value) / Target Value| x
100. Substituting the given parameters: |(10.8 - 10.0) / 10.0| x 100 = (0..0) x 100 = 8.0%.
10. A medical laboratory scientist is performing a routine manual WBC differential on a
peripheral blood smear. Under the 100x oil immersion objective, the field of view appears
dark, blurry, and exhibits severe chromatic aberration despite adjusting the fine focus
knob. Upon inspection, the objective lens is clean. Which action is the most appropriate
troubleshooting step to re-establish Köhler illumination and image clarity?
A. Open the field iris diaphragm completely and lower the substage condenser to its lowest
position
B. Focus and center the condenser, adjust the field diaphragm, and verify the condenser is in
its uppermost position
C. Switch the light source transformer to maximum voltage and remove the blue daylight
filter
D. Replace the immersion oil with xylene solution to increase the refractive index of the slide
media
Answer: B
Rationale: Proper Köhler illumination requires the condenser to be raised nearly to its
highest point, centered using the condenser centering screws, and the field diaphragm
adjusted to match the field of view, ensuring bright, glare-free, and evenly distributed light.
11. A phlebotomist draws blood from an inpatient receiving a continuous IV infusion of
0.9% normal saline in the left arm. Due to difficult vein access, the phlebotomist draws the
EDTA tube directly above the IV site in the left arm. The automated complete blood count
,reveals a hemoglobin of 5.2 g/dL and a Hct of 15.6%, whereas the patient's baseline
yesterday was 13.5 g/dL. What is the most appropriate immediate action by the
laboratory analyst?
A. Reject the specimen due to suspected IV fluid hemodilution and request a repeat redraw
from the opposite arm
B. Immediately report the critical hemoglobin value of 5.2 g/dL to the attending physician
C. Run a duplicate automated count on the same tube to confirm instrument precision
D. Centrifuge the tube and perform a manual microhematocrit to verify the automated Hct
Answer: A
Rationale: Drawing blood proximal (above) an active IV line causes severe specimen
hemodilution with IV fluid, resulting in falsely decreased cell counts and hemoglobin
concentrations. The specimen must be rejected as preanalytically compromised and redrawn
from a valid site (opposite arm).
12. While reviewing automated daily QC for an automated platelet counter, the
technologist observes that Level 1 and Level 2 controls have drifted progressively higher
over the past 5 consecutive operational shifts, culminating in both controls exceeding +2
SD on day 5. No reagents were changed. What is the primary cause and appropriate
corrective action?
A. Sudden random electrical interference; re-run the same control vials immediately
B. Improper anticoagulant ratio in control vials; mix controls on a mechanical shaker for 1
hour
C. Systematic instrument drift or aperture buildup; perform aperture cleaning and recalibrate
D. Preanalytic hemolysis in control vials; discard controls and report patient results with a
disclaimer
Answer: C
Rationale: A progressive 5-day trend across multiple control levels indicates systemic error,
frequently caused by gradual aperture fouling/protein build-up or optical sensing
degradation. The instrument requires maintenance/cleaning and recalibration before running
patient samples.
13. An outpatient clinic sends a lavender-top (EDTA) tube for routine CBC. Upon opening
the tube to prepare a blood smear, the technologist notes several small fibrin microclots
adhering to the applicator stick. The automated analyzer generates a WBC count of 7.2 x
, 10^3/uL and a platelet count of 42 x 10^3/uL. How should the technologist handle this
specimen?
A. Report the platelet count with a comment stating "specimen contained microclots"
B. Vortex the tube for 30 seconds to break up clots, re-run the CBC, and report the results
C. Perform a manual platelet estimation on the peripheral smear and report that value
D. Reject the specimen as clotted, cancel the CBC/platelet count, and request a fresh
specimen
Answer: D
Rationale: The presence of fibrin microclots consumes platelets and traps red/white cells,
rendering the sample completely non-representative. Clotted specimens cannot be
manipulated or reported and must be rejected preanalytically.
14. A patient's routine CBC results generated by an automated analyzer are: WBC 6.5 x
10^3/uL, RBC 4.20 x 10^12/L, Hb 14.1 g/dL, Hct 35.0%, MCV 83 fL. The technologist notes
that the Rule of Three is violated (RBC x 3 = 12.6 vs Hb 14.1; Hb x 3 = 42.3 vs Hct 35.0).
Lipemia is noted on visual inspection of the plasma. What is the best step to obtain
accurate results?
A. Perform a 1:2 dilution of whole blood with normal saline and re-run on the analyzer
B. Report the current results because lipemia does not interfere with spectrophotometric
hemoglobin assays
C. Warm the blood sample at 37°C for 15 minutes and immediately re-analyze
D. Perform a plasma blank replacement procedure to correct the falsely elevated hemoglobin
reading
Answer: D
Rationale: Severe lipemia causes turbidity that falsely increases spectrophotometric
absorbance measurements of hemoglobin, leading to an artificially high Hb value and falsely
elevated MCH/MCHC (violating the Rule of Three). A plasma blank replacement corrects for
plasma turbidity.
15. During routine bench processing, a blood tube ruptures inside a non-gasketed
benchtop centrifuge bowl, splattering blood across the internal rotor housing. What is the
proper personal safety and decontamination protocol?
A. Open the lid immediately, wipe the rotor with dry paper towels, and resume centrifugation
B. Spray 70% isopropyl alcohol directly into the spinning centrifuge bowl to neutralize
Part I: Basic Hematology Principles
Chapter 1: Introduction to Hematology and Basic Laboratory Practice
Chapter 2: From Hematopoiesis to the Complete Blood Count
Chapter 3: Red Blood Cell Production, Function, and Relevant Red Blood Cell Morphology
Chapter 4: Hemoglobin Function and Principles of Hemolysis
Part II: Red Blood Cell Disorders
Chapter 5: The Microcytic Anemias
Chapter 6: The Macrocytic Anemias
Chapter 7: Normochromic Anemias: Biochemical, Membrane, and Miscellaneous Red
Blood Cell Disorders
Chapter 8: The Normochromic Anemias Caused by Hemoglobinopathies
Part III: White Blood Cell Disorders
Chapter 9: Leukopoiesis, Wbc Differential, and Lymphocyte Function
Chapter 10: Abnormalities of White Blood Cells: Quantitative, Qualitative, and the Lipid
Storage Diseases
Chapter 11: Acute Leukemias
Chapter 12: Myeloproliferative Neoplasms
Chapter 13: Lymphoproliferative Disorders and Related Plasma Cell Disorders
Chapter 14: The Myelodysplastic Syndromes
Part IV: Hemostasis and Disorders of Coagulation
Chapter 15: Overview of Hemostasis and Platelet Physiology
Chapter 16: Quantitative and Qualitative Platelet Disorders
Chapter 17: Defects of Plasma Clotting Factors
Chapter 18: Fibrinogen, Thrombin, and the Fibrinolytic System
Chapter 19: Introduction to Thrombosis and Anticoagulant Therapy
Part V: Hematology Automation, Flow Cell Cytometry, and
Laboratory Procedures
Chapter 20: Hematology Automation and Flow Cell Cytometry
Chapter 21: Basic Procedures in a Hematology Laboratory
,Test Bank: Hematology in Practice, 4th Edition
(Betty Ciesla)
Chapter 1: Introduction to Hematology and Basic Laboratory
Practice
1. What is the primary function of the aperture diaphragm in a brightfield light
microscope?
A. To control the contrast and angle of light striking the specimen
B. To raise or lower the condenser lens height
C. To adjust the total magnification power of the objective lens
D. To compensate for refractive index differences in oil immersion
Answer: A
Rationale: The aperture diaphragm (condenser diaphragm) controls the angular aperture
and amount of light passing through the condenser, directly regulating contrast, resolution,
and depth of field during microscopic observation.
2. Name the term used to describe a sudden, persistent shift in Quality Control (QC) data
points that fall consistently on one side of the mean line on a Levey-Jennings chart.
Answer: Shift
Rationale: A shift is defined in quality control as a sudden and sustained change in the mean
of the control values, usually indicating an abrupt systemic failure such as a new lot of
reagent, light source degradation, or recalibration error.
3. What is the standard anticoagulant-to-blood ratio required for sodium citrate tubes
used in routine coagulation testing?
Answer: 1:9
Rationale: Sodium citrate tubes require an exact ratio of 1 part 3.2% sodium citrate
anticoagulant to 9 parts whole blood (or 1:9 ratio) to prevent artificial prolongation of
clotting times due to excess free anticoagulant.
,4. Which Westgard rule is violated when a single control measurement exceeds the mean
by more than three standard deviations?
Answer: 1_3s
Rationale: The 1_3s Westgard rule is a rejection rule triggered when one control result
exceeds the mean +/- 3 standard deviations, serving primarily as an indicator of random
error or severe systemic error.
5. What term refers to a preanalytic laboratory check that automatically compares a
patient's current test result with their previous recent test results?
Answer: Delta check
Rationale: A delta check compares a patient's present laboratory result with a previously
determined result. Significant unexpected variations signal potential preanalytic errors such
as patient misidentification, IV contamination, or sample mislabeling.
6. A hematology analyzer measures a control sample 10 times, obtaining a mean
Hemoglobin value of 14.0 g/dL and a standard deviation (SD) of 0.28 g/dL. Calculate the
coefficient of variation (CV%) for this control assay.
Answer: 2.0%
Rationale: The formula for coefficient of variation is CV% = (Standard Deviation / Mean) x
100. Substituting the given values: CV% = (0.28 g/dL / 14.0 g/dL) x 100 = 0.02 x 100 = 2.0%.
7. A laboratory establishes a normal reference interval for Platelet count using a Gaussian
distribution of healthy donors. The mean platelet count is 260 x 10^3/uL with a standard
deviation of 45 x 10^3/uL. Calculate the 95.5% central reference interval (Mean +/- 2 SD)
for this population.
Answer: 170 to 350 x 10^3/uL
Rationale: The 95.5% confidence/reference range under a normal Gaussian distribution
spans from (Mean - 2 SD) to (Mean + 2 SD). Lower limit = 260 - (2 x 45) = 260 - 90 = 170 x
10^3/uL. Upper limit = 260 + (2 x 45) = 260 + 90 = 350 x 10^3/uL.
8. A phlebotomist collects blood into a 3.2% sodium citrate tube from a patient with a
severe polycythemia whose hematocrit is 65%. Given the total blood volume in a standard
full tube is 4.5 mL (consisting of 0.5 mL anticoagulant and 4.0 mL whole blood), calculate
the corrected amount of sodium citrate anticoagulant required for this tube volume using
,the formula: C = (0.0018) x (100 - Hct) x V, where V is whole blood volume in mL.
Answer: 0.25 mL
Rationale: The formula for corrected anticoagulant volume is C = (0.0018) x (100 - Hct) x V.
Inserting the values: C = (0.0018) x (100 - 65) x 4.0 mL = 0.0018 x 35 x 4.0 = 0.252 mL (rounds
to 0.25 mL).
9. During quality control validation, a automated cell counter run shows an observed WBC
count of 10.8 x 10^3/uL. The manufacturer's assigned target mean value for the control is
10.0 x 10^3/uL. Calculate the percent error of this measurement.
Answer: 8.0%
Rationale: Percent error is calculated as: |(Observed Value - Target Value) / Target Value| x
100. Substituting the given parameters: |(10.8 - 10.0) / 10.0| x 100 = (0..0) x 100 = 8.0%.
10. A medical laboratory scientist is performing a routine manual WBC differential on a
peripheral blood smear. Under the 100x oil immersion objective, the field of view appears
dark, blurry, and exhibits severe chromatic aberration despite adjusting the fine focus
knob. Upon inspection, the objective lens is clean. Which action is the most appropriate
troubleshooting step to re-establish Köhler illumination and image clarity?
A. Open the field iris diaphragm completely and lower the substage condenser to its lowest
position
B. Focus and center the condenser, adjust the field diaphragm, and verify the condenser is in
its uppermost position
C. Switch the light source transformer to maximum voltage and remove the blue daylight
filter
D. Replace the immersion oil with xylene solution to increase the refractive index of the slide
media
Answer: B
Rationale: Proper Köhler illumination requires the condenser to be raised nearly to its
highest point, centered using the condenser centering screws, and the field diaphragm
adjusted to match the field of view, ensuring bright, glare-free, and evenly distributed light.
11. A phlebotomist draws blood from an inpatient receiving a continuous IV infusion of
0.9% normal saline in the left arm. Due to difficult vein access, the phlebotomist draws the
EDTA tube directly above the IV site in the left arm. The automated complete blood count
,reveals a hemoglobin of 5.2 g/dL and a Hct of 15.6%, whereas the patient's baseline
yesterday was 13.5 g/dL. What is the most appropriate immediate action by the
laboratory analyst?
A. Reject the specimen due to suspected IV fluid hemodilution and request a repeat redraw
from the opposite arm
B. Immediately report the critical hemoglobin value of 5.2 g/dL to the attending physician
C. Run a duplicate automated count on the same tube to confirm instrument precision
D. Centrifuge the tube and perform a manual microhematocrit to verify the automated Hct
Answer: A
Rationale: Drawing blood proximal (above) an active IV line causes severe specimen
hemodilution with IV fluid, resulting in falsely decreased cell counts and hemoglobin
concentrations. The specimen must be rejected as preanalytically compromised and redrawn
from a valid site (opposite arm).
12. While reviewing automated daily QC for an automated platelet counter, the
technologist observes that Level 1 and Level 2 controls have drifted progressively higher
over the past 5 consecutive operational shifts, culminating in both controls exceeding +2
SD on day 5. No reagents were changed. What is the primary cause and appropriate
corrective action?
A. Sudden random electrical interference; re-run the same control vials immediately
B. Improper anticoagulant ratio in control vials; mix controls on a mechanical shaker for 1
hour
C. Systematic instrument drift or aperture buildup; perform aperture cleaning and recalibrate
D. Preanalytic hemolysis in control vials; discard controls and report patient results with a
disclaimer
Answer: C
Rationale: A progressive 5-day trend across multiple control levels indicates systemic error,
frequently caused by gradual aperture fouling/protein build-up or optical sensing
degradation. The instrument requires maintenance/cleaning and recalibration before running
patient samples.
13. An outpatient clinic sends a lavender-top (EDTA) tube for routine CBC. Upon opening
the tube to prepare a blood smear, the technologist notes several small fibrin microclots
adhering to the applicator stick. The automated analyzer generates a WBC count of 7.2 x
, 10^3/uL and a platelet count of 42 x 10^3/uL. How should the technologist handle this
specimen?
A. Report the platelet count with a comment stating "specimen contained microclots"
B. Vortex the tube for 30 seconds to break up clots, re-run the CBC, and report the results
C. Perform a manual platelet estimation on the peripheral smear and report that value
D. Reject the specimen as clotted, cancel the CBC/platelet count, and request a fresh
specimen
Answer: D
Rationale: The presence of fibrin microclots consumes platelets and traps red/white cells,
rendering the sample completely non-representative. Clotted specimens cannot be
manipulated or reported and must be rejected preanalytically.
14. A patient's routine CBC results generated by an automated analyzer are: WBC 6.5 x
10^3/uL, RBC 4.20 x 10^12/L, Hb 14.1 g/dL, Hct 35.0%, MCV 83 fL. The technologist notes
that the Rule of Three is violated (RBC x 3 = 12.6 vs Hb 14.1; Hb x 3 = 42.3 vs Hct 35.0).
Lipemia is noted on visual inspection of the plasma. What is the best step to obtain
accurate results?
A. Perform a 1:2 dilution of whole blood with normal saline and re-run on the analyzer
B. Report the current results because lipemia does not interfere with spectrophotometric
hemoglobin assays
C. Warm the blood sample at 37°C for 15 minutes and immediately re-analyze
D. Perform a plasma blank replacement procedure to correct the falsely elevated hemoglobin
reading
Answer: D
Rationale: Severe lipemia causes turbidity that falsely increases spectrophotometric
absorbance measurements of hemoglobin, leading to an artificially high Hb value and falsely
elevated MCH/MCHC (violating the Rule of Three). A plasma blank replacement corrects for
plasma turbidity.
15. During routine bench processing, a blood tube ruptures inside a non-gasketed
benchtop centrifuge bowl, splattering blood across the internal rotor housing. What is the
proper personal safety and decontamination protocol?
A. Open the lid immediately, wipe the rotor with dry paper towels, and resume centrifugation
B. Spray 70% isopropyl alcohol directly into the spinning centrifuge bowl to neutralize
