Quality Management Exam Review For Radiologic Imaging Sciences

QUALITY
MANAGEMENT
REVIEW
QUALITY
MANAGEMENT
REVIEW
Steven B. Dowd, Ed.D., RT(R)(QM)(M)(MR)(CT)CPHQ
Associate Professor
Program Director Radiography Program
University of Alabama at Birmingham
Birmingham, Alabama
Elwin R. Tilson, Ed.D., RT(R)(QM)(M)(CT)

Professor of Radiologic Technologist
Armstrong State College
Savannah, Georgia
Richard R. Carlton, M.S., R.T.(R)FAERS

Assistant Professor of Radiologic Sciences
Arkansas State University
State University, Arkansas
Australia Canada Mexico Singapore Spain United Kingdom United States

Quality Review Management
by Stephen B. Dowd, Elwin R. Tilson, Richard R. Carlton
Business Unit Director: Executive Marketing Manager: Production Coordinator:

William Brottmiller Dawn F. Gerrain Catherine Ciardullo
Acquisitions Editor: Executive Editor: Art/Design Coordinator:
Candice Janco Cathy L. Esperti Jay Purcell
Editorial Assistant: Project Editor
Maria D’Angelico Jim Zayicek
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Contents
Preface vi
Chapter 1 Studying for the QM Registry 1
Recommended References / 1
Basic Material You Need to Know 5
Chapter 2 Program Standards/Mammography Criteria 29

Multiple-Choice Questions / 29
Answers to Chapter 2 Program Standards/
Mammography Criteria Questions / 44
Chapter 3 Quality Improvement Concepts 55

Answers to Chapter 3 Quality Improvement
Concepts Questions / 77
Chapter 4 Quality Improvement Data 93

Answers to Chapter 4 Quality Improvement
Data Questions / 107
Chapter 5 Physical Principles 115

Answers to Chapter 5 Physical Principles
Questions / 138
Chapter 6 Test Instrumentation 153

Answers to Chapter 6 Test Instrumentation
Questions / 160
Suggested Readings 165

Post-test 169
Answers to Multiple-Choice Questions / 194
v
Preface
USING THIS TEXT TO THE

BEST ADVANTAGE
This text is designed for radiographers wishing to take the
Advanced Certification Examination in Quality Management
(QM) offered by the American Registry of Radiologic Tech-
nologists (ARRT). It could be used in a number of other settings
where quality management is taught as well. In addition to study
questions, Chapter 1 of Quality Management Review contains a
detailed listing of “Knowledge Points”—facts relevant to the QM
exam, that would be useful for a class in quality improvement/
management.
Each chapter includes a brief overview of the material or
questions similar in format and content to those on the ARRT
examination. We have not attempted to completely mirror the
ARRT examination as we believe a book of this type must have
both educational and assessment components. Thus, some of the
questions attempt to teach as well as assess by using formats such
as True/False or All of the Above.
The basic formula of the book is to have at least three times
as many questions as each section of the examination, although
some subsections will have more; some less. This essentially cor-
relates with the breadth of coverage needed, depending on the
subject matter.
Each chapter of questions has annotated answers at the end
that indicate why the choice is correct, as well as why the distrac-
tors (the incorrect choices) are incorrect. We have made an attempt
to explain the answers for optimal review. There also is one final
post-test matching the examination to help gauge progress.
vi
Preface vii
ACKNOWLEDGMENTS
Steven B. Dowd
Thanks to my wife, Lisa and son, Josh for helping me out through
my various certification endeavors (including obsessing over my
expected score on the QM exam) and the writing of this book.
Also, thanks to Ann Steves and Randal Robertson for their profes-
sional support during the writing of this book and in my teaching.
Elwin R. Tilson
I would like to acknowledge Dr. Sharyn Gibson, Gloria
Strickland, Debbie Lamb, and Sharon Gillard-Smith—my profes-
sional colleagues who have nurtured me, taught me, inspired me,
and worked with me over the years. I also owe a great debt to my
students who have inspired me by always asking “Why?”. Finally,
this book would never been published without the hard work of
Candice Janco and Marie D’Angelico, both of Delmar Thomson
Learning. Thank you all!
Richard B. Carlton
A professional life requires a wide range of support to be suc-
cessful. The extent to which mine has succeeded recently is in
great measure due to a great dean, chair, and our faculty at
Arkansas State. Thanks to Susan Hanrahan, Ray Winters, Lyn
Hubbard, Jeannean Rollins, Tracy White, and Lynn Carlton (who
shares both my professional and personal life).
ABOUT THE AUTHORS

Dr. Steven B. Dowd is Program Director and Associate Professor
for the B.S. Radiologic Sciences program at University of
Alabama at Birmingham, as well as a faculty member in both the
nuclear medicine technology and radiation therapy programs. A
member of the graduate faculty, he also serves on dissertation
committees in the UAB School of Nursing. He has 20 years of
experience teaching and practicing radiography and advanced
imaging.
A graduate of Nova Southeastern University, the University
of Illinois-Springfield, Regent’s College, and Parkland College, his
viii Preface
research interests include Gerontology, Quality Management,

Radiation Protection, and Effective Teaching, especially the
teaching/learning environment for adult learners and the
development of effective teaching materials. He is the author or
coauthor of seven books, 100 peer-reviewed articles, and 300
total articles in the health sciences literature. He is certified in
a number of areas including radiography, quality management,
mammography, magnetic resonance imaging, and computed
tomography.
Dr. Elwin R. Tilson is Professor and Clinical Coordinator of

Radiologic Sciences at Armstrong Atlantic State University in
Savannah, GA. Dr. Tilson completed his radiography education
in the U.S. Army in 1969, earned a bachelor of science degree in
radiologic technology from Arizona State University in 1975, a
master of science degree in allied health education from San
Francisco State University in 1978, and a doctorate with an
emphasis in education technology from the University of
Georgia in 1986.
Dr. Tilson has extensive experience in general radiography,
trauma radiography, computed tomography, neuroradiology,
educational administration, and quality computed tomography
management. He is certified in radiography, mammography,
and quality management, and is the coauthor of a radiation biol-
ogy text, a quality management computer program, and numer-
ous articles.
Richard R. Carlton is an Assistant Professor of Radiologic

Sciences, Arkansas State University. Rick is a Charter Fellow of
the Association of Educators in Radiologic Sciences, holds a
master’s degree from National Louis University, a bachelor’s
degree from the University of Health Sciences/The Chicago
Medical School, and a pair of associate degrees from Illinois
Central College.
Rick has taught radiography for 23 years and speaks regu-
larly throughout the world. He has authored 16 books and
founded two journals.
Rick is currently the director of the Center for Medical
Imaging in Bioanthropology at Arkansas State, where he is
involved in x-raying mummies all over the world. For more
information on his work, visit him online at www.clt.astate. edu/
RadSci/cmib.htm.
Studying for the
QM Registry
One of the most important challenges in studying for the QM

registry is to figure out how to learn the broad mass of mate-
rial required for the test. There are many usable sources, but
no single source is comprehensive. We suggest following sev-
eral rules:
Rule 1: Know your physics and imaging.
Rule 2: Do not rely on one source.
Rule 3: Make a notebook that contains all the sources
you have compiled.
Rule 4: Drill-and-review often.
Rule 5: Make certain you understand QI/QM concepts.
RECOMMENDED REFERENCES
Diagnostic Imaging
Papp, J. Quality Management in the Imaging Sciences (Mosby-
Yearbook, 1998) is currently the main resource for QM for
radiography.
1
2 Chapter 1 Studying for the QM Registry
This book is an excellent overview of quality control (Chap-

ters 2–11) in diagnostic imaging. The author has an excellent
command of radiographic equipment and accessories.
Use this book for an overview of QC in diagnostic radiol-
ogy. Try other sources for actual drill-and-review, most non-
radiology regulations and accreditation guidelines, and under-
standing QM as an overall concept.
Physics
There are a number of books that provide information on
physics for the radiologic sciences.
Mammography
There is no substitute for actually reading the American Col-
lege of Radiology (ACR) manual. However, Papp provides a
good start for QC in mammography in Quality Management in
the Imaging Sciences.
Be sure to develop some method for distinguishing between
QC in mammography and general radiography because toler-
ances, etc. are not exactly the same.
Film Processing
The best resource for film processing is Haus and Jaskulski’s
The Basics of Film Processing in Medical Imaging (Medical
Physics Publishing, 1997), although McKinney’s Radiographic
Processing and Quality Control (initially Lippincott, repub-
lished in 1997 through another company) runs a close second.
The material in Haus and Jaskulski particularly on hard-to-
find information such as the make-up and operation of densit-
ometers, flooded replenishment, etc. is extremely valuable in
test preparation.
Note: The proper term DLOGE curve is used throughout this

book to describe what is also known as a Hurter and Driffield
(H&D) curve, characteristic curve, sensitometric curve, or
film average gradient (gamma) curve.
Government Regulations and Accreditation Guidelines

There is again no substitute for getting original copies of the
government documents, such as CFR 1910.1030 (bloodborne
pathogens), NCRP 99 and 105, and at least reviewing the
JCAHO guide. Some of these are available on the Internet, and
public domain documents can be photocopied at your local
medical library.
In addition, there is a good chapter on the Safe Medical
Devices Act in Ann Obergfell’s law book, Law and Ethics in
Diagnostic Imaging and Therapeutic Radiology (WB Saun-
ders, 1995).
Another great source for understanding definitions in the
quality arena is Timmreck’s Health Services Cyclopedic Dic-
tionary, 3rd ed., (Boston, Jones, & Bartlett, 1997). This one may
be available in the reference section of your library. If not, you
may want to try an interlibrary loan. If you have trouble under-
standing things like the difference between “effectiveness” and
“efficacy” (like we do), then this book (along with relevant
pages from the JCAHO guide) will help you tremendously.
QM/QI
Adams & Aurora’s book contains especially good test items
and diagrams relating to the QM process. Chapter 6 of Steve
Hiss’ book, Introduction to Health Care Delivery and Radi-
ology Administration (WB Saunders, 1997) has a good intro-
duction to QI. Tilson & Dowd’s article, “The benefits of using
CQI/TQM data” in Radiologic Technology, Vol. 67, no. 6, 1996:
pages 533–537, is also useful. Other good QM philosophy and

systems sources are Lauglin & Kaluzny’s Continuous Quality
Improvement in Health Care (Aspen, 1994). The National
Association for Healthcare Quality (NAHQ) publishes the
Guide to Quality Management, 8th ed. (1998), which is written
for their Certified Professional in Healthcare Quality (CPHQ)
exam.
The American Society of Radiologic Technologists
(ASRT) also sells two good homestudies on QM by Rebecca
Lam that we think would help anyone needing to learn the
basics of QM.
Statistics
The statistical concepts on the QM registry are basic, but you
must know them well. Don’t expect simple questions like
“What is the mean?”; you must instead know how to calculate
the mean and what it is used for. Do your best to find a good
statistics book that makes sense to you. Nursing statistics
books tend to give examples that are closest to radiography;
e.g., Burns & Grove, The Practice of Nursing Research:
Conduct, Critique, and Utilization (WB Saunders, 2001).
Drill-and-Review
There are two good drill-and-review programs: one distrib-
uted by Corectec of Athens, Georgia, and one through
Educational Software Concepts Inc. (ESC), by Elwin Tilson
and Steven Dowd. The ESC disk is about $30 and contains
over 600 questions with detailed annotated answers. You can
drill-and-review in specific sections and take multiple mock
registries. The Corectec disk is about $99 and contains one
well-designed mock registry.
BASIC MATERIAL YOU NEED TO KNOW

Although it is not recommended to simply memorize material
for this, or any other certification exam, here are some useful
starting points with basic things you should know before mov-
ing on to critical thinking about the material in the examina-
tion. Alternately, you can look upon them as “study notes” to
be used in the same fashion as if you had taken a formal class—
they contain the “bare bones” of the material, but not enough
for in-depth understanding.
This section contains lists of knowledge points from
some of the main reference documents. This is, of course,
material from several books and cannot be considered com-
plete in its description. When possible, key points from gov-
ernmental regulations have been cited in their entirety, or
summarized.
NCRP #105 (Sections 1, 2, 6, 7, 8)

Main source for radiation protection information
for the examination
KNOWLEDGE POINT 1.1:

The “Shalls” and “Shoulds”
● shall–recommendation that is necessary or essential to
meet the currently accepted standards of protection
● should–an advisory recommendation that is to be
applied when practicable
The specific shalls and shoulds are contained behind each
memorization point.

Radiation Units
● Exposure—Roentgen (R) and columb per kilogram
(c/kg)
● Absorbed dose—gray (Gy) and rad (gray is also defined
as the unit of kerma)
● Dose equivalent—Sievert (Sv) or rem
● Activity—Becquerel and Curie

Sources of Radiation
● Naturally occurring (background) radiation—cosmic and
terrestrial
● Patient doses—Typical exposures; U.S. average (39 mrem
or 0.39 mSv)
● Occupational exposure

Sources of Radiation Exposure in
the Medical Environment
● Radioactive materials
● Half-life (50%) of original intensity remains after each;
1/10 of 1% (0.1%) of the original number after 10 half-
lives)
● Alpha, beta, and gamma radiations
● Sealed and unsealed sources (e.g., brachytherapy)
● Types of radiation-producing equipment—Diagnostic,
therapeutic

Basic Principles of Radiation Protection
Time, Distance, Shielding

● Technologists should stand as far away as possible (at
least two meters) from the x-ray tube and patient.
Always use appropriate shielding or be out of the
room when possible.
Survey Meters
● Geigen-Muller (GM) counter (qualitative measurements
only), portable scintillation counters, and ionization
chambers are most often used.
● Individuals involved in the handling of radioactive
materials shall be competent in the use of survey
meters.
● The response of radiation detection instruments shall be
checked periodically using an appropriate radiation
source.
● The radiation safety officer (RSO) should be consulted
prior to the procurement of survey meters.
● Personnel dosimeters—Types, where worn, minimal
exposures
● The site where the dosimeter is worn should be docu-
mented in the records.

Radioactive Materials Labels, Signs,
and Warning Lights
Shoulds
● Use contamination control measures for radioactive
materials.
● Restrict use to authorized locations.
● Do not allow in areas where its presence can be an
unsuspected source of radiation exposure to the patient.
● Use warning signs.
● Display the recognized magenta radiation symbol on a
yellow background.
● Follow explicitly any instructions given on the signs.
Shalls
● Employees shall be given appropriate training and
safety instruction by a qualified individual.
● Follow all such instructions and directions.

Acquisition, Storage, and Disposition of
Radioactive Materials
Shoulds
● Obtain approved purchase orders in advance from RSO
or designee.
● Maintain inventory.
● Store materials in secured locked area.

● Inform all users of records to be kept and procedures to
be followed in preparing and disposing radioactive
waste.
● Keep users and potentially involved ancillary personnel
aware of institutional emergency procedures.
● Supervise all shipments leaving the facility.
Shalls
● Allow only authorized users to order and receive
radionuclides.
● Do not exceed individual authorizations for type and
amount of radionuclides.
● Have materials delivered to a designated receiving area.
● Provide a designated receiving site for night and week-
end deliveries (should be accompanied by guard to this
site; guard should be able to inspect package and call
RSO, if needed).
● No food allowed in refrigerator with radioactive
materials.
● No eating, drinking, or smoking permitted.

Radioactive Waste Management
Shoulds
● Consult RSO and policy manual before making deci-
sions on disposal of materials.
● Ensure RSO supervises packaging of waste for
shipment.
● Segregate radioactive and infectious wastes from ordi-

nary trash.
● Inspect unwanted materials such as tissue or infectious
material for decay prior to storage.
Shalls
● Appropriately package and manage waste.
● Plan releases to environment under the supervision of
RSO.
● Perform releases in accordance with federal, state, and
local regulations.
● Record and maintain releases to sewer.
● Sterilize infectious and radioactive waste before
disposal.

Diagnostic Radiographers
This is probably the most important section to know

since it directly relates to QA/QC/Radiation Protection
in diagnostic radiology.
Shoulds
● Achieve familiarity with equipment and operating
procedures.
● Periodically consult RSO, physicist, radiologist, or chief
technologist to ensure proper radiation safety practices
are being followed.
● Become familiar with CDRH regulations for equipment
manufacturing.
● Be aware of approximate personnel radiation exposure.

● Direct beam to achieve minimal exposure to all and to
obtain optimal image quality.
● Be aware of shielding and use equipment accordingly.
● Use beam centering when available and carefully colli-
mate to area of clinical interest.
● Stand as far away as practical from tube housing.
● Avoid holding patients routinely.
● Hold patients only when restraining or positioning
devices are inadequate.
● Provide lead aprons and gloves and achieve positioning
so that no body part is exposed to beam.
● Prohibit pregnant women or individuals under 18 from
holding patients.
● Review and implement guidelines by the radiation
safety committee.
● Assure that walls are designed to protect and operators
remain protected during exposure.
● Assure that exposure switches cannot energize the tube
when exposing radiographer is outside shielded areas.
● Dosimeter is normally worn at waist or collar level
outside of aprons.
● Never allow dose equivalent to a fetus to exceed 0.5 mSv
(50 mrem) per month.
● In fluoroscopy, set safety standards, including place-
ment of bucky slot cover, maximum distance to source,
use of lead gloves and lead drape, and room inspection
guidelines by RSO.
● When using mobile equipment, set safety standards,

including a check to see if the cord is long enough for
operator to stand 2m from source (patient). (cord may
be short if the console is used for protection), ensure
operator is cognizant of orientation of the beam with
respect to others, and maximize SSD to reduce patient
exposure.
● In dental, set safety standards to include proper location
of exposure so that operator can stand behind barrier,
ensure operator does not hold film or tube, and that a
proper beam limiting device is used.
Shalls
● Have an orientation program on radiation safety for
newly employed technologists and a continuing educa-
tion program to review the rules and regulations.
● Make technologists aware of the approximate amount of
radiation received by their patients during each radio-
graphic procedure used in their facility.
● Never allow beam size to exceed size of image receptor
for radiographic and fluoroscopic procedures.
● Wear a lead apron in fluoroscopy.
NCRP #99
Main source for quality assurance programs in
radiology (Sections 1, 6, 7)

Definition of QA
● Quality assurance is a comprehensive concept that com-
prises all practices instituted by the imaging physician
to ensure that:
1. every imaging procedure is necessary and appropri-
ate to the clinical problem at hand.
2. the images generated contain information critical to
the solution of that problem.
3. the recorded information is correctly interpreted
and made available in a timely fashion to the
patient’s physician.
4. the examination results in the lowest possible radia-
tion exposure, cost, and inconvenience to the
patient consistent with objective.

Storage, Darkroom, and Processing Conditions
● Photographic materials should be stored at less than
24°C (75°F), preferably 15–21°C (60–70°F); humidity
40–60%. Keep materials from fumes and pressure.
● Darkroom should be adequately illuminated, painted
white or light colors, with an appropriate temperature
and humidity (40–60%) and lead in walls.
● Most darkrooms will fog film; small amounts of dark-

room fog increase the apparent speed and density of the
film, but decrease contrast.
● When testing for darkroom fog:
1. Use the fastest film normally handled in darkrooms,
or the fastest of each type.
2. Make a visible light exposure using a step wedge or
densitometer.
3. Ideally, show less than 0.05 OD increase in middle
density region (1.2 OD) with a two-minute expo-
sure; less than 0.05 OD increase with one-minute
exposure is acceptable.
4. Do not test using unexposed film.
5. Testing must be done every six months.

Processor Quality Control
● Best method—freshly exposed sensitometric strip read
with densitometer.
● pH specific gravity, or bromide concentration methods
are not as valid.
● Some basic parameters—should be same film as
routinely used, recently exposed to light, and eliminate
as many variables as possible.
● Measure:
1. Base + fog (B + F)
2. Mid-density or speed point [1.0 + (B + F)]
3. Average gradient (slope of straight line of DLOGE

curve)
LOG exposure (2.50 + B + F) – (0.25 + B + F).
Sometimes referred to as the D.D.
Upper and lower control limits
Speed point and average gradient = ±0.10
B + F = ±0.05
Note: These numbers can vary and this does not affect
the validity of the data as long as they are consistent
throughout the results being compared.
● Isolate an emulsion batch of film sufficient to last at least
one month, and you must do a “crossover” (where the
speed point and D.D. of the new emulsion batch is com-
pared to the old emulsion batch and the points “reset” on
the chart.
● Some other basic parameters may include:
1. Assign one individual to the program.
2. Process strips same way each time, and at the same
time each day.
3. Clean and maintain equipment.

Fixer/Archival Quality
● Follow manufacturer’s recommendations for flow, etc.
● For archival purposes, staining should be prevented for
at least 10 years; preferably 20–25 years.
● Fixer retention test must be done at least every six
months, preferably every three.
● Less than 2µg/cm2 thiosulfate ion (fixer) should remain

in film after washing.

Time/Temperature/Rate
● Transport time is measured using a stop watch (on
installation and yearly thereafter).
● Developer temperature should be maintained within
±0.3°C (0.5°F); fixer within ±3°C (5°F).
● Never use a mercury thermometer.

Flow Rate, Replenishment, and Filters
● Flow rate should be checked daily.
● Replenishment rate must be kept accurate (check cali-
bration of meters quarterly).
● Filters should not allow particles larger than 25 µm to
pass.

Filtration
● Increases in the half-valve layer (HVL) tend to lower
patient exposure; most noticeable with larger patients
(with thicker body parts).
● When measuring HVL, use a dosimeter and sheets of type
1100 aluminum; measure annually as well as when tubes
are replaced/serviced, or when collimator is serviced.

Light Field/Collimation
● Light field must be accurate; allow collimation to
smaller size than film, even with positive beam
limitation (PBL).
● There are a number of ways to measure, including nine
coins or paper clips.
● Follow allowances:
■ ±2% of source-to-image receptor distance (SID) in
collimator light-to-x-ray field total misalignment.
■ Center of field aligned to center of image ±2% of
SID.
■ SID indicator accurate ±2%.
■ Manual collimation x-y scale indicators accurate
±2% of SID.
■ PBL, length or width of x-ray field, cannot differ by
more than ±3% of SID compared to image dimen-
sion; sum of absolute values of both must not be
more than ±4%.

Beam and Bucky Perpendicularity
● Beam and bucky must be centered and perpendicular
(avoid grid cut-off).
● Procedure: Radiograph a homogeneous phantom with
lead strips in middle to mark center of beam. Lead
strips must be in center of beam, and film must be
uniform within ±0.10 OD side-to-side (preferably

anode-to-cathode axis).

Focal Spot Size
● Acceptance testing may not be a worthwhile regular QA
check.
● If using NEMA standards, a slit camera is needed.

Tube Rating Charts
● Tube heat sensor should provide a warning (or expo-
sure terminator) when anode heat reaches 75% of
maximum.
● Four types of charts used are single exposure, anode
thermal and fluoroscopic, housing cooling charts, and
angiographic and cine rating charts.

kVp
● One of most important factors that affects quality of
beam, patient exposure, and contrast and density of
film.
● Invasive or noninvasive testing
● Noninvasive-Ardran and Crooks cassette ±3 kVp
● New electronic devices accurate ±2% and reproducible
± 0.5 kVp

Exposure Timers
● Tools—spin top (motorized or non-motorized); electronic
timing device to measure number of pulses or time
● 3-phase generators ±5% for times in excess of minimum
exposure time; one dot variance allowed on single
phase at 1/5 and 1/10 seconds and none at 1/20 and
1/30 seconds
● Measure at least annually, when problems occur with
light or dark films, and when repair has occurred on
generator.

Exposure per Unit of Tube Current and Time
● Measurement of µC/kg1 mAs—difficult to measure mAs
directly.
● Measure exposure at fixed kVp and mAs; set geometri-
cal conditions.
● Divide the exposure by the mAs (using the “old units”).
Many places measure the mR/mAs.
● Exposure should be maintained ±10% at 80 kVp for
rooms using the same types of generators, tubes, and
tables. If not, each unit needs a different technique
chart.
● Measure at least annually.

Linearity and Reproducibility
● Linearity—selecting various mA and timer stations that
produce the same mAs; producing radiographs of simi-
lar density.
■ Measure using a dosimeter and a fixed kVp (may
later vary kVp for additional measurements; keep
fixed at first).
■ ±10% between adjacent mA stations (with six sta-
tions, may vary as much as 50%); but should be
able to maintain across entire generator at ±10%.
● Reproducibility—make an exposure; change kVp, mA,
and exposure time; go back to original values; have
similar output; make three exposures (not three consec-
utive exposures using same technique and same output
without resetting the factors).
■ ±5% variation from average allowance
■ Measure at least annually and for troubleshooting.

Phototimers
● Maximum possible exposure cannot exceed 600 mAs.
● Phototimer evaluation at various mA stations should be
±10%.
● If using a homogeneous phantom, OD should be about
1.2, with a variance of ±0.030; film density variations
cannot exceed ±0.20 OD.
● Reproducibility should be ±5% of average exposure.
● Density controls should represent equal percentage

changes.

Grids
● Uniformity—evaluated using homogeneous phantom,
1.2 OD.
■ Dark or light areas are grounds for rejection.
■ No grid lines allowed for bucky.
■ Density should not vary more than ±0.10 OD per-
pendicular to anode-cathode axis.
■ Must be tested prior to use and annually thereafter
(grid cassettes and stationary grids must be tested
every six months).
● Alignment—same as for film.

Cassettes, Screens, and Films
● Requires proper spectral matching (matching film sen-
sitivity to intensifying screen phosphor emission).
● Densities of similar screens and films should be within
±0.05 OD. If not, take out of service or place in isolated
use.
● Must have screen-film contact
● Use wire mesh test. (Wait 15 minutes to expose after
loading.)
● Check prior to use, and at least annually thereafter, as
well as in response to problems.
● Screen cleaning—check at least every six months.

Patient Equivalent Phantom
● Last quality control check in a room, troubleshooting
problems, etc.
● Measure with exposure.
● Center density equals 1.20 ±0.15 OD.
● Similar densities are perpendicular and parallel to
anode-cathode axis.
● Exposure should range from 100–150 µC kg-1 (400–600
mR).
ACR Manual (Mammography Criteria)

Mammography Tests and
Their Parameters
● Daily Tests
■ Darkroom cleanliness: Damp wipe counter tops,
wipe feed trays, and damp mop floor
■ Processor quality control: M.D. & D.D. ± 0.15 and
B+F ± 0.03
● Weekly Tests
■ Screen cleanliness: Clean screens with approved
cleaning agent
■ Illuminators (viewboxes) and viewing conditions:
Clean plastic/glass covers, assure units provide
luminance of 3,500 nit
● Monthly Tests
■ Phantom images: Must see 4 fibers, 3 specks, and 3
masses. D.D. of 0.40 ± 0.05
■ Visual checklist: Mechanical integrity of locks, SID,
etc.
● Quarterly Tests
■ Repeat analysis: Less than 2% repeat rate ideal but
may not exceed 5%
■ Fixer retention: Should not exceed Stain #2 (Kodak)
which equals 0.05 g/m2
● Semiannual Tests:
■ Darkroom fog: +0.05
■ Screen-film contact: Large areas unacceptable
(greater than 1 cm) and up to 5 small areas (less
than 1 cm) acceptable
■ Compressor: Power drive should be 25–40 pounds
and manual drive between 25 and 40 pounds.
● Miscellaneous Tests
■ Replace illuminator bulbs every 18–24 months.

Physicist Performed Tests (Annual Basis)
● Average glandular dose
● Artifact evaluation
● Automatic exposure control performance assessment
● Automatic exposure control reproducibility
● Breast entrance exposure
● Collimation assessment
● Focal spot size

● Half-value layer
● Image quality evaluation
● kVp accuracy
● kVp reproducibility
● Uniformity of screen speed
● Unit Assembly inspection
OSHA Guidelines (CFR 1910.1030)

Some Basic Definitions
● Engineering Controls—controls that isolate or remove
the bloodborne pathogen hazard from the workplace.
● Exposure incident—a specific eye, mouth, other
mucous membrane, non-intact skin, or parenteral con-
tact with blood or other potentially infectious material
that results from performance of an employee's duties.
● Occupational exposure—reasonably anticipated skin,
eye, mucous membrane, or parenteral contact with
blood or other potentially infectious materials that may
result from the performance of an employee's duties.
● Personal protective equipment—specialized clothing
or equipment worn by an employee for protection
against a hazard (normal clothing is not included).
● Work practice controls—used to reduce the likelihood
for exposure by altering the manner in which a task is
performed.
What Must the Employer Do?

● Maintain an Exposure Control Plan.
● Determine probability of exposure.
● Institute engineering and work practice controls and
ensure employees follow these.
● Provide and maintain personal protective equipment if
there is potential for occupational exposure.
● Regulate housekeeping including equipment and regu-
lated waste.
● Make the HBV vaccine available to employees with
potential for exposure, at little or no cost, in a reason-
able time and place.
● Have a plan for post-exposure evaluation and follow-up.
● Use appropriate labels and signs.
● Provide information and training to employees.
● Maintain appropriate records (e.g., training, HBV vacci-
nation records), and maintain their confidentiality.
Basic Facts About MSDS

● Typically used to comply with OSHA’s Hazard
Communication Standard, 29 CFR 1910.1200.
● A number of methods are used to communicate vital
information. Hazards may be ranked numerically or
given descriptively. Possible sections include:
Section 1 Manufacturer’s name, address, etc.
Section 2 Hazardous Ingredients/Identity—including
chemical names
Section 3 Physical and Chemical Characteristics—

boiling point, solubility and reactivity in
water, appearance and odor melting point
Section 4 Fire and Explosion Date—including flash
point, special fire fighting procedures,
unusual first and explosion hazards
Section 5 Physical Hazards or Reactivity data—
stability, etc.
Section 6 Health Hazards—acute and chronic,
medical conditions aggravated by
exposure, whether it is a known carcino-
gen, routes of entry, emergency and first
aid procedures
Section 7 Special Precautions and Spill/Leak
Procedures
Section 8 Special Protection Information—respiratory
protection, gloves, other required clothing
● To obtain additional information, check many manufac-
turers’ Web pages on the Internet, which are often listed
on the product.

Basic Facts About the Safe Medical Devices Act
of 1991 (SMDA)
● The SMDA acts as a reporting mechanism for unsafe
devices. Two major components are adverse event
reporting and medical device tracking.
● Use Form 3500 for voluntary reporting and 3500A for
mandatory reporting.
● Report to FDA via an 800 number if necessary.
(Previous regulations allowed an employee to report to
the employer; now the employee can be fined several

thousand dollars for failure to report).
● An unsafe device is one that causes illness, injury, or
death to a patient.
● User facilities are hospitals, nursing homes, outpatient
treatment centers, and ambulatory surgical facilities.
Physician offices and group practices are affected
through the tracking rule.

Aggregate Data JCAHO Indicators
● Appropriateness of care—is the care necessary?
● Continuity of care—how is care coordinated among
practitioners and organizations?
● Effectiveness of care—what is the level of benefit of care
(under ordinary circumstances, average practitioners,
typical patients)?
● Efficacy of care—what is the level of benefit (under ideal
circumstances)?
● Efficiency of care—what is the highest quality of care
available in the shortest time with minimum expense
and positive outcome?
● Respect and caring—how well are patients treated?
(What is the level of patient satisfaction; how well are
complaints handled?)
● Safety in the care environment—includes competency,
equipment, and standard precautions.
● Timeliness of care—is care delivered in a reasonable
time (including waiting period)?
● Cost of care—is cost reasonable to marketplace?
● Availability of care—can the patient's needs be met?

Sentinel Event
● An event significant enough to trigger review each time
it occurs; reportable to JCAHO (e.g., patient death,
rape).
Program Standards/
Mammography Criteria
MULTIPLE-CHOICE QUESTIONS
1. The rate of spontaneous nuclear transformation of a
radioactive nuclide describes:
____ a. exposure
____ b. absorbed dose
____ c. becquerel
____ d. activity
2. Sources of background radiation include:
I. airplane flights
II. the earth
III. body tissues
____ a. I and II only
____ b. I and III only
____ c. II and III only
____ d. I, II, and III
3. What is the average bone marrow dose for an upper
GI?
____ a. 1–2 mGy (100–200 mrad)
____ b. 4–5 mGy (400–500 mrad)
____ c. 8–10 mGy (800–1000 mrad)
____ d. 20–30 mGy (2000–3000 mrad)
29
30 Chapter 2 Program Standards/Mammography Criteria
4. Which of the following represents the reduction of

radioactive atoms in a radioactive nuclide achieved
after ten half-lives?
____ a. 10%
____ b. 1%
____ c. 0.1%
____ d. 0.01%
5. Which of the following types of radiation is most

easily absorbed?
____ a. alpha
____ b. beta
____ c. x-ray
____ d. gamma
6. How often must sealed sources typically be leak-
tested?
____ a. weekly
____ b. quarterly
____ c. every six months
____ d. yearly
7. A linear accelerator produces:
I. high energy x-rays
II. high energy electron beams
III. high energy gamma radiation
8. The fundamental principles of time, distance, and
shielding should be understood by all hospital per-
sonnel that might be exposed to radiation.
____ a. true
____ b. false
9. High atomic-number shielding is effective for:
____ a. diagnostic x-ray
____ b. high energy gamma
____ c. beta radiation
____ d. all of the above
10. When a state inspector comes to inspect West City

Outpatient Center’s Radiographic Room, he finds that
the exposure for an AP abdomen (as well as other
exams) has increased to the point where West City is
no longer in compliance with state guidelines. The
technologist exclaims, “I don’t know how this could
happen. We phototime all of our exposures, which
guarantees consistency, doesn’t it?”
What is the most likely cause of this problem?
____ a. The state inspector’s devices must be
malfunctioning.
____ b. A bad batch of film is being used.
____ c. One or more mA stations is malfunctioning.
____ d. The kVp has drifted.
11. Which of the following best determines focal spot
size?
____ a. slit camera ____ c. star test pattern
____ b. pinhole camera ____ d. wire mesh test
12. Which of the following is true?
____ a. The site where a personal dosimeter is
worn shall be documented in radiation
exposure records.
____ b. The RSO should be contacted for guidance
on the appropriate monitor.
____ c. All hospital personnel shall have monitors
made available to them.
____ d. All dosimeters shall be of a type that can
measure exposures of less than 0.1 mSv
(10 mrem).
13. Which of the following is (are) true?
____ a. Radioactive materials shall be restricted to
authorized locations.
____ b. Warning signs shall be used for radioac-
tive material containers.
____ c. Employees shall be given appropriate
training and safety instructions.

____ a. All radioactive materials should be stored
in a secured (locked) area.
____ b. Food shall not be stored in the same
refrigerator or freezer used for storage of
radioactive materials.
____ c. Eating, drinking, and smoking shall be
prohibited in areas where radioactive
materials are stored or used.
15. Which of the following is considered to be a suffi-
cient storage period for radioactive waste?
____ a. one half-life
____ b. two half-lives
____ c. five half-lives
____ d. ten half-lives
____ a. Technologists shall be aware of the
approximate amount of radiation received
by their patients during each radiographic
procedure used in their facility.
____ b. Technologists shall have access to and be
familiar with state regulation regarding
the safe use of radiation-producing
equipment.
____ c. Technologists shall be informed of the
approximate amount of radiation they are
likely to receive for a normal workload.
____ a. The maximum allowable dimensions of
the x-ray beam shall never exceed the size
of the image receptor for both radio-
graphic and fluoroscopic exposures.
____ b. The technologist should be aware of the
shielding design of the room and use
equipment accordingly.
____ c. Patients should be held only after it is

determined that available restraining
devices are inadequate.
18. Where should a personal dosimeter be worn
according to the NCRP?
____ a. at the level of the trunk when no lead
apron is necessary
____ b. at the level of the head and neck when no
lead apron is necessary
____ c. at the level of the trunk when a lead apron
is necessary
____ d. at the level of the head and neck when a
lead apron is necessary
____ a. Leaded aprons shall be worn during fluo-
roscopy, special procedures, and cardiac
imaging.
____ b. Leaded gloves shall be worn during fluo-
roscopy, special procedures, and cardiac
imaging.
____ c. Leaded aprons shall be worn by operators
of mobile equipment.
20. The exposure cord shall be at least 6 feet (2m) long
on mobile equipment.
____ a. true
____ b. false
21. Under the Safe Medical Devices Act, deaths, serious
illness, and serious injury attributable to medical
devices must be reported to which of the following?
____ a. Occupational Safety and Health
Administration (OSHA)
____ b. Food and Drug Administration (FDA)
____ c. Nuclear Regulatory Commission (NRC)
____ d. Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
22. Which form is used for making voluntary reports

under the Safe Medical Devices Act?
____ a. 3500
____ b. 3500A
____ c. 3500B
____ d. 3500C
23. Which of the following are components of the Safe
Medical Devices Act?
I. adverse event reporting
II. patient follow-up
III. medical device tracking
24. Which of the following would be considered user
facilities under the Safe Medical Devices Act?
____ a. hospitals
____ b. nursing homes
____ c. outpatient treatment centers
25. Which of the following is true regarding the storage
of photographic materials?
____ a. Store at a temperature of 60–70°F.
____ b. Store at a humidity ranging from 40–60%.
____ c. Store standing on edge.
26. Why should smoking be prohibited in photographic
darkrooms?
____ a. Ashes can produce artifacts in cassettes.
____ b. Smoke residue can be deposited on
screens and processor detectors.
____ c. Smoking produces light that can fog films.
27. What color should darkroom walls be painted?
____ a. white or light colors
____ b. fluorescent colors
____ c. dark colors

____ d. any color
28. Which of the following is a potential result of high
temperature/high humidity on film?
____ a. difficult film transport
____ b. swelling of the screen
____ c. perspiration resulting in increased finger
marks on radiographs
____ d. white blotches on the radiograph
29. Which of the following is true regarding the film
used for testing for darkroom fog?
____ a. It is the fastest type normally used.
____ b. It is a film of medium speed.
____ c. It is the slowest speed normally used.
____ d. none of the above
30. Where does fog tend to reduce film contrast?
____ a. low-density regions
____ b. mid-density regions
____ c. high-density regions
31. An exposure of test film in the darkroom for less
than one minute should produce an increase of ___
in the ___ of the film.
____ a. less than 0.05; low-density region
____ b. less than 0.05; mid-density region
____ c. more than 0.05; low-density region
____ d. more than 0.05; mid-density region
32. Which of the following represents the sensitivity to
the effects of darkroom fogging by unexposed film
as compared to exposed film?
____ a. more sensitive
____ b. less sensitive
____ c. just as sensitive
33. Which of the following is the minimum number of

14- x 17-inch films that need to be processed each
day to maintain the chemicals at the appropriate
activity level?
____ a. 15 to 25
____ b. 25 to 35
____ c. 15 to 40
____ d. 25 to 50
34. Which of the following methods of processor moni-
toring do not have demonstrated value?
I. sensitometry
II. bromide concentration
III. pH
35. The limits (in density) for the upper control limit
(UCL) and lower control limit (LCL) for speed point
and average gradient on the processor control chart
should be set at ±:
____ a. 0.05
____ b. 0.10
____ c. 0.15
____ d. 0.20
36. What is the correct procedure following cleaning of
cross-over rollers at the end of the day?
____ a. They should be left out until the next day.
____ b. They should be left out for one hour.
____ c. They should be left out for five minutes.
____ d. They should be immediately replaced.
37. For archival purposes, staining of films should be
prevented for at least ___ years; preferably for ___
years.
____ a. 5; 10 to 15
____ b. 10; 10 to 15
____ c. 5; 20 to 30
____ d. 10; 20 to 25
38. Which of the following is a useful tool in addition to

fixer retention testing to ensure adequate washing of
film?
____ a. pH measurement
____ b. bromide retention
____ c. flow meter on the water line
____ d. temperature gauge on the water line
39. How often should flood replenishment replace all of
the developer in the tank?
____ a. in an 8-hour workday
____ b. in a 24-hour day
____ c. every 16 working hours
____ d. every 24 working hours
40. Copy films are ___ films able to reproduce densities
faithfully from originals up to densities of ___.
____ a. single-emulsion; 2.3–2.5
____ b. single-emulsion; 3.0–3.2
____ c. double-emulsion; 2.3–2.5
____ d. double-emulsion; 3.0–3.2
41. For the typical diagnostic x-ray unit, it is acceptable
to measure HVL at a single kVp such as 80 kVp.
____ a. true
____ b. false
42. One of the most valuable quality control tests for
regular monitoring is measurement of the focal spot
size.
____ a. true
____ b. false
43. How often should cables and counterweights on
overhead x-ray tube systems be inspected?
____ a. daily
____ b. weekly
____ c. monthly
____ d. annually
44. Which of the following are types of tube rating charts?

I. single exposure rating charts
II. anode thermal characteristic and fluoroscopic
rating charts
III. housing cooling charts
45. kVp can be measured with devices such as the mod-
ified Ardran and Crooks cassette or Wisconsin Test
cassette within ± ___ kVp.
____ a. 0.5
____ b. 1
____ c. 2
____ d. 3
46. The fact that noninvasive measurements vary from
invasive measurements by 2–5 kVp is problematic
from the standpoint of quality control.
____ a. true
____ b. false
47. For three-phase units, to what percent should expo-
sure times in excess of the minimum exposure time
be accurate?
____ a. 2
____ b. 5
____ c. 7
____ d. 10
48. What is the acceptance limit for variance of C/kg-1
(mR/mAs)?
I. not more than ±10% between rooms using the
same types of generators, tubes, and tables
II. not more than ±10% for a single unit over time
III. not more than ±10% at different levels of kVp.
49. How often should grid cassettes and stationary grids

designed to clip onto a cassette be checked?
____ a. each month
____ b. every three months
____ c. every six months
____ d. each year
50. What is the acceptance limit for the densities of
films from similar cassettes and screens exposed
under similar conditions?
____ a. ±2%
____ b. ±3%
____ c. ±5%
____ d. ±10%
51. Which of the following is considered to be the final
test performed after all other quality control tests?
____ a. processor sensitometry
____ b. grid alignment
____ c. phantom film evaluation
____ d. screen-film contact
52. The density of patient-equivalent phantom films
produced by different units should be ± ___% of all
films, and should be ± ___% of he average exposure
for identical rooms.
____ a. 5, 5
____ b. 10, 15
____ c. 15, 10
____ d. 10, 10
53. On the material safety data sheets (MSDSs), what
level hazard is indicated by a 1?
____ a. slight
____ b. moderate
____ c. serious
____ d. severe
54. On the material safety data sheets (MSDSs), what

level hazard is indicated by a 3?
____ a. slight
____ b. moderate
____ c. serious
____ d. severe
55. CFR 1910.1030 (Occupational exposure to blood-
borne pathogens) indicates that protective equip-
ment must always be supplied to all employees.
____ a. true
____ b. false
56. Contaminated glassware can be picked up with the
hands as long as the employee wears durable
gloves.
____ a. true
____ b. false
57. An employer must make the hepatitis B vaccine
“available” to employees with occupational expo-
sure, but the employee must pay for it.
____ a. true
____ b. false
58. Which of the following is true regarding the hepati-
tis B vaccine provided to all employees?
____ a. The vaccine must be provided before they
begin their work assignment.
____ b. The vaccine must be provided the day they
begin their work assignment.
____ c. The vaccine must be provided within a
week of work assignment.
____ d. The vaccine must be provided within 10
days of work assignment.
59. Employees cannot refuse a hepatitis B vaccine.
____ a. true
____ b. false
60. It is necessary to secure an employee’s consent to

have blood drawn post-exposure to potential
HBV/HIV.
____ a. true
____ b. false
61. If an employee consents to baseline blood collection,
but does not give consent for HIV serologic testing,
how long must the sample be preserved?
____ a. 30 days
____ b. 60 days
____ c. 90 days
____ d. indefinitely
62. Red bags or red containers may be substituted for
warning labels for infectious materials.
____ a. true
____ b. false
63. Regulated waste that has been decontaminated need
not be labeled or color-coded.
____ a. true
____ b. false
64. When must training for employees with potential
occupational exposure be conducted?
I. at the time of initial assignment to tasks with
potential exposure
II. whenever standards change
III. annually
65. How long must medical records for employee expo-
sure be kept after the employment ends?
____ a. 5
____ b. 10
____ c. 20
____ d. 30
66. How long must training records be maintained?

____ a. 1 year
____ b. 3 years
____ c. 5 years
____ d. 10 years
67. Employees cannot engage in work activities involv-
ing infectious agents until proficiency has been
demonstrated?
____ a. true
____ b. false
68. If an employee refuses the initial HBV vaccination, a
later vaccination must be provided if the employee
desires, but the employee must bear the cost of the
vaccination series.
____ a. true
____ b. false
69. Which of the following describes controls such as
Sharps disposal containers that isolate or remove a
bloodborne pathogens hazard from the workplace?
____ a. workplace controls
____ b. exposure controls
____ c. occupational controls
____ d. engineering controls
70. Which of the following should be used to make an
employee aware of unsafe chemicals in the work
environment?
____ a. Physicians Desk Reference (PDR)
____ b. Periodic Table
____ c. Material Safety Data Sheet (MSDS)
____ d. Code of Federal Regulations (CFR)
71. For mammography phantom radiography, the mini-
mum number of objects required to pass ACR
accreditation is ___ fibers, ___ speck groups, and ___
masses.
____ a. 2, 3, 4
____ b. 3, 3, 3
____ c. 4, 3, 3
____ d 4, 4, 4
72. In phantom radiography for ACR mammography

accreditation, if half of the fiber is shown and in the
correct location and orientation, a score of 0.5 is
given.
____ a. true
____ b. false
accreditation, if two or more of the speck group are
visible, a full point is given.
____ a. true
____ b. false
accreditation if the shape of the mass is not circular,
the score is zero.
____ a. true
____ b. false
75. At 80 kVp, changes of 2 or 3 kVp will typically
change HVL by ___ mm Al eq.
____ a. 0.1
____ b. 0.5
____ c. 1.0
____ d. 1.5
76. Where should the device be placed when perform-
ing quality assurance tests that take measurements
from film, such as the kVp test cassette, or a step
wedge?
____ a. perpendicular to the anode-cathode axis
____ b. parallel with the anode-cathode axis
____ c. toward the cathode end of the tube
____ d. toward the anode end of the tube
77. Which of the following chemicals would require
wearing gloves and goggles when mixing a
developer solution?
____ a. sodium carbonate
____ b. sodium sulfite
____ c. sodium hydroxide
ANSWERS TO CHAPTER 2
PROGRAM STANDARDS/MAMMOGRAPHY
CRITERIA QUESTIONS
1. d Exposure is a measure of ionization caused by the
absorption of x-rays in a specified mass of air at the
point of interest; absorbed dose is the amount of radi-
ation absorbed in matter; becquerel is one of the
units (along with curie) used to specify exposure; and
activity is the rate of spontaneous nuclear transfor-
mation of a radioactive nuclide.
2. d Sources of radiation include the earth and sky, and
increased altitudes increase one’s radiation exposure.
Body tissues themselves contain radioactive atoms,
including potassium-40.
3. b Both an upper GI and a lumbar spine series will pro-
vide about 4–5 mGy of bone marrow exposure.
4. c During each half-life, 50% of the atoms will be trans-
formed; thus 10 half-lives, less than 1/10 of 1% (0.1%)
of the radioactive atoms will remain.
5. a Alpha emitters are rarely used in medicine, and are
easily absorbed in air; beta particles can penetrate a
few mm into living tissue; and gamma and x-rays
have a wide range of penetrating ability, dependent
on energy.
6. c Unless specifically exempted, sealed sources used for
teletherapy and brachytherapy must be leak-tested at
least every six months to ensure detection of inadver-
tent escape of the radioactive material.
7. a When energized, linear accelerators produce high-
energy x-rays. They can also produce high-energy
electron beams useful for shallow depth tumors, such
as those of the skin or head and neck.
8. a The protection factors of time, distance, and shielding
should be understood by all hospital personnel who
might be potentially exposed due to wide uses of radi-
ation throughout the hospital. Note however, that
occasional exposure in the course of one’s job duties

does not necessarily make one an “occupationally
exposed worker.”
9. a Lead shielding is most valuable for diagnostic x-rays;
plexiglass shielding is often used for beta because
beta particles convert their energy to x-ray upon
interaction with matter; and lead shielding may not
be effective for high-energy gamma radiation.
10. d It is most likely that the kVp has drifted downward,
and the automatic exposure device (phototimer) has
compensated for this by increasing mAs, which has
increased patient exposure to unacceptable levels.
One clue might be a change in the contrast of images;
however, since lower kV most likely improved the
contrast scale, it may have gone unnoticed.
11. a The slit camera, according to the NEMA standards, is
the best method used to determine focal spot size,
modulation transfer function, and focal spot bloom-
ing. Orientation and intensity distribution are best
determined with the pinhole camera. The Star test
pattern is used to measure limits of resolution.
12. b The site where a personal dosimeter is worn should
be documented in radiation exposure records; the
RSO should be contacted for guidance on the appro-
priate monitor; monitoring is not essential for all per-
sonnel, and most dosimeters used to monitor person-
nel cannot accurately record exposures of less than
0.1–0.2 mSv (10–20 mrem) and represent these as
“M” or minimal.
13. d Radioactive materials should be restricted to author-
ized locations; warning signs should be used for radio-
active material containers; and employees should be
given appropriate training and safety instructions.
14. d All radioactive materials should be stored in a
secured (locked) area; food should not be stored in
the same refrigerator or freezer used for storage of
radioactive materials; and eating, drinking, and
smoking shall be prohibited in areas where radioac-
tive materials are stored or used.
15. d Following ten half-lives, and surveying the material

with the right instruments, materials can be consid-
ered non-radioactive. Other means of managing
waste, in addition to storage for decay, include ship-
ment for burial, release to the environment, and
release to the sanitary sewer.
16. d Technologists shall be aware of the approximate
amount of radiation received by their patients during
each radiographic procedure used in their facility;
should have access to and be familiar with state reg-
ulations regarding the safe use of radiation-produc-
ing equipment; and should be informed of the
approximate amount of radiation they are likely to
receive for a normal workload within their assigned
working area.
17. d The maximum allowance dimensions of the x-ray
beam shall never exceed the size of the image recep-
tor for both radiographic and fluoroscopic exposures;
the technologist should be aware of the shielding
design of the room and use equipment accordingly;
patients should be held only after it is determined
that available restraining devices are inadequate.
18. a A variety of potential uses of the dosimeter with and
without an apron are described in NCRP #105; the
one firm recommendation is that the dosimeter
should be worn at trunk level when no lead apron is
necessary. This recommendation may conflict with
other recommendations.
19. a Leaded aprons should be worn during fluoroscopy,
special procedures, and cardiac imaging; lead gloves
should be worn during fluoroscopy, special proce-
dures, and cardiac imaging; and leaded aprons
should be worn by operators of mobile equipment.
20. b The cord to the exposure switch for mobile equipment
should be long enough to permit the operator to be at
least 2m (6 feet) from the patient during an exposure;
this does not mean that the cord must be 2m (6 feet).
In fact, if the console of the machine is large enough
to permit the operator to be adequately shielded by
the console, the exposure cord should be short to

encourage the operator to remain behind the console.
21. b The Safe Medical Devices Act of 1990 requires that
both manufacturers and user facilities report to the
Food and Drug Administration (FDA) deaths, serious
injury, and illness attributed to medical devices.
22. a The MedWatch reporting program was implemented
in June 1993 by the FDA, providing two forms: Form
3500, for voluntary reporting, and Form 3500A for
mandatory reporting.
23. b The two major components of SMDA are adverse
event reporting and medical device tracking. Medical
device tracking went into effect in August of 1993.
24. d SMDA defines hospitals, nursing homes, outpatient
treatment centers, and ambulatory surgical facilities
as user facilities. Physician offices and group prac-
tices that implant or distribute tracked devices are
also regulated under the tracking rule.
25. d In addition to being a photosensitive material, photo-
graphic film is also sensitive to heat, humidity, chem-
icals, mechanical stress, and ambient radiation.
These materials should be stored at temperatures
less than 24°C (75°F), with a range of 15–21°C
(60–70°F) preferred. Once film is opened it should be
stored in an area with humidity ranging between
40–60%.
26. d Eating, drinking, and smoking should not be allowed
in any darkroom. Smoking can produce artifacts in
cassettes, smoke residue can be deposited on screens
and processor detectors, and smoking in the dark-
room would produce light that can fog film.
27. a White or light colors are preferred, as it will help
vision when illumination levels are low. Counter tops
should also be white or a light color.
28. c Humidity above 60% may make films sticky and dif-
ficult to handle, while high temperature and/or high
humidity can cause perspiration resulting in finger
marks. Either high or low humidity can cause diffi-

cult film transport.
29. a The fastest film normally used in the darkroom
should be used for the darkroom fog test, and if more
than one type of film is used, the fastest film of each
type should be tested.
30. b Film fogging reduces film contrast in the regions of
the film most important to producing a quality image,
the mid-density regions of the film.
31. b There should be an increase of less than 0.05 in fog in
the mid-density region of the film (density of about
1.20), and ideally less than an 0.05 increase should be
seen at this region with the two-minute exposure to
the safelight.
32. b Unexposed films are less sensitive to darkroom fog-
ging than exposed films due to a threshold effect.
33. d Most mechanized processors require a minimum of
25–50 14- x 17-inch films be processed each day to
maintain chemical activity in the processor. If this is
not possible, various adjustments can be made, such
as flood replenishment or changes in the replen-
ishment rate (if volume is sufficient, but mostly small
films are being processed, as in mammography).
34. c Due to the complexity of chemical interactions in the
solution and the many chemicals in the solution, pH
and bromide concentration have not been proven to
be of value in processor monitoring.
35. b The upper control limit (UCL) and lower control
limit (LCL) for mid-density and density should be set
at ± 0.10.
36. a At the end of the work day, the cross-over rollers are
cleaned with warm water and a damp, soft cloth, and
dried. However, these rollers are not replaced until
the start of the next day.
37. d Staining is prevented by ensuring that films are
stored at the proper conditions of 21°C. (70°F), and a
humidity of 40–60%, in addition to adequate washing.

Staining should be prevented for at least 10 years, and
preferably 20 to 25 years.
38. c A flow meter is valuable in ensuring adequate wash-
ing, but especially when water must be filtered to
ensure the removal of particulate matter before
reaching the processor.
39. c Flood replenishment automatically adds a predeter-
mined amount of modified replenisher at specified
time intervals, and is selected so that all of the develop
in the developer tanks is replaced every 16 working
hours.
40. c Single-emulsion films are unable to reproduce all
densities on a radiograph; copy films can typically
reproduce the densities on an original film up to 2.3
to 2.5.
41. a It is acceptable to measure HVL at one kVp; HVL
should be measured annually and whenever x-ray
tubes are replaced or engineers service the x-ray tube
or collimator. One common mistake is not replacing
or adding filtration.
42. b Although all focal spots should be measured as a part
of acceptance testing, and whenever tubes are
replaced there is no value to regular monitoring of
focal spot size.
43. d Cables and counterweights should be inspected at
least annually, and should be lubricated with the
assistance of a service engineer as directed by the
manufacturer.
44. d Types of tube and housing rating charts include sin-
gle exposure rating charts specific to focal spot size,
anode rotation speed, and generator; anode thermal
characteristic and fluoroscopic rating charts; housing
cooling charts; and angiographic and cine rating
charts. If an x-ray tube sensor is used, it should be set
to provide a warning when anode heat reaches 75%
of maximum.
45. d The modified Ardran and Crooks cassette is accurate

±3 kVp whereas noninvasive measuring devices are
accurate ± 2% with a reproducibility of ±0.5 kVp.
46. b The accuracy of kVp need only be measured initially;
thereafter, measures of consistency provided by the
Ardran and Crooks cassette are sufficient from the
standpoint of quality control.
47. b For three-phase units, exposure times above the min-
imum exposure time should be accurate ±5%. For
single-phase units, the acceptance limits are ±1 dot
for 1/5 and 1/ 16 second, and ±0 dots for 1/20 and
1/30 second.
48. a The C kg-1(mR)/mAs, measured at 80 kVp, should be
maintained to within ±10% among rooms using the
same types of generators, tubes, and tables. If not,
unless exposures are predominantly automated, dif-
ferent technique charts are needed. On a single unit,
it should not vary more than ±10% over time. It
should be measured at least annually.
49. c Grid cassettes and stationary grids designed to clip
onto a cassette should be checked at least every six
months if the grid appears to be damaged, or if the
grid is suspected of creating artifacts.
50. c The light output of screen doses changes with age,
and cassettes that produce film densities outside of
the range of ±5% should be taken out of service or
isolated.
51. c The use of a phantom as the last quality control check
ensures that proper images can be produced, helps
monitor differences in exposure, and can indicate
whether problems are a result of equipment or per-
sonnel problems.
52. c The density of all patient-equivalent phantom films
produced by different units should be within ±15% of
all film, and entrance exposures should be within
±10% of the average exposure for identical rooms. If
the difference in exposure is due to certain factors
(e.g., HVL or technique), such variation should be
reduced by standardizing these parameters.
53. a On the MSDS, 1 would be slight hazard, 2 moderate,

3 serious, and 4 severe.
54. c On the MSDS, 1 would be a slight hazard, 2 moder-
ate, 3 serious, and 4 severe.
55. b CFR 1910.1030 (Occupational exposure to blood-
borne pathogens) indicates that protective equipment
must always be supplied to all employees.
56. b Broken or contaminated glassware cannot be picked
up with the hands according to CFR 910.1030 (Occu-
pational exposure to bloodborne pathogens), but
shall be cleaned up using mechanical means such as
brush and dust pan, tongs, or forceps.
57. b According to CFR 910.1030 (Occupational exposure
to bloodborne pathogens), the employer must make
the vaccine available to the employee at no cost, as
well as available at a reasonable time and place,
and performed by an appropriately licensed health
professional.
58. d According to CFR 910.1030, the hepatitis B vaccine
must be provided to all employees within 10 days of
work assignment unless the vaccination is con-
traindicated for medical reasons, the employee is
immune (as shown through antibody testing), or the
vaccine has been previously received.
59. b Employees can refuse the hepatitis B vaccine.
60. a For post-exposure to HBV/HIV, the exposed employ-
ee’s blood should be collected as soon as feasible,
after consent has been received. The employee may
also consent to have only baseline blood collection
done and if he or she consents within 90 days to have
HIV testing performed, it shall be done as soon as
feasible.
61. c If an employee consents to baseline blood collection,
but does not give consent for HIV serologic testing,
the sample shall be preserved for at least 90 days. The
employee may also consent to have only baseline
blood collection done, and if he or she consents within
90 days to have HIV testing performed, it shall be done

as soon as feasible.
62. a Although the orange or orange-red label typically
indicates a biohazard is used, it is acceptable to sub-
stitute red bags or red containers for labels.
63. a Once regulated waste has been decontaminated, it is
no longer required to label or color-code it.
64. d Training program records for employees with occu-
pational exposure must be provided at the time of ini-
tial assignment, within 90 days after the effective date
of the standard, at least annually thereafter, and
whenever standards change.
65. d Medical records to include hepatitis B vaccination
status must be maintained for at least the duration of
employment plus 30 years.
66. b Training program records must be maintained for at
least 3 years, and must contain the dates of the train-
ing session, the contents or summary of the session,
the names and qualifications of those providing the
training, and the names and job titles of all attending
the session.
67. a The training program and the assignment of work
duties must follow a logical progression, and employ-
ees cannot engage in work activities involving infec-
tious material until they are proficient to do so.
68. b The cost of the vaccination is always bore by the
employer.
69. d Controls such as Sharps disposal containers that iso-
late or remove a bloodborne pathogens hazard from
the workplace are known as engineering controls.
70. c Employees are made aware of unsafe chemicals in
the work environment through the MSDS or Material
Safety Data Sheet.
71. c For radiography of the mammography phantom the
minimum number of objects required to pass ACR
accreditation is 4 fibers, 3 speck groups, and 3 masses.
72. a In phantom radiography by ACR mammography

accreditation, if half of the fiber is shown and in the
correct location orientation, a score of 0.5 is given.
The score is 1 applies if the entire fiber is visible at
the correct location and orientation, and zero if less
than half is visible.
73. b In phantom radiography by ACR mammography
accreditation, if four or more of the six specks are vis-
ible a full point is given. The score of 0.5 is given if
two are visible, and zero if less than two are visible.
74. b In phantom radiography for ACR mammography
accreditation, if the shape of the mass is not circular,
but the density difference is at the correct location,
the score is 0.5. It is given a full point if the density
difference is seen at the correct location with a circu-
lar border, and zero if there is only a hint of a density
difference seen.
75. a Change of 2 or 3 kVp at about 80 kVp will change HVL
by about 0.1 mm Al eq.
76. a The heel effect is the change in intensity of the x-ray
beam along the anode-cathode axis. Placing devices
perpendicular to the axis will ensure a minimal vari-
ation in intensity along the length of the device.
77. c Sodium hydroxide is the strongest alkali, commonly
called lye. It is very corrosive and can eat away at the
skin, requiring gloves and goggles.
Quality Improvement
Concepts
1. Which of the following is (are) true regarding
Deming’s 14 points?
____ a. It has specific managerial structure.
____ b. Its emphasis is on management by
objectives.
____ c. It has process orientation.
2. Which of the following are philosophical founda-
tions of CQI?
I. Systems View
II. Implementer Involvement
III. Single Causation
3. The primary decision-making criteria for CQI is
price.
____ a. true
____ b. false
55
56 Chapter 3 Quality Improvement Concepts
4. Which of the following would be considered internal

customers in a hospital?
I. physicians
II. employees
III. patients
5. Which of the following are considered customers in
a CQI system?
I. patient
II. provider
III. payer
6. Most participants in CQI can be considered both
customers and suppliers.
____ a. true
____ b. false
7. Which of the following is the best source for infor-
mation about quality?
____ a. supplier
____ b. customer
____ c. employee
____ d. manager
8. What is the function of management in CQI,
according to Deming?
____ a. Be responsible for data collection.
____ b. Provide rewards and punishment for
performance.
____ c. Track down the causes of poor
performance.
____ d. Optimize the system.
9. What is the main reason for failure of a team?

____ a. unskilled leadership
____ b. lack of effective training
____ c. unclear goals, including lack of adequate
customer definition
____ d. dysfunctional behavior by team members
10. Which of the following is (are) phase(s) in the
formation and use of CQI teams?
____ a. orientation
____ b. development
____ c. reiteration
11. Which of the following would be useful in docu-
menting problems with patient transport?
I. flowchart
II. cause-effect diagram
III. Pareto chart
12. Which of the following is expressed by the state-
ment, “Whenever a quality problem has multiple
causes, just a few of those causes account for most
of the incidents”?
____ a. Deming’s first principle
____ b. crosstab incidence
____ c. the Pareto principle
____ d. the quality improvement principle
13. It is not necessary to investigate the cause if a con-
trol chart is consistently on the low end (more than
eight occurrences) as long as it does not exceed
control limits.
____ a. true
____ b. false
14. How many standard deviations represent the limits

of a control chart for CQI?
____ a. one
____ b. two
____ c. three
____ d. four
15. What term describes a chart that documents the
mean?
____ a. x-bar chart
____ b. s-bar chart
____ c. r-bar chart
____ d. p-chart
16. Which of the following is frequently used late in the
quality improvement process to answer the ques-
tion, “Are we doing better?”
____ a. run chart
____ b. control chart
____ c. cause-and-effect diagram
____ d. histogram
17. Which of the following describes a bar chart that
does not provide the ordering of a Pareto chart?
____ a. run chart
____ b. control chart
____ c. cause-and-effect diagram
____ d. histogram
18. Which of the following is (are) consistent with a
focus on continuity of care?
____ a. The same level of care is provided
throughout the care setting.
____ b. If nurses give injections on the floor,
nurses should also be responsible for
giving injections in radiology.
____ c. Floor nurses should accompany their
patients throughout the hospital.
19. If level 1 is the lowest level of understanding the

needs of customers, and level 3 is the highest, which
of the following is (are) most likely to bring about a
level 3 understanding?
____ a. unsolicited complaints
____ b. telephone hotline
____ c. focus groups
20. Which of the following describes the potential effect
of the time of day a survey is given on customer
response?
____ a. environmental contaminant
____ b. reliability variation
____ c. validity deficit
____ d. response-set bias
21. Which of the following indicates reproducibility of
measures on a survey?
____ a. reliability
____ b. construct validity
____ c. content validity
____ d. criterion validity
22. Which of the following is the greatest reliability in a
measure of central tendency?
____ a. mean
____ b. median
____ c. mode
____ d. standard deviation
23. Which of the following is appropriate if one is inter-
ested in whether cases fall only within upper and
lower halves of the distribution and not how far
from the central point?
____ a. mean
____ b. median
____ c. mode
24. What is calculated if one wants to determine the

most typical case?
____ a. mean
____ b. median
____ c. mode
25. What is calculated if interpretations about the
normal distribution curve are needed?
____ a. mean
____ b. median
____ c. mode
26. What tests one or more hypotheses indicating that
the means of all groups sampled come from popula-
tions with equal means, differing only because of
sampling error?
____ a. standard deviation
____ b. range
____ c. simple correlation
____ d. analysis of variance
27. Range/6 is approximately equal to how many
standard deviation(s) when the sample size is
approximately 100?
____ a. one ____ c. four
____ b. two ____ d. six
28. An analysis of contrast reactions for the past year
shows 20 reactions that were serious, and 15 of
those came from patients above the age of 65. Which
of the following is a reasonable conclusion?
____ a. Younger patients are not as prone to con-
trast reactions.
____ b. There were more serious reactions in the
older population.
____ c. Older patients should be considered pri-
mary candidates for non-ionic contrast.
____ d. All of the above are reasonable
conclusions.
29. Which of the following process measures (profes-

sional performance) is (are) of most use?
____ a. when an accepted standard of care
exists
____ b. when technology is effective
____ c. when patient variables (level of illness,
age, etc.) are controlled
30. The assumption that a hospital with a lower rate of
adverse consequences is producing the better
patient outcomes is reasonable.
____ a. true
____ b. false
31. What terms describes adjusting for differences in
case mix and case complexity?
____ a. outcomes analysis
____ b. epidemiology
____ c. risk adjustment
____ d. risk management
32. Which of the following first established corporate
liability of hospitals?
____ a. HCFA mortality data
____ b. HMOs
____ c. PPOs
____ d. The Darling v. Charleston Memorial
Hospital case
33. Which of the following is (are) the goal(s) of bench-
marking?
____ a. identify best practices in related settings
____ b. identify best practices in unrelated
settings
____ c. find ways to emulate best practices or use
them as performance standards
34. What term describes standards that reflect the best

practices of medicine?
____ a. institutional
____ b. empirical
____ c. absolute (normative)
____ d. internal
35. Both poor and good handling of data can make a hos-
pital’s outcomes look worse.
____ a. true
____ b. false
36. Which of the following is the most direct customer of
a requisition for a chest x-ray generated by the
admissions desk of a hospital?
____ a. patient
____ b. staff technologist
____ c. chief technologist
____ d. physician
37. Which term related to qualify is most synonymous
with quality assurance?
____ a. conformance quality
____ b. quality of kind
____ c. requirements quality
____ d. total quality
38. IN CQI, the causes of a problem are determined
based on which of the following?
____ a. institution
____ b. customer opinion
____ c. empirical data
____ d. management’s decision
39. Which of the following is the most appropriate state-
ment of a quality goal?
____ a. Quality is our most important product.
____ b. This year we will work to improve our cus-
tomers’ satisfaction.
____ c. No one will leave our department dissatisfied.
____ d. During this quarter, we will reduce patient
waiting time to no more than 10 minutes
after arrival in the department.
40. The expression “quality is free” means that it costs

nothing additional to implement a CQI plan.
____ a. true
____ b. false
41. Crosby was a proponent of which of the following
ideas?
____ a. “Zero defects” is the only performance
standard.
____ b. The costs of quality are less than the losses
of nonquality.
____ c. Conform to requirements to perform a
task correctly on the first try.
42. CQI techniques are applied only to processes where
problems have been identified.
____ a. true
____ b. false
43. Approximately how long does it take for an organi-
zation to transform itself by implementing CQI
techniques?
____ a. 6 months
____ b. 1 year
____ c. 5 years
____ d. 10 years
44. In health care organizations, medical specialization
adversely affects which of the following essential
components of CQI?
____ a. knowledge
____ b. commitment
____ c. communication
____ d. patience
45. One of the benefits that results from a CQI program
is increased employee satisfaction with the work
environment.
____ a. true
____ b. false
46. The cost of waste and nonconformance in the health

care system has been estimated to be what percent-
age of total costs associated with health care?
____ a. less than 10%
____ b. 20% to 40%
____ c. 55% to 60%
____ d. over 75%
47. While multidisciplinary teams are generally
regarded as desirable in CQI, their diversity may
also interfere with their functioning.
____ a. true
____ b. false
48. Which of the following describes a process owner
who is a member of a CQI team?
I. supports the improvement process
II. hinders the improvement process
III. holds an upper level administrative position
49. A successful team experiences high level of both sit-
uational conflict and interpersonal conflict.
____ a. true
____ b. false
50. All of the following characteristics are consistent
with the CQI/TQM philosophy except:
____ a. collective responsibilities
____ b. accountability
____ c. professional autonomy
____ d. process expectations
51. The concept of benchmarking includes which of the
following actions?
____ a. responding only as problems arise
____ b. changing based on the values of services
providers
____ c. doing things the same way for a long time

____ d. comparing products and processes to
those of the best competitor
52. On of the chief functions of top management in a
CQI organization is to distribute resources to
support the changes in processes.
____ a. true
____ b. false
53. Why is it especially important for academic health
centers to become involved in CQI?
____ a. They set the standards for patient care
____ b. They educate most of the physicians in the
United States
____ c. They conduct a significant portion of
research that affects health care
54. Which of the following is the most significant
conflict between management and practitioners in
the health care setting?
____ a. the quality of clinical care
____ b. relationships with patients
____ c. cost reduction
____ d. professional reputations
55. Which of the following is the best measure of team
performance?
____ a. quality of work products
____ b. amount of time needed to solve the problem
____ c. leader performance
____ d. developing a large number of work products
56. Which of the following typically describes CQI
teams?
____ a. They are ineffective.
____ b. They outperform individuals acting alone.
____ c. They provide minimal opportunity for
advancement.
____ d. They are not cost-effective.
57. How does management influence team effectiveness?

____ a. by being directive
____ b. by demanding rapid solutions
____ c. by demonstrating the significance of effort
____ d. by providing the team’s work rules
58. Who provided the earliest known method of evalu-
ating quality of clinical care by assessing patient
outcomes?
____ a. Deming ____ c. Codman
____ b. Donabedian ____ d. Nightingale
59. Which of the following is (are) component(s) of a
good team?
____ a. a small number of individuals
____ b. individuals with complimentary skills
____ c. individuals with a common purpose
60. Which of the following is (are) related to the state-
ment: “Cooperating departments with the best
intentions often lose sight of subtle slippage in
effectiveness and efficiency”?
____ a. Slippage is seen as an acceptable post-
implementation adjustment.
____ b. Slippage can be reduced by a dedicated
individual in the institution monitoring
CQI efforts.
____ c. Periodic meetings with employees (team
members) and mangers are useful.
61. Which of the following best accomplishes reducing
average length of stay?
I. long-term purchase contracts
II. developing critical pathways
III. improving discharging planning
62. Which of the following are elements of a well-

developed CQI program?
I. identify all customers for each service
II. development of a CQI panel
III. strong, directive management policies
63. How does CQI define “process”?
____ a. the steps required to provide care
____ b. a series of steps that achieve a desired
outcome
____ c. patient care activities
____ d. technical aspects of providing care
64. Which of the following is (are) most likely to
describe how CQI can save money?
____ a. reduce time spent on training
____ b. reduce time spent on meetings
____ c. reduce labor and material waste
65. A sentinel event is a single negative outcome
focused on by a CQI team.
____ a. true
____ b. false
66. What are the four foundational elements of the
quality improvement process as seen in the
Shewhart cycle?
____ a. find, organize, clarify, understand
____ b. plan, do, check, act
____ c. find, plan, organize, do
____ d. plan, find, check, act
67. Which of the following represents an activity in a
flowchart?
____ a. rectangle
____ b. oval
____ c. triangle
____ d. quadrangle
68. Which of the following are ranking mechanisms

used in group decision-making?
____ a. multivoting
____ b. rank ordering
____ c. both of the above
69. How would a CQI team most likely view the devel-
opment of a new method of ordering “stat” exami-
nations to deal with excessive “stat” exams—
superstat?
____ a. a good idea
____ b. the problem of excessive stat exams has
not been dealt with
____ c. we should brainstorm and collect data first
____ d. two of the above
70. Who is the primary customer in the production of a
report based on the radiologist’s reading of a film?
____ a. radiologist
____ b. referring physician
____ c. patient
____ d. transcriptionist
71. Who is the primary customer when the insurance
company pays a patient’s bill for a barium enema?
____ a. insurance company
____ b. referring physician
____ c. technologist
____ d. hospital/radiology department
72. Which of the following are true about employees as
customers?
I. They require services from other employees to
perform their job and are known as external
customers.
II. Job dissatisfaction is a factor in making them
less effective in handling customers.
III. They serve a marketing function by serving as
representatives of the institution to friends,
family, and acquaintances.

____ b. II and III only
____ c. I and III only
73. Third-party customers see which of the following as
important?
____ a. cost
____ b. quality of clinical services
____ c. ease of administration and accuracy
____ a. It cost about 5–10 times as much to recruit
a new customer than to retain an old one.
____ b. Most customers will not continue to do
business with an organization with which
they have problems, regardless of attempts
by that organization to solve the problem.
____ c. Complainers are the least likely to return
to an organization with which they had
problems.
75. Which of the following is (are) imperative for the
survey administered following customer service
training?
____ a. that it be criterion-based
____ b. that it measures changes in participant’s
attitudes
____ c. that it evaluates effectiveness of presenta-
tion and appropriateness of content
76. Which of the following has been identified as the most
important aspect of customer service to physicians?
____ a. new technology
____ b. efficient personnel
____ c. quick access to other physicians
____ d. services that contribute to their ease of
practice
77. What term describes the process for correcting

customer complaints?
____ a. malpractice adjustment
____ b. risk management
____ c. service recovery
____ d. focus feedback
78. In which of the following scenarios in the customer-
supplier chain is the patient the primary customer?
I. patient comes to physician complaining of low
back pain
II. technologist performs lumbar spine x-ray
II. hospital sends bill to third-party payer
79. For which examination might the patient be both
customer and supplier?
____ a. lumbar spine
____ b. barium enema
____ c. mammography
80. According the principle of TQM, who has the most
intimate knowledge of an organization’s work?
____ a. management
____ b. central administration
____ c. workers
____ d. all have different understanding of the
same work
81. What advantages include employee contributions to
the improving the work environment according to
TQM theory?
I. sense of ownership
II. reduces adversarial relationships
III. improves profitability

82. What is the primary difference between TQM and
CQI?
____ a. a TQM is a management philosophy while
CQI is a data collection and analysis
technique.
____ b. TQM is a public/employee relations
approach and CQI is the evaluation tech-
nique for that approach
____ c. both a and b are true
____ d. neither a nor b are true
83. Which of the following is a major difference QA and
QM?
I. standards of acceptability are set
II. quality outcomes are the goal
III. the focus of the process is the problems
84. Which of the following is not a component of quality
Improvement (QI)?
____ a. developed locally and responds to the
needs of the organization
____ b. customer and supplier satisfaction
____ c. rewards employee contributions
____ d. nurtures the professional instinct for
continuous self-assessment and improve-
ment through evaluation of variations over
time
85. According to Deming's 14 points, what is the func-

tion of mass inspection of products?
____ a. used to develop statistical profile of quality
____ b. allows for prospective quality measures
____ c. helps keep employees honest and
productive
____ d. such inspections are counter productive
86. What are the fundamental aspects of any job-related
training program?
I. job responsibilities and how to accomplish them
II. cross training where effective or useful
III. basic statistical control methods
87. What are some of the possible outcomes of using a
merit rating system?
I. pride in workmanship increases
II. creates rivalries and destroys teams
III. directs work toward evaluation rather than
quality
88. In an organization, who is responsible for knowing
and understanding the vision, mission, and guiding
principles?
____ a. everyone
____ b. only managers
____ c. only manager and QM personnel
____ d. it doesn’t matter as they have no impact of
organizational action
89. Which of the following are criteria any vision state-

ment should meet?
I. have consistency of purpose
II. be simple and easily understood
III. be energizing, compelling, and inspiring
____ a. I and II only ____ c. II and III only
____ b. I and III only ____ d. I, II, and III
90. Which of the following are aspects of a good
mission statement?
I. clearly defines the product of the organization
II. defines the scope of individual responsibility
III. clearly defines the efficiency goals of the
organization
91. What are the functions of guiding principles?
I. Empower employees to carry out the aims of the
organization without micromanagement.
II. Clearly define lines of authority within the
organization.
III. Enhance the flavor of the organization as estab-
lished in the mission and vision statements.
92. When designing customer satisfaction surveys,
which of the following is not acceptable?
____ a. must be administered by an
employee
____ b. must be short, precise, and concise
____ c. should include demographic variables
____ d. should allow for multiple responses to
most questions
93. What are KQCs?

____ a. aspects of the service important to the
customer
____ b. measurement points for quality control
____ c. the ratio between manpower commitment
and customer satisfaction
94. In quality management, KVPs have what
characteristics?
I. contain the cause and effect of process
variable
II. related to manpower, machines, material,
methods, environment, and measures of the
system
III. compare the cost of the product to the customer
satisfaction
____ d. I, II, and III only
95. Who are the customers of the radiology
receptionist?
____ a. referring physician
____ b. patients
____ c. technologists
96. Which of the following are steps in quality
measurement?
I. defining the process
II. defining the KQCs
III. creating data collection plan
97. What is operational definition?

____ a. a well worded definition?
____ b. explicit directions on how something is
evaluated
____ c. a definition based on a proven theory
____ d. any definition related to the operation of
equipment
98. Which of the following is not one of the five steps in
a process?
____ a. action
____ b. output
____ c. evaluation
____ d. customer
____ e. input
99. Who in a process defines “quality”
____ a. the customer
____ b. the supplier
____ c. the worker
____ d. management
100. Which of the following is not part of the continuous
improvement process?
____ a. identifying the customer
____ b. determining what the customer needs and
wants
____ c. providing what the customer wants and
improving on that
____ d. projecting what the customer will want in
the future
101. What is the difference between a common variation
and a special variation?
____ a. common variations are normal and con-
trollable while special variations are
uncontrollable
____ b. common variations are random in nature
and can not be controlled while special
variations are those that are caused by
changes in the process
____ c. special variations are those outside the

actual system that have an impact on the
system while common variations are with-
in the system
102. Which of the following contains an item that is not a
variable category?
____ a. machine and methods
____ b. environment and manpower
____ c. materials and finance
____ d. policy and methods
QUALITY IMPROVEMENT CONCEPTS
QUESTIONS
1. c Deming’s 14 points discuss processes, rather than
organizational structures, on a continuous process of
improvement, and the use of data. One of the fourteen
points specifically speaks against management by
objectives.
2. a The philosophical foundations, or elements, of CQI
are customer focus, systems view, data-driven analy-
sis, implementer (owner) involvement, multiple cau-
sation, solution identification solution identification,
process optimization, continuing improvement, and
organizational learning.
3. b Shewhart, on of the “founders” of the CQI/TQM
approach, has noted that price without an under-
standing of quality is meaningless, and that a focus
on low price would lead to additional expense in the
long run.
4. a Physicians and employees are the internal customers
of a hospital; patients are typically considered exter-
nal customers. Physicians are considered by most
managers as “internal customers essential to any
quality improvement initiative,” although consider-
ing employee satisfaction from the view of employee
as customer is a relatively new concept.
5. d All of these are considered to be customers in a CQI
system, and efforts must be directed to ensure that
customer satisfaction is maintained. Probably the
newest aspect of a CQI approach is viewing payers
(e.g. insurers) as customers that must be satisfied,
typically by providing service at the lowest possible
cost.
6. a A physician, for example, supplies patients (customers)
to the hospital, but is also a consumer of its services
and must be satisfied on both levels for optimum
quality.
7. b Although all of these individuals provide valuable

information about both process and outcome, the
definer of quality is the consumer of services, not the
provider (employee/supplier) or the optimizer of
processes (manager).
8. d In CQI, there is an emphasis on optimizing the deliv-
ery process to meet customer needs, regardless of pre-
cedents, and to implement system changes, regardless
of turf issues.
9. b Although all of these are reasons for team failure, as
well as jumping to solutions before identifying root
causes, lack of rewards and recognition, and a lack of
urgency or a champion for the project, the main rea-
son for team failure is lack of effective training.
10. a The three phases in the formation and use of CQI
teams are orientation, which includes establishment
of operating procedures, sharing of problem-related
information, and presentation of specialized/techni-
cal information; evaluation, which includes analysis
of the problem, generation of alternatives, establish-
ment of evaluation criteria, evaluation of alternatives,
and reconciliation of interests; and control, which
positions group solutions in relation to those accept-
able to environmental powers, recommendation of
alternatives, and implementation of the plan.
11. d All of these might indicate problems in the process of
patient transport. A flowchart will show the steps in
the process, which might help in identifying the “week
link.” A cause-effect diagram will help a group or indi-
vidual in charge of solving a patient transport problem
with brainstorming a solution, and the Pareto chart
(e.g., of time it takes to complete each step in the pro-
cess) might identify where the longest delays are
occurring.
12. c The Pareto principle states that whenever a quality
problem has multiple causes, just a few of those causes
account for most of the incidents. By using a Pareto
chart, which is a histogram that displays the relative
frequency of causes, a quality team can determine
which problems need to be attacked first.
13. b A process is considered under control when most

observations are near the centerline, with a few
points near both the upper and lower control limits.
However, most health care errors tend to be asym-
metrical, a consistent observation of points above or
below the center can indicate a problem as well.
14. c The control limits of a control chart are typically
standard deviations.
15. a The x-bar chart plots the mean; s-bar, the standard
deviation; r-bar, the range; and a p-chart, errors or
proportions of success.
16. a Run charts serve the function of showing where one
is compared with where one has been, and do not
specify control limits.
17. d A histogram is a bar chart that represents the fre-
quency distribution of a set of data without the order-
ing seen in a Pareto chart.
18. a Continuity of care reflects a consistent standard of
care; it would not indicate who provides that care.
Although one would expect a similar level of training,
barring legal mandates, it is not unreasonable to
expect that a radiographer could not give injections
as long as the training received was consistent. In a
CQI setting, all employees are considered staff.
19. c Unsolicited complaints and telephone hotlines are
only good for bringing about lower level understand-
ing of customer needs. Focus groups, benchmarking,
personal interviews, and structured surveys will
bring about the highest level of understanding of cus-
tomer needs.
20. a Individual variation in response due to predispo-
sition or other biases may influence response
(response-set bias); however, variations in response
due to time of day, temperature of the room or the
presence of others may influence response. For
example, poor parking facilities may cause a cus-
tomer to rate radiology services lower than expected.
21. a The reproducibility of measures describes reliability.

Construct validity is the extent to which a measure
agrees with others instruments thought to measure the
same thing; content validity is the extent to which a
survey covers the content area; and criterion validity
compares the results of a survey to a criterion measure.
22. a The mean provides the greatest reliability in the
three measures of central tendency (mean, median,
and mode); the standard deviation is a measure of
dispersion.
23. b Whenever a distribution is skewed or incomplete, or
if it is most important to determine whether cases
fall into upper or lower halves of the distribution and
not how far from the central point, the median is
calculated.
24. c The mode provides information about the most typi-
cal case, but provides only a rough estimate of central
value.
25. d The standard deviation will provide interpretive infor-
mation about the normal distribution curve, and pro-
vides information that will be needed if further inter-
pretation and calculations are necessary.
26. d The analysis of variance tests one or more hypotheses
indicating that the means of all groups sampled come
from populations with equal means, differing only
because of sampling error. Simple correlation meas-
ures the degree of relationship between two variables.
27. a The range divided by six should be approximately
equal to one standard deviation when the sample size
is approximately 100.
28. b All this data shows is that more serious reactions
exist in the older population. If this is a hospital that
serves a primarily geriatric population, fewer reac-
tions among younger patients should be expected,
simply because the population of older patients is
larger than that of younger patients. The statistical
proportion of contrast reactions in the older popula-
tion may be the same as or even less than that of the
younger population. Without further information, only

“b” can be seen as correct.
29. d Provider performance is often easy to measure; how-
ever, it does not necessarily provide the best infor-
mation, especially in situations where accepted stan-
dards of care do not exist, the technology is new or
untested, and great range exists in patient variables.
30. b This is not necessarily a correct assumption; outcomes
vary based on inputs (patient population) as well as
the process (resources available, provider perform-
ance). This is the information that has predominantly
been available in databases. For example, a cancer
center may be accepting only the sickest patients with
little hope of remission or recovery and thus engages
in mostly experimental treatments. In such a case, a
survival rate of one year is perhaps phenomenal and
cannot be compared to a cancer center with a five year
survival rate, but has patients that, on the most part,
have a reasonable hope of “recovery”.
31. c Risk adjustment or severity adjustment allows for
better comparison of hospitals in terms of outcomes
(report cards); a particular problem for academic
health centers who tend to receive the cases with the
highest risk and complexity through referral networks
or dumping.
32. d Although all of these movements have indicated or
reinforced the need for hospitals to be responsible for
establishing standards of care, the Darling vs. Char-
leston Memorial Hospital case first established that a
hospital governing body must know the standards of
care and the actions staff take to resolve them.
33. d Benchmarking seeks to identify the best practices in
related and unrelated settings and find ways to emu-
late best practices or use them as performance stan-
dards. Often the emulation of best practices in unre-
lated settings is the most difficult for health care pro-
fessionals (e.g., “My patients aren’t customers?”).
34. c Absolute or normative standards typically come from
academic health care centers and through clinical
trials; empirical standards are relative to other insti-

tutions treating similar patients; and institutional stan-
dards are those of the institution. The danger of insti-
tutional standards is that the institution uses itself as
its own control, whereas absolute standards may be
unattainable, and the “average” standard of the com-
munity may be misleading, if this level of care is poor.
35. a For example, a hospital that does a poor job in coding
comorbidities will have an apparent “poor” ranking
in relationship to other hospitals, and a hospital that
does a good job in coding complications will also
have a ranking that appears “poor” in relationship to
other hospitals. It must be remembered that data is
simply information, and poor or good handling of
that information will have definite outcomes on the
presentation of that information.
36. b All of these individuals are customers due to the fact
that they are influenced in their satisfaction by the
product (requisition) generated by the admissions
desk. However, the individual with the greatest stake
is the technologist. Thus, an improperly generated
requisition causes extra work for, and decreases the
satisfaction of, the staff technologist.
37. a Both conformance quality and quality assurance are
related to meeting a predetermined set of standards.
Requirements quality refers to meeting all the cus-
tomer’s requirements with a product, or providing
service that meets or exceeds those requirements.
Quality of a kind refers to a product or service that
greatly exceeds the customer’s requirements. Total
quality is a system of continuous improvement.
38. c Customer opinion is certainly important (in terms of
quality—the most important attribute), and may form
one data-set, but determining the cause of a problem
requires empirical data.
39. d Quality goals must be specifically worded, and vague
statements are to be avoided. Instead, according to
Juran, they must be phrased in such a way that their
achievement (or lack thereof) can be evaluated.
40. b Philip B. Crosby’s statement, “quality is free,” does not

mean that quality does not cost money; in fact achiev-
ing quality can be quite expensive. Instead, it means
that overall (including hidden costs), the cost of not
achieving quality or zero defects can be much more
expensive than the obvious costs associated with
quality improvement efforts.
41. d These are all components of Crosby’s approach to
total quality, and the emphasis on hidden costs is
usually quite good to illustrate to managers who have
not bought into quality improvement how valuable
quality can be to their institution, as well as the neg-
ative outcomes if they do not seek zero defects.
42. b It can be said that no process is truly problem-free,
and CQI works even for processes in which no appar-
ent problems are observed.
43. d Unfortunately, many individuals see CQI as just
another quick fix or management fad. In reality, unless
the institution is really committed to quality, it might
be better to not even attempt CQI. It takes 6–12 months
to get people knowledgeable enough to begin plan-
ning for CQI; another 6–12 months to complete the
first wave of training, and up to 10 years to fully imple-
ment CQI.
44. c Although all of these are influenced by medical spe-
cialization, communication is the most impacted. It
leads to “fiefdoms,” individuals who believe that only
their area can provide what the customer needs, so
they do not speak each other’s language. Also, spe-
cialization tends to encourage individuals to “learn
more and more about less and less.”
45. a One thing the empirical studies about CQI have found
consistently is that employee job satisfaction increases
with the implementation of CQI.
46. b The amount of waste in health care costs is estimated
at about 20–40%, which does not include costs such
as the cost of clinical errors.
47. a Too much diversity may mean that teams no longer

share common goals, limiting their effectiveness.
Some of this can be ameliorated by training in group
processes.
48. a A process owner can either support or hinder the im-
provement process, and must possess both knowl-
edge of the customer and the task-related knowledge
of a process.
49. b One of the dilemmas of CQI is making professionals
understand that situational conflict, which is typically
high in any successful organization, is not the same
thing as interpersonal conflict. A successful team will
be able to manage all types of conflict and help team
members differentiate interpersonal from situational
conflict.
50. c The TQM philosophy is based on collective responsi-
bility, accountability, and participation, all of which
may conflict with traditionally held notions of profes-
sional autonomy.
51. d TQM recognizes that there is competition to be studied
and surpassed, with the customer’s experience as the
basis of comparison, and the continuous improvement
is to be built into the process. To study competition
requires comparing one’s current performance against
that of the competition, known as benchmarking.
52. a In CQI/TQM, management makes fewer decisions,
but instead manages the culture of the organization
and allocates resources to support the change process.
53. d As leaders in health care, especially health care teach-
ing and research, academic health centers need to be
involved in CQI and TQM both to teach future lead-
ers about quality, as well as to conduct research that
will set standards for health care quality.
54. c By far the biggest disagreement between CEOs and
professional employees, such as physicians, is the need
for cost reduction; this can be true even in the managed
care setting.
55. a The best measure of team performance is quality of

work products. Focusing on the amount of time needed
to solve the problem, leader performance, and devel-
oping a large number of work products reflect a more
traditional approach which has not proven to be espe-
cially effective.
56. b Teams outperform individuals working alone. They
may appear to be more costly only if one does not
take into account the hidden costs of not achieving
quality.
57. c Management needs to get out of the way to help a team
work, and its best function is to continue to stress the
importance of the work effort.
58. d In the 1860s, Florence Nightingale used a systematic
approach to collecting and analyzing mortality rates
in hospitals.
59. d A small number of individuals, individuals with com-
plimentary skills, and individuals with a common pur-
pose are all components of effective teams.
60. d Cooperating departments with the best intentions
often lose sight of subtle slippage in effectiveness and
efficiency, seeing those as acceptable post implemen-
tation adjustments. Periodic meetings with employ-
ees (team members) and managers are useful to pro-
vide ongoing critique and assessment. Also, a dedi-
cated individual in the institution should monitor
CQI efforts.
61. c Long-term purchase contracts might be useful in reduc-
ing the cost of direct supplies. Developing critical path-
ways, improving discharge planning, reducing days
lost due to waiting for diagnostic tests, and developing
process improvement plans are all ways to reduce the
average length of stay.
62. a Identifying all customers for each service and devel-
opment of a CQI panel are both fundamental ele-
ments of a well-developed CQI program, along with
providing a well-developed vision statement and goals,
development of a monitoring group, and stakeholder
(including physician) involvement; however, the

main job of management in CQI is to optimize the
system and then get out of the way.
63. b Although all of the responses discuss or describe por-
tions of the process, the best definition of a process is
a series of steps that achieve a desired outcome.
64. c CQI typically requires a lot of training, and the team
approach requires a number of meetings to assess and
optimize the process. This will cost money. Where CQI
should save money is in reducing waste of labor and
waste of materials.
65. a Although teams should look at all the data, and assess
accordingly, in some cases, one negative event—called
a sentinel event—is the component that requires imme-
diate or sole attention.
66. b The Shewhart cycle consists of plan, do check, act
(PDCA), and today has been amended to FOCUS-
PDCA (find a process to improve, organize to im-
prove the process, clarify current knowledge of the
process, understand the sources of process variation,
select the process improvement plan, plan the improve-
ment, do the improvement to the process, study the
results, and act to hold the gain and continue to
improve the process).
67. a In a flowchart, an input or output is represented by an
oval; an activity by a rectangle; and a decision by a
quadrangle.
68. c Multivoting and rank ordering are used to rank the
ideas generated in a group. In multivoting, each mem-
ber is allowed to vote for 1/3 of the ideas, and in rank
ordering all ideas are ranked, with “1” being the most
important ideas. In both cases, the ideas with the fewest
votes or lowest rankings are eliminated.
69. d Simply adding another layer of “stat” will probably
not be helpful, instead what is needed is brainstorm-
ing and the collection of data to see why the “stat”
designation is so abused.
70. b Although the radiologist and patient are certainly

customers in the production of a report, the primary
customer is the referring physician. The transcrip-
tionist is considered to be the supplier of the service.
71. d The insurance company is the supplier of services in
this instance. The primary customer is the hospital or
radiology department.
72. c Employees, known as internal customers, require serv-
ices from other employees to perform their job. Job
dissatisfaction is a factor in making employees less
effective in handling customers, particularly in terms
of problems they feel unable to control. They also serve
a marketing function by serving as representatives of
the institution to friends, family, and acquaintances.
73. d Although it is often assumed that third-party customers
or payers only care about cost, they also expect quality
clinical services for their constituent groups, ease of
administration, and accurate, timely information. This
can be seen, for example, in the “report cards” that
have been developed by many payers regarding the effi-
cacy of clinical services by providers.
74. a It does cost about 5–10 times more to recruit a new cus-
tomer than to retain an old one. Most customers will
continue to do business with an organization with
which they have problems, if the organization attempts
to address those problems. Interestingly, complainers
are more likely to return to an organization with which
they had problems than non-complainers.
75. d Training outcomes are measured by a survey follow-
ing the seminar or training. Any such survey must be
based on the criteria established for customer service
(based on needs assessment), and should include
measurement of changes in attitude, effectiveness,
and appropriateness.
76. d Although certainly new technology and efficient per-
sonnel are important, and may lead to a physician’s
happiness, the most important thing for any service
provider to realize is that physicians value most serv-
ices that contribute to their ease of practice.
77. c The process for correcting customer complaints is

known as service recovery. The JCAHO requires
accredited institutions to have such a process in place.
78. b The patient is the primary customer when visiting
the physician and when the technologist performs
the examination; the insurance company, or payer, is
the customer when the bill is sent to the third-party
payer.
79. c Although traditionally the supplier has been the refer-
ring physician when patients present for radiology
services, the ability of patients in many instances to
self-refer themselves for mammography services would
make them both supplier and customer.
80. c Workers who are closest to a problem are the most
likely to see and understand their problem.
81. a Although profitability and efficiency are some of the
desired outcomes of TQM, theory does not predict
such an outcome.
82. a TQM is a management philosophy that states quality
is the ultimate goal of any organization so as to improve
the product and increase market share. CQI is the meth-
odology of identifying potential problems, designing
possible solutions, collecting data, and analyzing the
outcome. CQI is a circular process which repeats itself
endlessly.
83. b Quality outcomes are the goal of both Quality Assur-
ance and Quality Management. However, QA focuses
on setting standards and addressing only those parts
of the system that are not within those standards. QM
implies that there are no upper levels of quality past
which the quality is “good enough.”
84. c Although one possible focus of an effective organiza-
tion may be employee rewards, the focus of QI is on
the needs of the organization, employees, customers,
and supplies.
85. d A statistical profile of quality is usually obtained by
sampling products as opposed to mass inspections.
Because these inspections are retrospective, they are
only identifying “problems” and do not add to the qual-

ity of the product directly. Such an approach allows
individual employees to neglect quality as someone
else is responsible for that.
86. d In addition to the above, job training should include
how a job contributes to the purpose and an opera-
tional understanding of others jobs (professions/posi-
tions) within the organization.
87. c According to Deming, merit rating systems have
almost the exact opposite impact of an organization
than they are intended to have. The net effect of such
a system is reduced quality, reduced employee satis-
faction, and lack of cooperation.
88. a Unless everyone in an organization understands and
takes responsibility for striving to meet the mission,
vision, and principles of the organization, it will be
impossible to meet them.
89. d Vision statements should describe a possible, desirable
future, visualize new responsibilities for the organiza-
tion and the employees, describe how others should
see your organization, and define a target to reach. In
order to successfully do that, the vision statement
should meet all three of the above criteria.
90. d All of the listed criteria should include a good mis-
sion statement.
91. b Guiding principles do not address authority within
an organization but do identify core values, incorpo-
rate TQM principles, empower employees, and are con-
sistent with the mission and vision statements.
92. a For valid and reliable information gathering, a high
rate of response is needed. If a questionnaire is only
given by an employee, the level of response will fall.
93. a Key Quality Characteristics (KQCs) are those aspects
or qualities that are most important to the customer.
Unless these are constantly measured and improved,
customer satisfaction will not increase.
94. a Key Process Variable (KPVs) are the components of any

process that affect the outcome of the process. Items
listed in I above are the components of any system
being evaluated.
95. d A “customer” is anyone who is affected by the “owner”
of a process such as receptionist from whom KQCs
can be determined. In this example, the patient is the
obvious customer but the technologists receive and
act on the results of the receptionist’s actions. Physi-
cians are also customers in that their actions are deter-
mined, in part, by the actions of the receptionist. As an
example, if the receptionist misschedules, delays, or
inconveniences, the patient, the timeliness of the physi-
cian’s actions can also be affected.
96. d There are four steps necessary to define and measure
quality. The first step is to define the process. The sec-
ond step is to identify the Key Quality Concepts that
need to be measured. The third step is to operation-
ally define the DQCs so that the proper data can be
collected. Finally, a data collection plan needs to be
created and implemented.
97. b An operational definition is one that is so explicit that
there is no interpretation necessary to determine if
something meets that definition. For example, the
definition of “excessive base + fog” might be given as
any OD value above .30 when measured with a cali-
brated densitometer on an area a developed sheet of
film that has not been exposed to light or radiation
prior to development.
98. c The five steps of any simple process are supplier, input,
action, output, and customer. A process is that series
of actions repeated over and over again in order to
transform the inputs into the outputs.
99. a According to Deming, it is the customer that deter-
mines what constitutes quality. If customers are not
satisfied with the end product (output) they will stop
using the process and it will cease to exist.
100. d In the continuous improvement process, projecting
the future is not necessary. As the cycle of identifying
the customers and determining what they want and

need, the future needs and wants will be incorpor-
ated into the system as the customers become aware
of them.
101. b All processes have some level of inherent random
variation that cannot be controlled by changing the
system. These are outside the control of the system
and are referred to as common variations. Special
variations are those that are introduced into the sys-
tem by changing the steps of the system itself.
102. c The five major categories of variables in specific Key
Quality Concepts are manpower (then number and
qualification of people in the process), machines (equip-
ment used in the process), materials (the types and
quality of materials used in the process), methods
(how the machine, manpower, and materials come
together to produce the output), environment (physi-
cal and psychological aspects of the milieu in which
the process occurs), and policies (steps in the proce-
dure and policy manual used in the process).
Quality Improvement
Data
1. A chief technologist of a 250-bed hospital radiology
department wishes to compare staffing in his hospi-
tal with similar hospitals. He surveys 10 other
hospitals in his region, finding the following:
A B C D E F G H
Number of R/F Rooms 5 4 6 7 5 6 5 5
Number of Technologists 7 8 10 11 8 10 9 9
What is the mean number of technologists
employed?
____ a. 5
____ b. 5.2
____ c. 8
____ d. 9
2. In the following data set:
A B C D E F G H
Number of R/F Rooms 5 4 6 7 5 6 5 5
Number of Technologists 7 8 10 11 8 10 9 9
What is the ratio of technologists to rooms, on
average (mean)?
____ a. 1:1 ____ c. 1.89:1
____ b. 1.67:1 ____ d. 2:1
93
94 Chapter 4 Quality Improvement Data
3. In room 1, 2 of every 25 films are repeated. In room

2, it is 3 or every 35. Which room has the lower
repeat rate?
____ a. room 1
____ b. room 2
4. Which of the following is true with a mean score of
80, and a standard deviation of 5.
I. A score of 85 is one standard deviation above the
mean.
II. A score of 90 is two standard deviations above
the mean.
III. A score of 95 is four standard deviations above
the mean.
5. Although the temperatures in Nome, Alaska and
Honolulu, Hawaii over the course of a winter day
might be quite disparate, their variance might be
similar.
____ a. true
____ b. false
6. If you gave two surveys of patient satisfaction, and
achieved a 90% return on the first set, and 60%
on the second set, which of these is a reasonable
conclusion?
____ a. The second set cannot be trusted.
____ b. Both sets are within acceptable parame-
ters for returned surveys.
____ c. The second set would most likely provide
sampling error.
7. A study of your repeat rate for trauma reveals that it

is 8.0%. In general radiography, it averages 5.0%.
Which of these are reasonable conclusions?
____ a. Trauma is probably higher due to patient
mix and complexity.
____ b. Trauma’s rate is unacceptable.
____ c. Both rates are unacceptable.
____ d. There is probably one “bad” technologist
in trauma.
8. The percent of area under the normal curve that is
± one standard deviation from the means is:
____ a. 68%
____ b. 95%
____ c. 99%
____ d. 100%
9. Calculate the standard deviation of the following set:
1, 2, 4, 6, 8, 9.
____ a. 1.95
____ b. 2.95
____ c. 3.95
____ d. 4.95
10. A large variance in response will most likely have
what effect on standard deviation?
____ a. It gives a high standard deviation.
____ b. It gives a low standard deviation.
____ c. It has a moderate effect on standard
deviation.
____ d. It has no effect on standard deviation.
11. In general, the larger a focus group, the better, as it
will provide more chance for input to be statistically
significant.
____ a. true
____ b. false
12. Which of the following typically involves a retro-

spective research study?
____ a. clinical trials of medications or
procedures
____ b. review of databases
____ c. evaluation of patient outcomes
____ d. b and c
13. Which of the following is the minimum of data sets
required for reproducibility?
____ a. one
____ b. two
____ c. three
____ d. twenty
14. Raymond Jones thinks that the wait times for outpa-
tients in his facility are excessive, having gathered
the following data:
Wait Time % of Patients
>5 min 20
>10 min 30
>15 min 30
>10 min 10
20+ min 10
His benchmarks are 2 local competitors who guar-
antee wait times of 15 minutes or less. Which of the
following is (are) logical conclusions, based on the
above?
____ a. His wait times are excessive.
____ b. His wait times are acceptable.
____ c. He needs more information on how well
his competitors comply with their
guarantee.
15. What is the most likely effect shown in Figure 4-1?

____ a. patient communications errors
____ b. patient satisfaction
____ c. patient noncompliance
____ d. missed diagnoses
Patient Radiographs
Comatose Density not correct
Contrast not correct
Unable to communicate
Detail not recorded
No clinical signs manifested
Noise on image
Too young to communicate
Artifact on image
Multiple problems mask diagnosis
Distortion
Missed
Diagnosis
Misinterpret films
False positive
Misinterpret lab tests
False negative
Incomplete medical history
Wrong test
Rule out instead of rule in
Contaminated results
Incorrect hypothesis
Lab Tests Physician
Figure 4-1
16. What is the most likely effect shown in Figure 4-2?

____ a. physician problems with radiology
____ b. patient problems with radiology
____ c. reasons for canceling barium contrast
examinations
Patient is not prepped Patient refusal
Doesn't want exam performed

Did not use prep kit properly
Dignity will be taken away
Nurses forgot to prep
Barium tastes bad
Ate before exam
Afraid they will get sick
Reasons B.E.s
are cancelled
Misinterpret films
Heard other patients talk Misinterpret lab tests
Worried about what is wrong Incomplete medical history
Does not know what to expect Necessary exam
Patient is not prepped
Patient anxiety Radiologist
Figure 4-2
17. Which of the following is illustrated in Figure 4-3?

____ a. histogram ____ c. run chart
____ b. Pareto chart ____ d. scatter diagram
% Repeats Room 1
40
30
20
10
0
Too Too Centering Positioning Motion
dark light
Figure 4-3
18. Which of the following is most likely true in

Figure 4-4?
____ a. Patient factors caused the most repeats.
____ b. Machine factors caused the most repeats.
____ c. Technologist factors caused the most
repeats.
19. Which of the following most likely true regarding
Figure 4-5?
____ a. The inservice was implemented in June.
____ b. The inservice was implemented in January
and a new employee began in August.
____ c. The zero cases in November are normal
random fluctuation.
____ d. Two of the above are true.
% Repeats Room 1
40
30
20
10
0
Too Too Positioning Centering Motion
light dark
Figure 4-4
Number of Infections
Following Service
12
10
8
6
4
2
0
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Figure 4-5
20. Which of the following are designed to work with

subsystems containing trend charts?
____ a. one major variable
____ b. two major variables
____ c. three or four major variables
____ d. any number of major variables
21. What is the purpose of a trend chard?
____ a. It shows how well you are doing.
____ b. It shows failure.
____ c. It sustains quality
22. A system in control should show no variation.
____ a. true
____ b. false
23. Which of the following is not a clue on a trend chart
that a system is out of control?
____ a. three or more points on the target line
____ b. three or more points at the limit
____ c. three points above or below the target line
____ d. a majority of data points on one side of the
target line
24. Which of the following are reasons, from a trend
chart, to suspect that your system is out of control.
____ a. Three data points exceed one standard
deviation.
____ b. Three data points exceed two standard
deviations.
____ c. Five data points exceed two standard
deviations.
____ d. Five data points exceed two standard
deviations.
25. What is the definition of a histogram?
____ a. a variance in the system over time
____ b. a bar graph showing the frequency vs. time
____ c. an assessment of central tendencies over
time
26. Which of the following sets contains variables that

do not lend themselves to histograms?
I. patient waiting time, patient time of day, patient
types of exams
II. disease population, workload by hour, exam
value
III. procedure type of hours, computer down time,
number of incomplete requests by unit
27. At which interval on Figure 4-6 is the mode?
____ a. A
____ b. B
____ c. C
____ d. D
A B C D E
Figure 4-6
28. What is the relationship of the value to the baseline

at point ‘E’ of Figure 4-7?
____ a. higher
____ b. lower
____ c. same
____ d. not enough information
A B C D E
Figure 4-7
29. What is the name of the type of graph shown

in Figure 4-8?
____ a. scattergram
____ b. point graph
____ c. matrix graph
____ d. linear graph
Figure 4-8
30. What is the definition of a false positive?

____ a. something that is true but the test shows it
to be not true
____ b. something that is false but the test shows it
to be true
____ c. something that is true and the test shows it
to be true
____ d. something that is false and test shows it to
be not true
31. What is sensitivity?
____ a. the ability to detect values close to zero
____ b. the ability to detect very small changes in
values
____ c. the size of the units used by the instrument
____ d. the range of values the instrument can
measure
32. Which statement best differentiates reliability and
accuracy?
____ a. Reliability is getting the correct informa-
tion and accuracy has to do with how
often the information is correct.
____ b. Reliability is the ability of an instrument to
detect and accuracy has to do with how
correct that information is.
____ c. Reliability is how correct the information
is and accuracy has to do with how faith-
ful it is to reality.
____ d. Reliability is always getting the same value
from the same conditions and accuracy
has to do with how correct that value is.
33. What is inter-observer reliability?
____ a. The same observer always give the same
observation.
____ b. All observers give different values for the
same situation.
____ c. The variation in values between observers
is acceptably low.
34. What is the definition of correlation?

____ a. cause-and-effect
____ b. precursor and event
____ c. events tend to occur at the same time
35. What is the most common way to diagram factors
that cause variability in a system?
____ a. line graph
____ b. cause-and-effect diagram
____ c. flow chart
36. What is another name for the Pareto Chart?
____ a. bar graph
____ b. scatter graph
____ c. line graph
____ d. flow chart
37. What term describes the result of actions under
ideal circumstances or results, and usual or normal
circumstances?
____ a. efficacy
____ b. efficiency
____ c. effectiveness
38. What requires a consideration of outcomes but does
not require consideration of the cost of the action?
____ a. efficacy
____ b. efficiency
39. Which of the following describes the quality of an
output achieved for a given level of input?
____ a. efficacy
____ b. efficiency
40. What term describes the distribution and types of

patients cared for in a health facility?
____ a. epidemiology
____ b. case mix
____ c. outpatient care
____ d. case mix index
41. What term describes the amount by which the cost
of treating the average Medicare patient in a hospital
varies from the comparable cost for all hospitals?
____ a. epidemiology
____ b. case mix
____ c. outpatient care
____ d. case mix index
42. Which of the following is defined by the JCAHO as a
measurement tool to monitor the quality of an
indicator?
____ a. important governance functions
____ b. management
____ c. clinical functions
43. Which of the following is true according to JCAHO
regarding an incident?
I. applies to patients only
II. causes harm
III. has the potential to cause harm
44. Which of the following describes quality management?
____ a. A management activity aimed at improving
effectiveness.
____ b. A management activity aimed at improving
efficiency.
____ c. A management activity that is ongoing.
45. Which of the following is the goal of benchmarking?

____ a. to be the best in the business
____ b. to know the limits
____ c. to show patients you are as good as other
hospitals
46. Which of the following are included by JCAHO
under “doing the right thing?”
I. efficacy
II. appropriateness
III. availability
47. What term describes the degree to which care for
the patient is coordinated, over time, among practi-
tioners and organizations.
____ a. efficiency ____ c. continuity
____ b. efficacy ____ d. appropriateness
48. What term describes the characteristics of what is
done and how it is done?
____ a. efficacy
____ b. appropriateness
____ c. safety
____ d. dimensions of performance
49. Which of the following are uninterpreted observa-
tions or facts?
____ a. functions ____ c. information
____ b. data ____ d. assessments
50. Which of the following describes the degree to
which the risk of an intervention and the risk in the
care environment are reduced for the patient and
others, including health care providers?
____ a. timeliness ____ c. efficiency
____ b. efficacy ____ d. safety
QUALITY IMPROVEMENT DATA QUESTIONS
1. c The mean is obtained by adding up a set of scores and
dividing by the number of scores. Adding up the num-
ber of technologists gives 72, and there are 9 scores;
72 divided by 9 is 8.
2. b The mean number of rooms is 4.78 (43 divided by 9);
the mean number of technologists is 8. To calculate
the ratio of technologists to rooms, divide 8 by 4.78,
which gives 1.67.
3. b The repeat rate is calculated by dividing the number
of necessary repeats by the total number of films, thus:
2 ÷ 25 = 0.08 or 8%, and 3 ÷ 35 = 0.086 or 8.6%. Room
2 has a slightly higher repeat rate.
4. a Each increment of 5 is one standard deviation above
or below the mean; thus a score of 70 is two standard
deviations below the mean; 75 is one standard devia-
tion below the mean; 85 is one standard deviation
above the mean; and 90 is two standard deviations
below the mean.
5. a Even though it may be very cold in Nome, and pleas-
antly warm in Hawaii, the variance (the amount the
temperature varies) could be similar or even identi-
cal for both.
6. c Since the original sample size is not known, it cannot
be determined whether a sufficient sample exists in
either case; however, the second set is more likely to
produce sampling error.
7. a The most reasonable conclusion is that trauma has a
higher repeat rate due to patient mix and complexity.
Whether one or either rate is acceptable depends on
a number of factors, and jumping to the conclusion
that it must be one “bad” technologist is counterpro-
ductive, and not consistent with a CQI approach.
8. a The percent of area under the normal curve is ± 1
standard deviation from the mean is 68%, within ± 2
standard deviations is 95%, within ± 3 standard devi-

ations is 99%, and within ± 6 standard deviations is
almost 100%.
9. b Standard deviation is the square root of the sum of
the squared deviations from the mean divided by the
total number of scores. The mean of this set is 5; thus,
for example 9–5 = 4, and 4 squared is 16; 8–5 = 3, and
3 squared is 9, and so on. The sum of all the squares
is 52, when that is divided by the total number of
scores, we get 8.67, and the square root of 8.67 is 2.95.
10. a Standard deviation is an easily, algebraically manip-
ulated measure of variability; thus increases in vari-
ability or variance will increase standard deviation
proportionally.
11. b A focus group is best seen as a type of team, and teams
do not follow the same rules as one would make for a
survey. In general, some diversity is needed, but exces-
sive diversity could lead to lack of common goals or
viewpoints, which could limit the team’s effectiveness.
12. d Clinical trials are typically prospective (future-based)
studies, whereas epidemiologic, database, and out-
come evaluations are typically retrospective studies.
13. c The minimum number of data sets required for repro-
ducibility is three, with some sources recommending
five or ten. Typically more are required to document
a service problem than for routine QC.
14. c Benchmarking is not simply comparing numbers; it
is also looking at how those numbers are achieved. A
visit or call to other administrators would be helpful
here.
15. d In this cause-and-effect or fishbone diagram, in the
box on the right, the effect is missed diagnoses.
16. c In this cause-and-effect or fishbone diagram, in the
box on the right, the effect is reasons for canceling
barium contrast examinations.
17. a This unordered bar chart is a histogram. Pareto charts
are similar, but show the data from the longest bar on
the left to the shortest on the right.
18. c Patient factors (e.g., motion) are not the most likely
cause of repeats from this Pareto chart. It is unlikely
that a machine fluctuates from light to dark; thus, tech-
nologist factors are the most likely cause of repeats
here.
19. d The inservice was implemented in January and
took some time to take hold; a new employee starting
in August caused the rate to increase slightly; the
zero cases in November represent normal random
fluctuation.
20. c Trend charts are designed to work with subsystems
containing three or four major variables. Major vari-
ables are assignable and cause major movement; minor
variables are unassignable and fluctuate randomly.
21. c The goal of a trend chart is not to show how well you
are doing or to show failure; it is designed to prevent
failure by providing clues. This helps to sustain qual-
ity rather than working to fix a process after failure.
22. b Even a system under the best control will show a ran-
dom distribution of values with numbers that stray to
the high and low ends.
23. c According to McKinney (1997), the following are all
indicators that a system is out of control: any one data
point beyond a limit; any pattern over time; sawtooth
patterns that move up or down over five days or longer;
five consecutive data points all above or below the
target line; three or more consecutive points at the
limit; three or more points on the target line; three
data points exceeding two standard deviations with
two points on one side; five consecutive points increas-
ing or decreasing (three for MQSA); majority of
points on one side; if five data points exceed one s.d.
with four on one side; a wave pattern; or no change
after a change in a major variable.
24. d According to McKinney (1997), the following are all
indicators that a system is out of control: any one data
point beyond a limit; any pattern over time; sawtooth
patterns that move up or down over five days or longer;
five consecutive data points all above or below the
target line; three or more consecutive points at the

limit; three or more points on the target line; three
data points exceeding two standard deviations with
two points on one side; five consecutive points
increasing or decreasing (three MQSA); majority of
points on one side, if five data points exceed one s.d.
with four on one side; a wave pattern; or no change
after a change in a major variable.
25. b The proper term for a “bar graph” is histogram. They
graph frequency (at the height of the bar) over time
or by other subset such as exam type.
26. b The value of an exam and the population of a disease
are not frequency over time or subsets and would not
lend themselves to a bar graph.
27. c The mode is the value that has the highest frequency
or number or is the most common value. It is one of
the central tendencies of mean (average), mode (most
common), and medium (half of the scores are above
and half below).
28. c When a graph has a vertical (X) axis that goes above
and below the horizontal (Y) axis, values are either
positive (greater than the baseline), on the horizontal
axis (even to the baseline), or negative (below the hori-
zontal axis).
29. a A scattergram is used to give a visual presentation of
the relationship of values along a two dimensional
axis. The purpose of the scattergram is to give visual
clues about possible relationships. As an example,
the scattergram in this Figure shows that there is a
tendency for the values on the vertical axis to increase
as the values on the horizontal axis increase.
30. b The above choices are the four possible outcomes
from any test or evaluation. The actual situation may
either be acceptable/true or the situation may be unac-
ceptable/false. Any test on the situation may show the
condition to be acceptable/true or it may show the sit-
uation to be unacceptable/false. The graph in this
Figure shows the possible combinations.
31. b Sensitive is related to the ability to detect small changes

in values. With a high level of sensitivity, values close
to zero should be detected but the sensitivity relates
to detecting values throughout the range. The units
used by the instrument and the minimum/maximum
values of the instrument are related to the range.
32. d Reliability and accuracy are related terms but have
different meanings. Reliability means getting the same
value in the same situation each time. For example, if
a thermometer always read 5º low, it is reliable as it
always gives the same information in the same situa-
tion. Accuracy has to do with how correct the infor-
mation is. In the above example, the thermometer is
reliable but it is not accurate. It is possible to have a
reliable instrument that is not accurate but not to
have an accurate instrument that is not reliable.
33. c Inter-observer, or inter-rater, reliability is a measure
of the amount of variation among observers looking
at the same situation. In order for quality assess-
ments to be made, that level of variation must be kept
to an acceptable, low limit. An example of where a
high level of inter-observer variance (low reliability)
is evaluation of the maximum number of line/pairs
visible on a test radiograph. As everyone’s eyes vary,
and different people have different operational defini-
tions of what a visible line/pair is, the results will
have low reliability.
34. c Correlations are comparisons between two events or
values. A correlation in no way explains cause-and-
effect, nor does it indicate a precursor and event. A
correlation only indicates that when one thing hap-
pens, something else tends to happen or not happen.
Correlation can be direct/positive where one value
goes up and the other goes up. Or it can be indirect/
negative where one value goes up, the other goes
down. An example is that there is a negative correla-
tion between the number of trees in an area and the
crime rate. There is no cause-and-effect between
trees and the crime rate nor is one a precursor for the
other. The correlation is due to the fact that the crime
rate is very low in the middle of a forest and much

higher in the middle of a city where there are few
trees.
35. b A cause-and-effect (sometimes called a fishbone dia-
gram) is the most common method of diagraming
factors that effect a system. Below is a simple fish-
bone diagram on patient waiting times in radiology.
36. a The Pareto Chart is the name given to a specific type
of bar graph where the frequency (number) of vari-
ations is graphed against the types of variations. An
example of this chart is to graph the number of
repeated examinations by reason for the repeat.
37. a The result of actions under ideal circumstances or
results under usual or normal circumstances defines
efficacy.
38. c Effectiveness requires a consideration of outcomes
but does not require consideration of the cost of the
action.
39. b Effectiveness describes the quality of an output
achieved for a given level of input.
40. b Case mix is the distribution and types of patients cared
for in a health facility. Age, type of illness, source of
payment, and acuity are some of the factors that affect
case mix.
41. d The case mix index is the amount by which the cost
of treating the average Medicare patient in a hospital
varies from the comparable cost for all hospitals. A
number greater than one indicates a more complex
case mix than the average, with most hospitals falling
between .8000 and 1.200.
42. d The JCAHO defines indicator as a measurement tool
to monitor the quality of important governance, man-
agement, clinical, and support functions.
43. c According to JCAHO, an incident is any event in a
hospital or other health-care facility that is harmful,
may result in injury, that results in an unexpected
outcome, or that could cause liability.
44. d Quality management is a management activity aimed

at improving effectiveness and efficiency. It is an
ongoing and continuous process.
45. a The goal of benchmarking is to be the best in the busi-
ness and to surpass all competitive organizations.
46. a Both efficacy (the degree to which the care of the
patient has been shown to accomplish the desired or
projected outcome) and appropriateness (the degree
to which care provided is relevant to the patient’s clin-
ical needs, given the current state of knowledge) are
included under “doing the right thing.” Availability
(the degree to which appropriate care is available to
meet patients’ needs) is included under “doing the
right thing well.”
47. c The degree to which care for the patient is coordi-
nated among practitioners, organizations, and over
time describes continuity, according to JCAHO.
48. d Dimensions of performance are the characteristics of
what is done and how it is done.
49. b Uninterpreted observations or facts are data; infor-
mation is interpreted sets of data; organized data that
can assist in decision-making.
50. d Safety is the degree to which the risk of an interven-
tion in the health care environment is reduced for the
patient and others, including health care providers.
Physical Principles
1. Which of the following describes waves that are
totally in phase with the resultant composite
waveform?
____ a. decreased amplitude
____ b. increased amplitude
____ c. the amplitude of the highest waveform
____ d. the amplitude of the lowest waveform
2. In a three-phase, sic-pulse generator at 80 kVp, what
is the lowest voltage across the x-ray tube in theory?
____ a. 0 kV
____ b. 40 kV
____ c. 69 kV
____ d. 80 kV
3. The type of generator where the AC voltage wave-
forms are rectified and then fed into a DC frequency
modulator is:
____ a. single-phase
____ b. three-phase, six-pulse
____ c. three-phase, twelve-pulse
____ d. high-frequency
115
116 Chapter 5 Physical Principles
4. Which of the following is the ideal voltage ripple?

____ a. 100%
____ b. 13.5%
____ c. 3.5%
____ d. 0%
5. Which of the following comprises most anode disks
for diagnostic radiography equipment?
____ a. tungsten
____ b. rhenium
____ c. molybdenum
6. What is the typical anode disk diameter range?
____ a. 2.5 cm (1 in)–10 cm (4 in)
____ b. 2.5 cm (1 in)–12.5 cm (5 in)
____ c. 5 cm (2 in)–10 cm (4 in)
____ d. 5 cm (2 in)–12.5 cm (5 in)
7. Which of the following is true if the tilt angle of the
anode is near 0?
____ a. The actual focal spot will be larger than
the effective focal spot.
____ b. The effective focal spot will be larger than
the actual focal spot.
____ c. The effective focal spot will be equal to the
actual focal spot.
____ d. The above does not provide enough infor-
mation to determine the relationship
between effective and actual focal spot
size.
8. What occurs if the tilt angle of the anode is
increased?
____ a. The size of the actual focal spot increases.
____ b. The size of the effective focal spot
increases.
____ c. The size of the actual focal spot decreases.
____ d. The size of the effective focal spot
decreases.
9. Poor screen-film contact tends to be more common

in which cassettes?
____ a. smaller
____ b. larger
____ c. slower
____ d. faster
10. What is the actual cause of blurring in poor screen-
film contact?
____ a. motion of the light produced in the screen
____ b. increased divergence of light
____ c. increased distance of the part from the
film
11. What effect does fog have on the manifest image?
____ a. base + fog increases, contrast increases
____ b. base + fog increases, contrast decreases
____ c. base + fog decreases, contrast decreases
____ d. base + fog decreases, contrast increases
12. The lesser-exposed side of the sensitometric strip is
fed into the processor first to minimize which of the
following?
____ a. bromide drag
____ b. the time the strip is in the processor
____ c. electron activation
____ d. chemical contamination
13. Which of the following might be expected as a result
of slight contamination of developer with fixer?
____ a. increased speed and decreased contrast
____ b. decreased speed and increased contrast
____ c. increased speed and increased contrast
____ d. decreased speed and decreased contrast
14. When the slope of the straight-line portion of the
DLOGE curve is greater. Which of the following
describes the film in comparisons to other films?
____ a. It would be faster.
____ b. It would be slower.
____ c. It would have lower contrast.
____ d. It would have higher contrast.
15. When the plotted curve of a film is “more to the left”

or closer to the Y axis, which of the following best
describes it in comparison to other films?
____ a. It would be faster
____ b. It would be slower.
____ c. It would have lower contrast.
____ d. It would have higher contrast.
16. What is the optical density range of unexposed
processed x-ray film?
____ a. 0–0.5
____ b. 0.1–0.15
____ c. 0.5–0.1
____ d. 0.15–0.2
17. What is the approximate light transmission rate
through unexposed, processed x-ray film?
____ a. 100%
____ b. 90%
____ c. 80%
____ d. 70%
18. What is the average gradient range of most
radiographic films?
____ a. 1.0–2.5
____ b. 1.5–3.5
____ c. 2.5–3.0
____ d. 2.5–3.5
19. What term describes the slope of the tangent at any
point on the DLOGE curve?
____ a. gradient
____ b. speed
____ c. Dmax
____ d. Dmin
20. What term describes a film with a wider range of
exposures in the useful density range?
____ a. less latitude
____ b. greater latitude
____ c. more density
____ d. less density
21. At what point is Dmax observed in the DLOGE curve?

____ a. gradient ____ c. toe
____ b. latitude ____ d. shoulder
22. On which of the following will spectral matching
have an effect?
I. density
II. contrast
III. latitude
23. What is the control value acceptance limit for base
+ fog in mammography?
____ a. 0.01 ____ c. 0.1
____ b. 0.03 ____ d. 0.3
24. What is the proper range of temperatures for pro-
cessing chemical storage?
____ a. 40–60º F
____ b. 50–60º F
____ c. 60–70º F
____ d. 70–80º F
25. What term describes the slope of the straight line
portion of a DLOGE curve?
____ a. Dmax
____ b. shoulder
____ c. average gradient
____ d. toe
26. The following sensitometry OD readings were made
using a 21-step penetrometer: step 8 = .035; step 9 =
0.55; step 12 = 1.95; step 13 = 2.12; and step 14 = 2.78.
How would density difference (DD) be calculated?
____ a. subtract step 14 from step 8
____ b. subtract step 13 from step 8
____ c. subtract 14 from step 9
____ d. subtract step 13 from step 9
27. Which of the following is (are) true about using a

molybdenum as a target material in mammography?
____ a. more low energy photons are produced
____ b. production of specific x-ray energies
required for breast imaging
____ c. increased patient dose
28. What percent of the beam will be composed of
bremsstrahlung with a tungsten target, at 80 kVp?
____ a. 100%
____ b. 90%
____ c. 70%
____ d. 50%
29. Comparing emission spectrum graph A (Figure 5–1)
to the other graphs, which demonstrates increasing
the “Z” number of the target?
____ a. graph B ____ d. graph E
____ b. graph C ____ e. graph F
____ c. graph D
30. Comparing emission spectrum Graph A (Figure
5–1) to the other charts, which demonstrates reduc-
ing the mAs?
____ c. graph D
5–1) to the other charts, which demonstrates reduc-
ing the kVp?
____ c. graph D
5–1) to the other charts, which demonstrates a
reduction in filtration?
____ c. graph D
Radiation Distribution Curves
# of # of
photons photons
kV Level kV Level
Graph A Graph B
# of # of
photons photons
kV Level kV Level
Graph C Graph D
# of # of
photons photons
kV Level kV Level
Graph E Graph F
Figure 5-1
33. Comparing emission spectrum of three phase pro-

duction in Graph A (Figure 5–1) to the other charts,
which demonstrates single phase production?
____ a. graph B
____ b. graph C
____ c. graph D
____ d. graph E
____ e. graph F
34. Of the following generators, which would have the

highest amplitude on the x-ray emission spectrum?
____ a. high-frequency
____ b. three-phase
____ c. single-phase
____ d. all of the above would have the same
amplitude
35. Which of the following are true about the dryer sys-
tem in an automatic processor?
I. Tubes used have a slit for air to exit.
II. A common temperature would be about
120º F.
III. The duct to the outside should be as straight as
possible.
36. Chemical deposits are more likely to form on
crossover racks.
____ a. true
____ b. false
37. What term describes the first set of rollers in many
processors that the film comes into contact within
an automatic film processor that is designed to acti-
vate the replenishment system?
____ a. entrance rollers
____ b. detection rack
____ c. feed rack
38. Unexposed silver halide crystals are completely
unaffected by the developer.
____ a. true
____ b. false
39. Which of the following would be considered to be

corrosion-resistant materials for the purposes of
mixing and storing processor chemistry?
I. enamel
II. polypropylene
III. aluminum
40. Which is the correct order of the assemblies in an
automatic processor?
____ a. entrance roller, racks, crossovers, turn-
arounds, squeegees, dryer
____ b. entrance roller, racks, turnarounds,
crossovers, squeegees, dryer
____ c. entrance roller, turnarounds, racks,
crossovers, dryer, squeegee
____ d. entrance roller, squeegee, racks, turn-
arounds, crossovers, dryer
41. Uniformly mixing the processing and replenisher
solutions, maintaining proper temperature and
chemical activity, and keeping thoroughly mixed
and agitated solutions in constant contact with the
films is accomplished by which of the following?
____ a. transport system
____ b. water system
____ c. recirculation system
____ d. replenishment system
42. To be used for processing, the water supply must be
drinkable.
____ a. true
____ b. false
43. What method of silver recovery uses iron, usually in
the form of steel wool?
____ a. electrolytic recovery
____ b. chemical precipitation
____ c. reverse osmosis
____ d. metallic replacement
44. What term describes the focal spot size as set by the
manufacturer?
____ a. normal
____ b. nominal
____ c. resolution
____ d. small
45. What term describes the byproducts that, when
allowed to accumulate in large amounts, will act as
a barrier to the developer solution?
____ a. pi marks
____ b. reaction particles
____ c. free radicals
____ d. solution inhibitors
46. What determines the size of the effective focal spot?
I. actual focal spot size
II. target angle
III. kVp
47. Which of the following affect resolution?
I. screen speed
II. screen-film contact
III. kVp
48. Spectral matching is the process of ensuring that the
set kVp matches the expected emission spectrum.
____ a. true
____ b. false
49. Which of the following have an effect on radiograph

contrast?
I. film
II. screens
III. focal spot size
50. A technique of 200 mA and .1 sec generated an
exposure of 60 mR. What is the mR/mAs?
____ a. 60
____ b. 20
____ c. 12
____ d. 3
51. Which of the following is (are) true regarding expo-
sures in mammography?
____ a. Too short of a time of exposure is not
problematic.
____ b. Too long of a time of exposure may cause
reciprocity law failure.
____ c. Exposure times will be fairly consistent for
breasts compressed to the same size.
52. Which of the following is (are) true about mammog-
raphy exposures?
____ a. Backup times may be reached due to the
inability of the set kVp to penetrate the
breast.
____ b. AECs can be designed to compensate for
reciprocity law failure during long
exposures.
____ c. Many new machines have circuits that
adjust the kVp to a higher level by sensing
the exposure in the first 100 milliseconds.
53. Which of the following is (are) true regarding

mammography?
____ a. The anode end of the tube is placed
directly over the chest wall side of the
image to take advantage of the prominent
heel effect of the anode.
____ b. Due to the line-focus principle, resolution
is decreased at the chest wall.
____ c. The actual focal spot and central ray must
be placed over the center of the image to
compensate for the line focus principle.
54. Which of the following is (are) an advantage(s)
of using rhodium (atomic # = 45) over molybde-
num (atomic # = 42) for mammography tube
targets?
____ a. It provides energies for a few keV above
molybdenum.
____ b. It allows for longer exposure times.
____ c. It is useful for all breast sizes.
55. What is the minimum HVL on a mammography
unit?
____ a. 0.2 mm Al eq
____ b. 0.3 mm Al eq
____ c. 2.0 mm Al eq
____ d. 2.5 mm Al eq
56. Which of the following describes the process where
one filament wire is used for both large and small
focal spots and a negative voltage is applied to
reduce the size of the electron stream?
____ a. double focusing
____ b. grid focusing
____ c. bias focusing
____ d. line focusing
57. Which of the following are common methods of

measuring contrast in diagnostic radiography?
____ a. gamma
____ b. average gradient
____ c. middle gradient
58. What would the average gradient be if D2 is 2.2, D1
is 0.45, E2 is 1.2, and E1 is 0.6?
____ a. 1.47
____ b. 1.75
____ c. 2.65
____ d. 2.92
59. The DLOGE curve of film 1 shows on E1 of 0.8, and
an E2 of 1.5. The H&D curve of film 2 shows an E1
of 0.6 and and an E2 of 1.5. Which of the following
is a true statement?
____ a. Both films will have an equal effect on
subject contrast.
____ b. Film 1 will exaggerate subject contrast
more than film 2.
____ c. Film 2 will exaggerate subject contrast
more than film 1.
60. Which of the following is (are) true about the pro-
cessing chemical hydroquinone?
____ a. It controls the toe of the curve.
____ b. It is the primary controller of contrast.
____ c. It is considered to be a stronger agent.
61. Which of the following is (are) true about the pro-
cessing chemical phenidone?
____ a. It is fast working.
____ b. It controls the grays of the image.
____ c. It is the primary controller of sensitivity of
the film.
62. Sensitometers are useful in the comparison of dif-

ferent types of radiographic film.
____ a. true
____ b. false
63. Which of the following will be exaggerated if a film
has an average gradient above 1?
____ a. subject contrast
____ b. gross density
____ c. image size
____ d. film-screen contact
64. Increasing the time or temperature of development
will have which of the following effects?
I. decrease average gradient
II. increase film speed
III. increase fog
65. Which of the following can be expressed in numeric
terms?
I. average gradient
II. speed
III. latitude
66. What term describes a film with a dye added to
enable it to better absorb light in the red spectrum?
____ a. orthochromatic
____ b. panchromatic
____ c. high speed
____ d. slow speed
67. Which of the following represents a doubling of the

relative exposure on a DLOGE curve?
____ a. 0.1
____ b. 0.3
____ c. 1.0
____ d. 3.0
68. If a 100-speed film is represented logarithmically
by 2.0, how is a 200-speed film be represented
logarithmically?
____ a. 2.0 ____ c. 3.0
____ b. 2.3 ____ d. 3.3
69. Which of the following is the minimum quantity of
fixer capable of contaminating a 1 gallon developer
tank?
____ a. 2 ml
____ b. 4 ml
____ c. 20 ml
____ d. 40 ml
70. On occasion, your chest unit appears to be “shooting
dark.” At first, technologists responded by halving
density, which produces a light film on the next
exposure. Service personnel have found nothing
wrong with the unit. This problem only occurs
around shift change at 4 PM. Which of the following
is the most plausible explanation?
____ a. Someone is loading the cassettes with
wrong speed film.
____ b. The processor chemicals are depleted.
____ c. There is probably a fluctuation in the elec-
trical supply
____ d. Any of the above may explain the problem.
71. What is the typical resolving power of a medium
speed intensifying screen?
____ a. 1 lp/mm
____ b. 3-10 lp/mm
____ c. 30-100 lp/mm
____ d. 100-300 lp/mm
72. Which of the following best describes high average

gradient films?
____ a. high contrast, high speed, and wide
latitude
____ b. high contrast, high speed, and narrow
latitude
____ c. low contrast, low speed, and wide latitude
____ d. low contrast, low speed, and narrow
latitude
73. What term describes the region of image reversal
once the DLOGE curve passes Dmax?
____ a. gamma
____ b. gradient
____ c. solarization
____ d. antihalation
74. Which of the following are advantages of using
greater SIDs?
I. less magnification
II. decreased patient exposure
III. less tube loading
75. Which of the following are characteristics of single-
emulsion films over double-emulsion films?
____ a. faster speed
____ b. lower contrast
____ c. narrow latitude
____ d. poorer recorded detail
76. What process is designed to prevent the loss of
recorded detail in single-emulsion film?
____ a. gradation
____ b. halation
____ c. antigradiation
____ d. antihalation
77. Which DLOGE curve appears as the “opposite” of

radiographic film (i.e., large exposures = lower
densities)?
____ a. cine film
____ b. single emulsion film
____ c. duplicating film
____ d. t-grain film
78. Which of the following are reducing agent in the
x-ray film developer?
I. hydroquinone
II. metol
III. phenidone
____ a. I only ____ c. II and III only
____ b. I and II only ____ d. I, II, and III
79. What is the proper pH of the developer solution?
____ a. acidic
____ b. basic
____ c. pH variable
80. What is the proper pH of the fixer solution?
____ a. acidic
____ b. basic
____ c. pH variable
81. Which chemical is responsible for the rapid devel-
opment of the gray tones of the radiograph?
____ a. phenidone
____ b. aluminum chloride
____ c. ammonium thiosulfate
____ d. hydroquinone
82. Which chemical is responsible for development of
the black tones of the radiograph?
____ a. phenidone
____ b. aluminum chloride
____ d. hydroquinone
83. What is the function of chelates in the developer?

____ a. controls pH
____ b. maintains chemical concentrations
____ c. controls for metallic ions
84. What is the function of acetate in the fixer?
____ a. maintains pH
____ b. controls oxidation
____ c. buffers the water bath
85. If 100% of the light is transmitted, what will be
the OD?
____ a. 0
____ b. 0.3
____ c. 1.0
____ d. 4.0
86. Which of the following does not control image
quality and brightness in an image intensifier?
____ a. kVp variations
____ b. mAs variations
____ c. video signal variations
____ d. electrostatic lens variations
87. What determines the penetration energy of an
x-ray?
____ a. the speed of the electron
____ b. the kVp
____ c. the type of electron/electron interaction
88. Which of the following is removed by filtration of
the primary beam?
____ a. long wavelength, high-frequency radiations
____ b. short wavelength, high-frequency
radiations
____ c. short wavelength, low-frequency radiations
____ d. long wavelength, low-frequency radiations
89. What is beam harding?

____ a. increasing the peak value
____ b. increasing the percentage of high energy
photons
____ c. increasing the percentage of low energy
photons
____ d. shifting the modal point of the graph to
the left
90. Generally, as the speed of a screen goes down, what
happens to the resolution?
____ a. it goes up
____ b. it goes down
____ c. it depends on the type of backing
91. Which of the following affects the speed of an intensi-
fying screen?
____ a. crystal size
____ b. phosphor layer thickness
____ c. phosphor type of screen
92. Which statement is not correct about adding antihala-
tion dyes to mammography film?
____ a. The dyes increase speed.
____ b. They reduce the density from screen light.
____ c. They reduce the lateral spread of phosphor
light.
____ d. They increase detail
93. Which element has the highest k-shell binding energy?
____ a. W
____ b. Ga
____ c. La
____ d. Y
94. Which of the following will give the greatest radi-
ographic density?
____ a. 50 speed screen
____ b. 100 speed screen
____ c. 200 speed screen
____ d. 300 speed screen
95. Which of the following is true about reciprocal law

failure?
I. It occurs frequently in diagnostic imaging.
II. It occurs at very short times.
III. It occurs at very long times.
____ a. I only
____ b. I and II only
96. What is reciprocity law failure?
____ a. The density of a film goes down when the
exposure is very short.
____ b. The density of a film goes down when the
exposure is very long.
____ c. The density of a film goes up as the expo-
sure is shortened.
____ d. both a and b
97. Which of the following is the formula for Optical
Density (OD)?
____ a. log (10) Io/It
____ b. log (10) It/Io
____ c. log (nat) Io/It
____ d. log (nat) It/Io
98. Why are some heavy metal filters such as holmium
and gadolinium used?
____ a. to absorb all energy levels except those
matched to a contrast media
____ b. to remove only high energy photons
____ c. to remove more of the low energy photons
____ d. to remove the middle range photons
99. What is the best means of preventing developer
chemical oxidation?
____ a. Use replenisher holding tanks that are as
large as possible.
____ b. Store chemicals at recommended
temperatures.
____ c. Use mixed chemicals within 10–14 days.

____ d. Use a floating lid in the developer tank.
100. Which of the following are appropriate uses of aver-
age gradient?
I. a comparison of the published average gradient
form films from a specific manufacturer.
II. as a relative measure of contrast
III. to compare the contrast of different film-screen
combinations
101. Which of the following film types will have the high-
est average gradient?
____ a. radiation therapy port film
____ b. mammogram
____ c. chest x-ray
____ d. CT scan
102. An exposure of 5 mr shows a density of 0.8 on a radi-
ograph. What density would be shown by 10 mR?
____ a. 0.9
____ b. 1.1
____ c. 1.6
____ d. 3.2
103. Which of the following is (are) true about quantum
mottle?
____ a. Quantum mottle increases with increased
film speed.
____ b. Quantum mottle increases with increased
kVp.
____ c. Quantum mottle has the greatest effect on
the perceptibility of low-contrast structures.
104. Which of the following is (are) true regarding latent

image fading?
____ a. Fading occurs if mammographic images
are not processed within one hour.
____ b. Fading occurs if the sensitometric strip is
not processed soon after exposure.
____ c. Fading occurs on the contrast scale of the
image.
105. Which of the following are reasonable exceptions
for latent image fading after 48 hours?
____ a. Optical density decreases by 0.3.
____ b. Film speed loss will be 20%.
____ c. Contrast loss will be 5%.
106. Which of the following is (are) true about reci-
procity law failure?
____ a. It can be high or low intensity.
____ b. It occurs at very short and very long expo-
sure times.
____ c. It produces little change in film contrast.
107. What term describes the misrepresentation of true
image size or shape?
____ a. crossover blur
____ b. parallax blur
____ c. absorption unsharpness
____ d. distortion
108. What increase in film density could be expected
from a 2º F increase in developer temperature?
____ a. 5%
____ b. 15%
____ c. 25%
____ d. 50%
109. Which of the following is a geometric variable?

____ a. kVp
____ b. pathology
____ c. SID
____ d. processor temp
PHYSICAL PRINCIPLES QUESTIONS
1. b When waves are totally in phase, the resultant com-
posite wave will have increased amplitude (additive
of the two); whereas when two waves are totally out
of phase (180º out of phase) a wave of reduced ampli-
tude (highest minus lowest) will be produced. Adding
waves of various phase relationships will produce a
composite wave of greater complexity.
2. c The ripple (maximum drop in voltage expressed as a
percentage of Vmax) of a three-phase, six-pulse gen-
erator should be 13.5%; thus 80 – (80 x 13.5% = 10.8)
= 69.2 kV.
3. d In a high-frequency unit, the single-phase or three-
phase AC voltage waveforms are rectified, and then
fed into a DC frequency modulator where the fre-
quency is converted from 60 Hz to the kHz range.
4. d Single-phase units provide the most ripple of 100%,
which means that maximum voltage across the tube
ranges from 100% to 0%; three-phase, six-pulse units
provide 13.5% ripple, meaning that maximum volt-
age across the tube ranges from 100% to 86.5%; three-
phase, twelve-pulse units provide 3.5% ripple, mean-
ing that maximum voltage across the tube ranges
from 100% to 96.5%; and high-frequency provide less
than 3.5%. Ideally, 0% ripple would exist, which would
mean that 100% of the maximum voltage was being
delivered across the tube.
5. d Although early anode disks were made entirely of
tungsten, today a compound anode disk is used that is
made of a base material, usually molybdenum, with a
good heat storage density, relatively low density, and a
coating layer of tungsten or tungsten alloy (often 90%
tungsten and 10% rhenium). The addition of rhenium
reduces roughening and cracking of the target surface
that can result from thermal stress.
6. d Disk size is an important factor, along with disk mass

and speed of rotation in determining safe thermal
loads; typical anode disks tend to range from 5 cm (2
in.) to 12.5 cm (5 in.) on rotating anodes.
7. a If the anode is not tilted, the actual and effective focal
spots will be the same size. Thompson uses the term
apparent focal spot rather than effective focal spot.
8. b Although an angle is necessary to provide an effective
focal spot that is smaller than the actual focal spot,
increasing the size of the angle will increase the size
of that effective focal spot. The actual focal spot size
remains constant.
9. b Causes of poor screen-film contact include foreign
bodies in cassettes, loose springs and hinges, and
twisted or warped frames; and it tends to be more
common in larger cassettes.
10. b The increased divergence of light caused by the
increased space between the film and screen causes an
increased divergence of light that appears as a darker
area on the film.
11. b Fog will increase the overall amount of base + fog in
the visible, or manifest, image and decrease contrast.
Fog is unwanted since it is a blanket that covers every
useful density on the radiograph.
12. a Bromide drag, also called bromide flow or directional
effect, occurs when the side of the strip with the great-
est exposure is fed first into the film processor. Putting
the darker end in first causes bromide byproducts to be
dragged over the film, which may retard development.
13. a When there is a slight contamination of the devel-
oper with fixer, the fixer tends to break down the sil-
ver bromide crystals, allowing the developer to reduce
more unexposed crystals. This increases chemical fog,
resulting in an increase in speed and a reduction in
contrast.
14. d The slope of the DLOGE curve indicates film contrast.
A steeper slope indicates higher contrast.
15. a Film speed is indicated by the position of DLOGE

curve. Faster speed films have their speed points to
the left of the film to which they are being compared.
16. b Although sources vary somewhat, and base + fog will
vary by film and manufacturer; in general, base + fog
of an unexposed film should range from 0.1–0.15.
17. c Unexposed, processed x-ray film should allow no
more than 80% of light to be transmitted through it. A
film with an optical density of 0.1 will allow 79% of
light to pass through; 0.15 optical density will allow
71% of light to pass through.
18. d The average gradient of x-ray films tends to be much
larger than 1.0 (which improves subject contrast), and
most have average gradients in the range of 2.5–3.5.
19. a The slope of the tangent at any point on the charac-
teristic curve defines gradient. There are a number of
gradients that can be calculated on the curve, includ-
ing average gradient and toe gradient.
20. b Latitude is the range of exposures over which the x-
ray film responds with densities in the diagnostically
useful range. A film with a wider range of exposures
is said to have greater, or wider, latitude.
21. d The level of portion or shoulder of the DLOGE curve is
the Dmax, or maximum density.
22. d Improper spectral matching (using a film that does
not match the spectral characteristics of the screen)
can influence density, contrast, and latitude, as well
as patient dose.
23. b In mammography, base + fog is allowed to vary with-
in 0.03 of the control value. In general radiography,
base + fog is usually allowed to vary with 0.05 of the
control value.
24. c The higher the temperature, the shorter the life of the
chemicals. Above 100º F, chemicals might only last
one month; at 70º F, their life is about 12 months.
25. c Average gradient is the average of all gradient points
on a DLOGE curve that exist between 0.25 and 2.0.
26. d Density difference (DD) or contrast is calculated by

the difference between the step closest to 2.2 but not
below 2.0 and the step closest to but not below 0.45.
Thus, in this case one would subtract step 13 from
step 9.
27. d Advantages of Molybdenum
a. produces more low energy
b. resultant image has higher contrast
c. produces x-ray energies
Disadvantages
a. less x-ray photon output photons due to lower
atomic number
b. increased mAs requiring radiographic contrast to
maintain film density
c. increases dose to the patient required for breast
imaging.
28. b With a tungsten target at less than 70 kVp, about 100%
of the beam will be bremsstrahlung; at 80 kVp, about
90%, at 150 kVp, about 70%.
29. b Changing the “Z” number of the target material
affects both the bremsstrahlung radiation production
and the characteristic production. If the “Z” number
increases, there will be more high energy photons
produced as well as a higher characteristic line.
30. c Changing mAs will change only the amplitude in both
the bremsstrahlung and characteristic areas of the
spectrum; energy will be unaffected.
31. d Changing the kVp lowers the peak energy, increases the
number of lower energy photons produced, and re-
duces the number of characteristic photons produced.
32. e Reducing the filtration increases the number of low
energy photons in the beam but does not change the
peak energy or the characteristic radiation production.
33. e Single-phase radiation production has lower average
energy, fewer overall photon production, and fewer
characteristic production than three-phase production.
34. a When compared with single-phase, three-phase shows

about a 12% increase in the number of x-rays; high
frequency shows an increase of about 16% over single-
phase.
35. d In the dryer system in an automatic processor, the
tubes used have a slit for air to exit, a temperature of
about 120º F is commonly used, and the duct to the
outside should be as straight as possible to maintain
efficiency.
36. a Since crossover racks are positioned partly in solu-
tion and partly in air, there is an increased potential
for chemical deposits to form on them. This necessi-
tates additional cleaning of these racks.
37. d The detection rack or feed rack is the first set of rollers
the film comes into contact with. They begin a process
that will activate the micro-switch controlling the
replenishment system. These are also called entrance
rollers.
38. b Although unexposed silver halide crystals are mostly
unaffected by the developer, there is a small number
that can be affected. This results in chemical fog.
39. a Enamel, hard-glazed earthenware, polyethylene,
polypropylene, glass, hard rubber, and ANSI Type
316 stainless steel with 2–3% molybdenum are con-
sidered to be corrosion-resistant materials for the
purposes of mixing and storing processor chemistry.
Reactive materials such as tin, copper, zinc, aluminum
or galvanized iron should never used.
40. b The correct order of the assemblies in an automatic
processor is entrance roller, racks, turnarounds, cross-
overs, squeegees, dryer. The number of assemblies and
specific designs may vary but the basic plan is the
same.
41. c The recirculation system uniformly mixes the process-
ing and replenisher solutions, maintains the proper
temperature and chemical activity, and keeps thor-
oughly mixed and agitated solutions in constant con-
tact with the films. The transport systems moves the
film through the processor, the water washes films

and stabilizes processing temperatures, and replen-
ishment keeps chemicals in their proper portions.
42. b Water used for radiographic processing must not nec-
essarily be drinkable; however, if undrinkable water
is used, its suitability must be assessed. Excessively
hard water and water containing dissolved sulfides
may not be suitable.
43. d Metallic replacement chemically replaces the silver in
solution with another metal, usually iron or steel wool.
Electrolytic recovery uses an anode and cathode, and
chemical precipitation is a commercial method that
adds various compounds to the fixer bath. Reverse
osmosis and ion exchange are methods of recovering
silver usually used in photo finishing operations.
44. b The size of the focal spot as quoted by the manufac-
turer of equipment is called the nominal focal spot.
This is not the same as the measured focal spot.
45. b Bromide and gelatin deposits known as reaction parti-
cles form on the surface of the film. A large amount of
them may cause the developing solution to be unable
to react with the exposed silver bromide crystals,
resulting in underdevelopment. Agitation is designed
to shake these particles loose from the film.
46. d The size of the effective focal spot depends on the
actual focal spot size and the target angles. The size of
the effective focal spot will decrease with smaller
actual focal spot sizes and smaller target angles. Focal
spot size is also affected by kVp and mA, which can
cause focal spot “blooming.”
47. a Resolution is a geometric image factor, and is expressed
in line pairs per millimeter. Although kVp might influ-
ence the visibility of detail, it does not directly affect
detail. Screen speed and screen-film contact, focal spot
size, OID, and SID all affect resolution.
48. b Spectral matching is producing equal wavelengths of
light; it usually refers to suiting the wavelength of
light generated to that of the imaging system. Thus,
for film-screen combinations, it involves assuring

that the light generated by the screens is the same
type of light that the film is most sensitive to.
49. a Radiographic contrast is the difference between den-
sities and is a photographic property of the image. It
is generally divided into two categories: film and sub-
ject. Film, screens, subject (e.g., pathology or tissue
composition), development, and kVp are all primary
factors in radiographic contrast. Focal spot size will
affect the image geometrically.
50. d mR/mAs is calculated simply by dividing the expo-
sure in mR by the mAs setting chosen. Thus, here
60 ÷ 20 = 3.
51. b In mammography, too short of an exposure time may
cause grid artifacts, too long of an exposure time may
cause reciprocity law failure, and exposure times can
vary greatly for breast compressed to the same size
due to variations in tissue makeup.
52. d In mammography, backup times may be reached due
to the inability of the set kVp to penetrate the breast,
AECs can be designed to compensate for reciprocity
law failure during long exposures, and many new
machines have circuits that adjust to the kVp to a
higher level by sensing the exposure in the first 100
milliseconds.
53. b The cathode end of the tube is place directly over the
chest wall side of the image to take advantage of the
prominent heel effect of the anode; due to the line-focus
principle, resolution is decreased at the chest wall; and
the beam is placed off-center to provide a smaller focal
spot at the chest wall, as well as allowing the vertical
central ray to enter straight in at the chest wall.
54. a The advantages of rhodium over molybdenum is that
it provides slightly higher kVs, which allow for reduc-
tions in exposure times. However, the higher kVp
may not be appropriate for smaller breasts.
55. b Regulations specify that HVL shall not be less than
0.30 mm Al eq at 30 kVp, the operating capability of
mammography equipment. Too high of an HVL (e.g.,

more than 0.40 mm) will decrease radiographic image
contrast.
56. c Bias focusing is a process where one filament wire is
used for both large and small focal spots and a nega-
tive voltage is applied to reduce the size of the elec-
tron stream, creating a smaller focal spot.
57. b Gamma is a measure of steepness of the DLOGE curve
along the straight-line portion, and is often used in
industrial and cine radiography and photography.
Average gradient is the average of the gradient points
that exist between the densities of 0.25 and 2.00, and is
commonly used in diagnostic radiography. Toe gradi-
ent (between 0.25 and 1.0), middle gradient (between
1.0 and 2.0) and upper gradient (between 2.0 and 2.5)
are not widely used.
58. d Average gradient is calculated by dividing (D2-D1),
which is always 1.75, by (E2-E1), giving in this case,
2.92.
59. b In film 1, average gradient is calculated by dividing
1.75 by (E2-E1) (0.7), which gives 2.5. In film 2, aver-
age gradient is calculated by dividing 1.75 by 0.9,
which gives 1.9. The higher the average gradient, the
greater the exaggeration of subject contrast will be;
thus film 1 will exaggerate subject contrast more
than film 2.
60. b Hydroquinone is slow working and is easily oxidized,
and thus, is considered to be a weaker developing
agent than phenidone. It affects black tones primarily,
controls the shoulder of the H&D curve (Dmax), and
thus, is a primary controller of contrast.
61. d Phenidone is fast working and plateaus after a time.
It controls the grays of the image, influencing the toe
of the DLOGE curve, controls the Dmin, and is the pri-
mary controller of film sensitivity or speed.
62. b Comparisons between films are only useful if those
comparisons are made with the exact type of light
used to expose the film (the spectral matching between
film and screen). However, for normal quality control

purposes, the type of light in the sensitometer does
not matter.
63. a A film with an average gradient of 1 will not affect
subject contrast; less than 1 decreases subject con-
trast; and more than 1 exaggerates subject contrast.
Image size and film-screen contact are geometric fac-
tors and are unaffected by a photographic property
such as average gradient.
64. c Increasing the time or temperature of development
will increase average gradient, increasing film con-
trast; increase film speed; and increase fog, which
decreases film contrast.
65. a Average gradient and speed are expressed numeri-
cally; latitude is not. However, in general, the latitude
of a film varies inversely with film contrast.
66. b Silver halide will normally absorb light in the ultra-
violet, violet, and blue regions of the spectrum. Adding
a dye to help it better absorb light in the green spec-
trum makes it an orthochromatic film; adding a dye
that helps it absorb light in the red spectrum, it is
called panchromatic film.
67. b An increase of 0.3 in log relative exposure represents
a doubling of the relative exposure; thus 0.3 = 2x rel-
ative exposure; 0.6 = 4x relative exposure, and so on.
68. b A doubling of the relative exposure is represented log-
arithmically by an increase of 0.3; thus a 200 speed
film would be represented in the example by 2.3; a
400 speed by 2.6, and so on.
69. b If 0.1% of the developer tank’s capacity contains fixer,
it can become contaminated; thus, for a one gallon
(4000 ml) tank, as little as 4 ml of fixer could con-
taminate the tank.
70. a If the processor chemicals were depleted, it would be
more gradual and occur at times other than at 4 PM. If
the unit was improperly attached to the power source,
variations in the output would be noticeable but not
just at one time of the day.
71. b Although film can resolve up to 100 lp/mm, screens

are typically a “weak link” in the imaging chain in
that most can only resolve up to about 10 lp/mm. In
general, the slower the screen, the greater is resolv-
ing power.
72. b Films with a high average gradient will tend to have
high contrast and speed; also, in general, latitude of a
film varies inversely with film contrast.
73. c Solarization is the term for the region of reversal once
the DLOGE curve passes Dmax . Theory suggests that
this is due to a recombination of silver and bromide;
this process should not occur with radiographic films
processed in automatic processors.
74. a Greater SIDs decrease magnification and also pro-
vide a reduced patient exposure, but since increased
technical factors must be selected to compensate for
the increase in distance, tube loading may increase.
75. b Single-emulsion films tend to have slower speeds (and
thus a decreased density at the same technical factors),
lower contrast, wider latitude, and better recorded
detail.
76. d Light reflected back at the film (base-air interface)
will cause the formation of a diffuse “halo” (the process
of halation), which will cause some loss of recorded
detail. This problem is solved by adding an antihala-
tion layer to single-emulsion film, which can be rec-
ognized as the glossy side of the film.
77. c Duplication film is designed so that longer exposure
times result in less density; thus their DLOGE curves
appear to be the opposite of radiographic films, begin-
ning with high densities on the left side of the curve
and terminating with low densities.
78. c Hydroquinone, metol, and phenidone are the three
most common reducing agents (developers). The func-
tion of the reducing agents in the developer is to
donate electrons to the exposed silver bromide crys-
tals and reduce them to elemental silver. Elemental
silver makes up the black portion of the radiograph.
79. b In order for the reducing (development) to take place,

the proper pH must be present. The developer is
slightly basic or alkaline.
80. a The function of the fixer is to stop development, remove
unexposed crystals, and fix the image for archival
storage. In order to stop the development, the fixer is
very acidic.
81. a Phenidone is responsible for development of the gray
tones on a radiograph and works faster than hydro-
quinone, which is the other reducer found in most
developers.
82. d Hydroquinone is the principal reducing agent in devel-
oper. It is responsible for development of the black
tones on a radiograph and works slower than
phenidone, which is the other reducer usually found
in developers.
83. c Metal salt ions build up in the developer. These speed
up the oxidation of hydroquinone and reduce the effec-
tiveness of the developer. Chelates sequester ions and
prevent them from attacking the developer.
84. a The fixer must be acidotic and acetate is added to the
solution to help maintain the pH.
85. a Optical Density (OD) is based on the log value of the
percentage of light that does not pass through a film.
The formula is OD = Log(10) Io/It. If Io = It, then
Log(10) of 1 = 0.00.
86. d Fluoroscopic brightness is controlled be varying the
mA, the kVp, or the video signal. If only variation of
mAs and kVp are used, it is sometimes called auto-
matic dose rate control. When video signal is varied,
it is called automatic gain control. The sensitivity of
the camera can also be controlled, which is called
automatic brightness control.
87. d The potential difference of the x-ray tube is measured
in kVp and controls the speed of the electrons as they
hit the anode. The speed of the electrons impacts the
types of interactions (brems at different energies and
characteristics).
88. d Low “Z” number materials, such as aluminum, are

used for filters as they tend to absorb mostly low
energy, low frequency, long wavelength radiation.
89. b Beam harding is the process of removing low energy
photons, leaving only the higher energy ones in the
beam. Harding the beam reduces patient dose and
scatter formation.
90. a Generally, anything that increases the speed of a
screen (with the exception of going from CaWO4 to
rare earth) will decrease detail formation. Increasing
the size of the phosphors, increasing the thickness of
the phosphor layer, removing the antihalation dyes,
and adding a reflective backing increase speed.
91. d Increasing the size of the phosphors, increasing the
thickness of the phosphor layer, removing the anti-
halation dyes, and adding a reflective backing in-
crease speed and reduce recorded detail. Going from
CaWO4 to rare earth increases speed without loss of
detail.
92. a Antihalation dye is a coating added to any single-sided
film to reduce reflection of screen light transmitted
through the emulsion and base.
93. a The binding energy of the k-shell electron determines
the probability of a photoelectric interaction and is
important in screen technology as well as contrast
media. The k-shell binding energy of Tungsten (W) is
approximately 70 keV, Gadolinium (Ga) is 64 keV,
Lanthanum (La) is 57 keV, and Yttrium (Y) is 39.
94. d The speed of a screen is relative and linear. The higher
the number, the faster the speed. Doubling the num-
ber, doubles the speed.
95. c Reciprocity law failure is the reduction in density at
very long and very short exposure times. It is almost
never seen with short times in diagnostic radiology,
but is occasionally seen with the long exposure times
in mammography.
96. d Reciprocity Law states that when an exposure is very
long (such as in mammography) or very short (not
usually seen in diagnostic radiology) the density may

be reduced below that expected from given mAs.
97. a Optical Density (OD) is based on the log value of the
percent of light that does not pass through a film. The
formula being OD = Log(10) Io/It.
98. a Filters such as holmium have a k-edge slightly above
the k-edge of iodine and leave energy levels that have
a much higher probability of having a photoelectric
interaction with the iodine. This makes the contrast
media more visible on the radiograph.
99. d Typically, a replenisher holding tank large enough to
hold a week’s worth of chemicals should be used. Al-
though storing chemicals at recommended tempera-
tures and using mixed chemicals within 10 to 14 days
are both good means of preventing oxidation, the best
prevention is to use a floating lid in the developer
tank.
100. a Average gradient can be used to compare the pub-
lished average gradient for films from a specific man-
ufacturer or as a relative measure of contrast; it should
not be used to compare the contrast of different film-
screen combinations.
101. a Radiation therapy port films will have an average
gradient of about 5.7; mammogram, about 3.3; gen-
eral purpose x-ray, about 2.8; chest x-ray, about 2.2;
CT and MR, about 1.9-2.5.
102. b A change of 0.3 is roughly a doubling; thus if 5 mR is
recorded as 0.8, then 10 mR should show a density of
1.1.
103. d Quantum mottle is the effect of using a limited num-
ber of x-ray quanta to form the image. It increases with
increased film speed and kVp; and has the greatest
effect on the perceptibility of low-contrast structures
such as cysts or soft tissue lesions.
104. b Latent image fading should not be significant as long
as mammographic images are processed by the end
of the day. It may, however, have a significant effect on
the sensitometric strip. It causes little change in con-

trast scale.
105. d Haus and Jaskulski give a loss of 0.27 for optical den-
sity, percent speed loss of 23%, and contrast loss of
5% as an example of latent image fading.
106. d Reciprocity law failure can be high or low intensity,
occurring at very short and very long exposure times.
It typically requires additional exposure, and may
be a problem in mammography, where long expo-
sure times are used. It produces little change in film
contrast.
107. d Misrepresentation of true size (magnification) or shape
are both forms of distortion.
108. a 2º increase in temperature would increase film den-
sity by about 15%.
109. c Of all the variables listed, the one that is most clearly
a geometric variable is SID or source-to-image recep-
tor distance.
Test Instrumentation
1. How many wires per inch should the copper wire
mesh used to test screen-film contact contain?
____ a. 10
____ b. 20
____ c. 40
____ d. 80
2. There is no need to warm up the densitometer prior
to reading QC strips.
____ a. true
____ b. false
3. What are the typical spoke angles used for a star test
pattern?
____ a. 0.5 to 2.0º
____ b. 1.0 to 2.0º
____ c. 2.0 to 4.0º
____ d. 2.0 to 5.0º
4. What term describes the intensity of light falling on
a surface from other sources?
____ a. illuminance
____ b. luminance
____ c. extraneous light
____ d. color
153
154 Chapter 6 Test Instrumentation
5. What is the unit for luminance?

____ a. candela (cd/m2)
____ b. lumen/m2
____ c. lux
6. What is the maximum readable density with a
brightness of 1500 cd/m2?
____ a. OD 0.8
____ b. OD 1.8
____ c. OD 2.8
____ d. OD 3.8
7. No contrast will be lost with ambient lighting of 50
lux.
____ a. true
____ b. false
8. Which of the following is not a key element in pro-
viding the best possible lighting for reading films?
____ a. proper luminance
____ b. eliminating extraneous light
____ c. use of homogeneous light source
____ d. increasing ambient light (luminance)
9. How many nit equal 3000 cd/m2 (candelas)?
____ a. 1000 ____ c. 6000
____ b. 3000 ____ d. 10000
10. What term describes ambient light + extraneous
light?
____ a. luminance
____ b. illuminance
____ c. lux
11. What is the typical incremental log exposure pro-
vided by simulated light sensitometers?
____ a. OD 0.05
____ b. OD 0.10
____ c. OD 0.15
____ d. OD 0.30
12. Which of the following is (are) true about simulated

light sensitometers?
____ a. Canned air, shaken prior to use, should be
used for cleaning.
____ b. The area in which it is used should be
temperature controlled (59–86º F)
____ c. Recalibration should not be necessary.
13. Which of the following are types of densitometers?
____ a. spot-reading
____ b. manual
____ c. automatic
14. What is the usual setting on a sensitometer for
single-emulsion mammography film?
____ a. single and green
____ b. single and blue
____ c. double and green
____ d. double and blue
15. Which of the following is (are) true about the
apertures of spot-reading densitometers?
____ a. Large apertures require less accuracy in
positioning.
____ b. Large apertures produce a better signal-to-
noise ration.
____ c. Large apertures provide less reliable
results.
16. It is mandatory to check the response of radiation
detection instruments using an appropriate radia-
tion source?
____ a. true
____ b. false
17. Which of the following is best used for qualitative,

rather then quantitative, low-level radiation expo-
sure measurements?
____ a. personnel monitoring device
____ b. Geiger-Mueller counter
____ c. portable scintillation detector
____ d. ionization chamber
18. How many chamber are in the move kVp meters?
____ a. 1
____ b. 2
____ c. 3
____ d. 5
19. Which of the following is not normally used for
radiation detection in kVp meters?
____ a. ion chambers
____ b. photo diodes
____ c. voltage diodes
20. When using a sensitometer, how often should they
be calibrated?
____ a. yearly
____ b. bi-yearly
____ c. monthly
____ d. never
21. Which of the following devices uses an optical
step-wedge?
____ a. densitometer
____ b. dosimeter
____ c. penetrometer
____ d. sensitometer
22. What type of film is used specifically for sensitome-
try in a general diagnostic department?
____ a. the same film most commonly used in the
department
____ b. the fastest film used in the department
____ c. non-screen film, as no screen was used
____ d. the most processor sensitive film
23. What is the most appropriate type of sensitometry

film to use in a processor where general and mam-
mography film is processed?
____ a. the most processor sensitive film
____ b. mammography film
____ c. the fastest film in the department
____ d. the most commonly used film in the
department
24. Which type of thermometer should not be used in a
processor?
____ a. mercury type
____ b. analog type
____ c. electrified
____ d. metric
25. What is the temperature range that a processor
developer thermometer should have?
____ a. 0–150º F
____ b. 50–125º F
____ c. 90–108º F
____ d. 95–100º F
26. Of the following types of thermometers, which type
is recommended for use in a processor?
____ a. digital
____ b. alcohol
____ c. mercury
____ d. analog
27. What is the acceptable level of accuracy for a devel-
oper solution thermometer?
____ a. 2º F
____ b. 1º F
____ c. 0.5º F
____ d. 0.3º F
28. What is the typical incremental log exposure differ-
ence between steps on a sensitometer?
____ a. OD 0.10
____ b. OD 0.15
____ c. OD 0.25
____ d. OD 0.25
29. What type of sensitometer is recommended for

processor QC?
____ a. single-sided exposure
____ b. double-sided exposure
____ c. varies depending on situation
30. Which of the following is not a requirement for a
sensitometer?
____ a. blue and green light emissions
____ b. single-or double-sided exposures
____ c. adjustable light intensity
31. A simulated light sensitometer can be used for film
speed and contrast evaluations.
____ a. true
____ b. false
32. When using mammography film for sensitometry,
what setting should be used?
____ a. green and single
____ b. green and double
____ c. blue and single
____ d. blue and double
33. When using asymmetric near-zero crossover film in
sensitometry, what is used to compensate for the
different emulsions on either side of the film?
____ a. double exposures
____ b. spectral mismatching
____ c. graduated filters
____ d. neutral density filter
34. Which of the following is not a type of densitometer?
____ a. automatic scanning densitometer
____ b. mammographic phantom densitometer
____ c. spot reading densitometer
35. What aperture diameter is recommended for use on

a densitometer?
____ a. 1 mm
____ b. 2 mm
____ c. 3mm
36. When using a densitometer, how often should it be
calibrated?
____ a. yearly
____ b. bi-yearly
____ c. monthly
____ d. never
37. How accurately should a densitometer be calibrated?
____ a. ± .01 OD
____ b. ± .02 OD
____ c. ± .05 OD
____ d. ± .10 OD
38. What color light is used in a densitometer?
____ a. blue
____ b. green
____ c. yellow
____ d. white
TEST INSTRUMENTATION QUESTIONS
1. c In testing for screen-film contact, a test tool contain-
ing at least 40 wires per inch grid density is placed
directly on the cassette.
2. b The densitometer should be turned on at least 10 to
15 minutes before QC strips are read. Not doing so
may produce values outside control limits. Smaller,
portable densitometers require less warm-up time.
3. a The spoke angles used for the star pattern are typi-
cally form 0.5–2.0º, 0.5º for focal spots less than 0.3
mm, 1º for focal spots of 0.3–0.6 mm, 1.5º for 0.6–1.2
mm, and 2º for focal spots above 1.2 mm.
4. a The intensity of light falling on a surface from other
sources describes illuminance. Luminance is the inten-
sity of light at the surface of the illuminator.
5. a The unit for luminance is candela (cd/m2) or the nit,
which are identical measures. Lumen/m2 or lux are
measurements of illuminance.
6. c The maximum readable density with a brightness of
1500 cd/m2 is OD 2.8; with 3000/m2, it is OD 3.1
7. b 50 lux, which is about equivalent to a moonlit night,
can remove as much as 30% of the contrast from a film.
8. d Proper luminance, eliminating extraneous light, use
of a homogeneous light source (luminance uniform-
ity), and minimizing ambient light (luminance) are
all key elements in providing the best possible light-
ing for reading films.
9. b 3000 cd/m2 (candelas) are equal to 3000 nit. They are
equivalent units.
10. d There is no entity that consists of the combination of
ambient light and extraneous light. Ambient light is
also known as illuminance, and its unit is lumen/m2
or lux. Extraneous light is light coming from the viewer
outside of the area being examined.
11. c Simulated light sensitometers are devices used to

expose x-ray film to different light intensities in a step
fashion; each step or incremental log exposure is typ-
ically 0.15.
12. b Canned air should be used for cleaning a sensitome-
ter; however, it should not be shaken prior to use. The
area should be temperature controlled from 59–86º F,
and recalibration may be necessary as the tungsten
light source or electro luminescent panel ages.
13. d Types of densitometers include spot-reading (also
called manual) and automatic.
14. a There are two settings on most simulated light sen-
sitometers; one is exposure (single or dual), another
is color (blue or green). For single-emulsion mam-
mography film, the usual setting is single and green.
15. b Spot-reading densitometers usually provide different
size apertures such as 1, 2, and 3 millimeters. The
large apertures require greater accuracy in position-
ing, but provide a better signal-to-noise ratio and
more reliable results.
16. a the response of radiation detection instruments shall
be checked periodically using an appropriate radia-
tion source; whereas the RSO (radiation safety offi-
cer) should be consulted prior to the procurement of
survey meters.
17. b Geiger-Mueller counters are very sensitive and use-
ful for the qualitative measurement of low levels of
radiation; they tend to over-respond to low levels of
radiation. Ionization chambers are less energy-
dependent and give a more accurate depiction of
exposure; whereas portable scintillation detectors are
sensitive to low-level photons such as those emitted
from iodine-125.
18. b In most kVp meters, there are either two ion cham-
bers or photo diodes. The amount of filtration differs
between the two chambers and, based on the differ-
ence in absorption, kVp can be calculated.
19. c Both the ion chamber and photo diode are commonly
used radiation detection components in kVp meters.
Voltage diodes and oscilloscopes are also used for kVp
measurement because they are more accurate than
ion chambers or photo diodes. However, it takes sig-
nificantly longer to use them, so they are not com-
monly used.
20. a The Bureau of Radiologic Health recommends that a
sensitometer be calibrated monthly, but that recom-
mendations was made in the 1970s. Most sensitome-
ters come with a recommendation to be calibrated
yearly.
21. d A sensitometer is used to deliver a graduated light
exposure to film for use in processor quality control.
In order to do that, a light emitting crystal is covered
by an optical step-wedge to give the film exposure
graduation.
22. d When selecting film to be used with a sensitometer,
the type most sensitive to processor changes is the
most appropriate choice. This allows the QM tech-
nologists to detect changes in the processor sooner.
23. b Because of the special nature of mammography film,
only this type of film should be used in a processor
that deals with a mixed set of film types.
24. a Mercury is a heavy metal similar to silver and, if a
mercury thermometer broke inside a processor, the
mercury would interact with and contaminate the
chemicals. Unfortunately, because mercury is liquid
at room temperature, it would tend to get into the
recirculating systems and elsewhere in the processor
and continue to contaminate the chemicals for some
time.
25. c Most processor developer solutions are maintained
around 95º F. Also, as the range of the thermometer
increases, the accuracy decreases. Based on those two
facts, most thermometers have a range of 90–108º F.
This makes this specialty thermometer useless for
measuring temperatures in the fixer or water.
26. a The digital thermometer is recommended because of

its ability to measure units as little as one-tenth of a
degree, and because they can not contaminate the
solution. Analog thermometers are less accurate as
digital ones. Any glass type thermometer, such as
alcohol and mercury, should not be used because of
the possibility of breakage and contamination.
27. c A thermometer should be accurate within 0.5º F for
use in a processor 0.5º F is equivalent to 0.3º C.
28. b In most sensitometers, the log exposure difference
between steps is OD 0.15. this gives approximately a
40% difference in density from step to step.
29. c Whether a sensitometer is set for single- or double-
sided exposure is determined by the type of film being
used for sensitometry. If mammography film is used, it
is a singe-emulsion film and, therefore, the sensitome-
ter should be set for single-sided exposure. If a gen-
eral diagnostic film is used, double-sided exposure is
preferred.
30. c All sensitometers should be able to emit blue or green
light as needed. If a sensitometer is capable of giving
a double-sided exposure, there needs to be a switch to
turn off one side when exposing single-emulsion film.
As the main function of the sensitometer is to give
consistent exposures, adjusting the light intensity is
not advisable. Many sensitometers do have dip
switches on the back to set the intensity based on the
type of film being use.
31. b The light emitted from a sensitometer is different in
intensity and distribution compared to that emitted
by intensifying screens, and the film reacts differently
to the two sources. Therefore, the response from the
two sources will differ, making an evaluation based
on sensitometry data not appropriate.
32. a Best results are obtained from the sensitometry pro-
cess when the setting best matches the film being used.
Mammography film is green sensitive and single-
sided emulsion so the settings should be green and
single.
33. a Certain types of films have a different (asymmetric)

type of emulsion on each side. Often with these types
of film, no light passes from one side of the emulsion
to the other (near-zero crossover). The most common
use of these film types is in chest radiography. Because
of these characteristics, a neutral density filter is used
to achieve a front-to-back light ratio similar to the
screens used with this type of film.
34. b The spot-reading densitometer is the most commonly
used densitometer. It gives a transmission reading that
must be manually recorded after the film is manually
placed. An automatic scanning densitometer reads all
steps on a sensitometric film at one time and prints
out processor QC information plus any other desired
information.
35. c Any aperture can be used with a densitometer but a
larger aperture is recommended. As the size of the
aperture increases, the precision of the position needs
to increase but the signal-to-noise ratio decreases.
Therefore, better results are obtained with a larger
aperture and accurate positioning.
36. a Densitometers should be calibrated at least once a
year. In order to do this, use the calibration strip that
was returned with the densitometer the last time it
was calibrated at the factory. These calibration strips
must be traceable to the National Institute of Stan-
dards and Technology.
37. b A densitometers should be calibrated to OD .02 or 2.5%,
whichever is greater.
38. d As a densitometer is designed to measure the percent-
age (in log values) of light transmitted from a typical
illuminator, white light is used.
Suggested Readings
Adams, H. G., & Arora, S. (1994). Total quality in radiology: A
guide to implementation. Boca Raton, FL: Saint Lucie Press.
Adler, A., Carlton, R., & Wold, B. (1992). A comparison of stu-
dent radiographic reject rates. Radiologic Technology 64
(1): 26–32.
American College of Radiology Committee on Quality Assurance
in Mammography (1999). Mammography quality control
manual. Reston, VA: Author.
Burns, C. (1995). Achieving darkroom and processing quality
control in mammography: A step beyond minimum rec-
ommendations. Seminars in Radiologic Technology 3(2):
68–85.
Burns, N, & Grove, S. K. (2001). The practice of nursing research:
Conduct, critique & utilization. Philadelphia: WB Saunders.
Bushberg, J. T., Seibert, J. A., Leidholdt, E. M., et al. (1994). The
essential physics of medial imaging. Baltimore: Williams
and Wilkins.
Bushong, S. (1997). Radiologic science for technologists: Physics,
biology, and protection. St. Louis: Mosby.
Carlton, R. R., Adler, A., & Burns, B. (2000). Principles of radi-
ographic imaging: An art and a science. Albany, NY:
Delmar.
Carroll, Q. B. (1998). Fuch’s radiographic exposure, process-
ing & quality control. Springfield, IL: CC Thomas
Publisher.
Chaff, L. F. (1994). Safety guide for health care institutions.
Chicago: American Hospital Publishing, Inc.
165
166 Suggested Readings
Claflin, N. (1998). NAHQ guide to quality management. Glen-

view, IL: National Association for Healthcare Quality.
Correctec. (1998). Quality management advanced examination.
(Computer Software) Athens, GA: Author.
Curry, T. S., Dowdey, J. E., & Murry, R. C. (1990). Christensen’s
physics of diagnostic radiology. Philadelphia, PA: Lippin-
cott, Williams & Wilkins.
Dowd, S. B., & Tilson, E. (1996). The benefits of using CQI/
TQM data. Radiologic Technology 67(6): 533–537.
Dowd, S. B., & Tilson, E. (1998). Quality management exami-
nation review. (Computer Software) Edwardsville, KS: Edu-
cational Software Concepts.
Eastman Kodak. (undated). The fundamentals of radiography
(12th ed.). Rochester, NY: Author.
Frank, E. (1995). The design and application of the mammog-
raphy x-ray generator and x-ray tube. Seminars in Radio-
logic Technology 3(2): 56–87.
Giesberg, D. J. (1997). Film viewing condition in mammogra-
phy. Radiologic Technology 68: 429–431.
Haus, A. G., & Jaskulski, S. M. (1997). The basics of film pro-
cessing in medical imaging. Madison, WI: Medial Physics
Publishing.
Hiss, S. S. (1997). Introduction to health care delivery and radi-
ology administration. Philadelphia: WB Saunders.
Hiss, S. S. (1993). Understanding radiography (3rd ed.). Spring-
field, IL: CC Thomas Publisher.
Jenkins, D. (1980). Radiographic photography and imaging
processes. Baltimore: University Park Press.
Lam, R., & Golden, L. (1996). Continuous quality improvement
for hospital radiology services. Part 1: Understanding the
JCAHO process. Albuquerque, NM: American Society of
Radiologic Technologists.
Lam, R., & Golden, L. (1996). Continuous quality improvement
for hospital radiology services. Part 2: Implementing a
Suggested Readings 167
successful CQI program. Albuquerque, NM: American

Society of Radiologic Technologist. (Homestudy).
Levin, J. (1983). Elementary statistics for social research (3rd
ed.). New York: Harper and Row.
McKinney, W. E. J. (1988). Radiographic processing and qual-
ity control. Philadelphia: JB Lippincott.
McKinney, W. E. J. (1995). Radiographic processing and qual-
ity control. Los Angeles, CA: Academy Medical Systems.
McKinney, W. E. J. (1997). Analyzing trend charts. Radiologic
Technology 68(4): 343–344.
McLaughlin, C. P., & Kaluzny, A. D. (1999). Continuous quali-
ty improvement in health care: Theory implementation,
and applications. Gaithersburg, MD: Aspen.
National Council on Radiation Protection and Measurements.
(1988). Report 99: Quality assurance for diagnostic imag-
ing equipment. Bethesda, MD: Author.
National Council on Radiation Protection and Measurements.
(1989). Report 102: Medical x-ray, electron beam and
gamma-ray protection for energies up to 50 MeV (Equip-
ment design, performance and use). Bethesda, MD: Author.
National Council on Radiation Protection and measurements.
(1998). Report 105: Radiation protection for medical and
allied health personnel. Bethesda, MD: Author.
NEMA Standards Publication No. XR-5-1984. (1984). Measure-
ment of dimensions and properties of focal spots of diag-
nostic x-ray tubes. Washington, DC: Author.
Obergfell, A. M. (1995). Law & ethics in diagnostic imaging &
therapeutic radiology: With risk management and safety
applications. Philadelphia: WB Saunders.
Papp, J. (1998). Quality management in the imaging sciences.
St. Louis: Mosby.
Thompson, M. A., Hattaway, M. P., Hall, J. D., & Dowd, S. B.
(1994). Principles of imaging science and protection. Phila-
delphia: WB Saunders.
168 Suggested Readings
Timmereck, T. C. (1997). Health services cyclopedic dictionary:

A compendium of health-care and public health terminol-
ogy. Sudbury, MA: Jones and Bartlett.
Tortorici, M. (1992). Concepts in medical radiographic imag-
ing: Circuitry, exposure & quality control. Philadelphia:
WB Saunders Company.
Towsley, D. (undated). Customer service: A commitment to
quality. Albuquerque, NM: American Society of Radio-
logic Technologists. (Homestudy).
U.S. Government. (1994). OSHA Guideline CPL 2-2.60 – Expo-
sure control plan for OSHA personnel with occupational
exposure to bloodborne pathogens. Washington, DC: United
States Government Printing Office.
U.S. Government. (2000). Code of federal regulations, Title 21,
food & drugs, Pt. 1300-end. Washington, DC: United States
Government Printing Office.
Post-test
1. The production of this type of radiation results in very
specific energies characterized by the differences be-
tween electron binding energies of the target material.
____ a. Bremsstrahlung
____ b. photoelectric
____ c. characteristic
____ d. gamma
2. The atomic number of the target affects both the quan-
tity and quality of the x-rays produced. As the atomic
number of the target ____ , the efficiency of the produc-
tion of Bremsstrahlung radiation ____ .
____ a. increases, increases
____ b. increases, decreases
____ c. decreases, decreases
____ d. decreases, increases
3. Material that emits light in response to outside stimu-
lation is said to:
____ a. luminesce
____ b. fluoresce
____ c. phosphoresce
____ d. lag
4. A collection of negatively charged electrons forming a
small cloud around the filament is termed:
____ a. electron wall
____ b. space effect
____ c. electron emission
____ d. space charge
169
170 Post-test
5. Radiation produced by the interaction of high-speed

electrons and metal surfaces other than the focal track
of the anode is termed:
____ a. scatter radiation
____ b. off-focus radiation
____ c. secondary radiation
____ d. both a and b
6. This component of an intensifying screen is largely
composed of cellulose mixed with other polymers. It
provides a surface that can be cleaned.
____ a. base layer
____ b. reflective layer
____ c. phosphor layer
____ d. protective layer
7. The ability of light emitted by the phosphor of an
intensifying screen to escape from the screen and
expose the film is termed the:
____ a. screen efficiency
____ b. intensification factor
____ c. conversion efficiency
____ d. phosphor factor
8. What results from statistical fluctuation in the number
of x-ray photons absorbed by the intensifying screens
to form the light image recorded on film?
____ a. noise
____ b. quantum mottle
____ c. distortion
____ d. more than one but not all of the above
9. The two most important ingredients of a photographic
emulsion are:
____ a. gelatin and bromide
____ b. silver halide and gelatin
____ c. bromide and silver halide
10. For radiographic film the sensitivity speck is usually
located on the surface of the:
____ a. gelatin
____ b. bromide crystals
____ c. silver halide crystals
Post-test 171
11. Subjecting radiographs to a combination of low

humidity, high temperatures, and other stress such as
bending may result in:
____ a. cracking artifacts
____ b. static artifacts
____ c. slap lines
____ d. skivings
12. This agent in the high-temperature alkaline developer
solution hardens the film to prevent excessive swelling
of the gelatin and damage to the film.
____ a. sodium sulfite
____ b. potassium alum
____ d. glutaraldehyde
13. The consequences of incomplete fixing become mani-
fest after the image has been stored for some time.
These include:
____ a. brown films
____ b. slap lines
____ c. spots of nonuniform density
14. This term is defined as the ratio of the mass of a body
to the mass of an equal volume of water at a specified
temperature.
____ a. fluence
____ b. granularity
____ c. halation
____ d. specific gravity
15. The pH measurement indicates the:
____ a. acidity of a solution at a specified tempera-
ture
____ b. alkalinity of a solution at a specified temper-
ature
____ c. both a and b
16. Starter solution mainly adds ____ ions to the developer.
____ a. bromide
____ b. antifog
____ c. sulfate
____ d. sulfide
172 Post-test
17. The advantages of room light processing areas include:

____ a. more flexibility in processing certain special-
ty films
____ b. lower investment in equipment
____ c. effective use of people
18. The purpose of the ____ is to help avoid corrosion to
the sensitive electronic components of the processor.
____ a. dryer exhaust
____ b. processor ventilation
19. A floating lid should always be used on top of the
developer replenisher to reduce evaporation and:
____ a. chemical oxidation
____ b. environmental hazards
____ c. accidental spillage
____ d. unnecessary replenishment
20. The exposure time accuracy should be checked:
____ a. annually
____ b. semiannually
____ c. monthly
____ d. bimonthly
21. A manual spin top test on a single-phase radiographic
room only demonstrates half the expected number of
dots. What conclusion do you draw from this test?
____ a. faulty AEC
____ b. faulty rectification
____ c. faulty timer
22. The recommended frequency for testing light
field/beam alignment is:
____ a. annually
____ c. monthly
____ d. weekly
Post-test 173
23. When testing light field/beam alignment, at a 48-inch

SID, the light represented light field should be within
±:
____ a. .48 inches
____ b. .96 inches
____ c. 1.44 inches
24. When testing kilovoltage accuracy, the kilovoltage
should be within ±:
____ a. 6 kVp
____ b. 5 kVp
____ c. 4 kVp
____ d. 2 kVp
25. A reciprocity test for mAs should result in a value of ±:
____ a. 2%
____ b. 5%
____ c. 10%
26. Which of the following values would be acceptable
when testing a three-phase generator for radiation out-
put? The kVp used when performing the test was 80.
____ a. 5.12 mR/mAs
____ b. 8.96 mR/mAs
____ c. 13.44 mR/mAs
____ d. 20.48 mR/mAs
27. A test for exposure linearity should be performed:
____ a. annually
____ c. monthly
____ d. weekly
28. The following data are obtained to evaluate exposure
linearity. Do the values indicate that the mAs stations
are in need of calibration?
200 ms 50 mA 45 mR
200 ms 100 mA 84 mR
____ a. yes
____ b. no
174 Post-test
29. This procedure is designed to confirm that the

installed tube filtration is acceptable in minimizing
exposure to the patient.
____ a. exposure reproducibility
____ b. exposure dose linearity
____ c. half-value layer
30. The three steps necessary for an acceptable QC
program are:
____ a. routine performance monitoring, record
keeping, and maintenance
____ b. acceptance testing, routine performance
monitoring, and maintenance
____ c. acceptance testing, routine performance
monitoring, and record keeping
____ d. routine performance monitoring, analysis,
and record keeping
31. The grid uniformity test should insure that the grid:
____ a. is not producing artifacts
____ b. is appropriate for portable radiography
____ c. is aligned with the tabletop and x-ray beam
32. When testing a grid for alignment, the ____ hole
should have the highest optical density with ____
densities to either side.
____ a. center, increasing
____ b. center, decreasing
____ c. aligned, increasing
____ d. aligned, decreasing
33. Tomographic equipment should be tested to confirm
section level is accurate:
____ a. annually
____ c. monthly
____ d. weekly
34. At a 72-inch SID, which of the following values is
acceptable when testing the collimator?
____ a. 2.8 inches ____ c. 1.5 inches
____ b. 2 inches ____ d. 1.2 inches
Post-test 175
35. The testing frequency for fluoroscopic beam limitation

is:
____ a. annually
____ c. monthly
____ d. weekly
36. High-contrast fluoroscopic resolution testing is
designed to verify that the resolution of the imaging
system is within acceptable limits. What is an accept-
able limit when testing in the 6-inch mode?
____ a. 40 mesh/inch at the center of the image and
30 mesh/inch at the edge
____ b. 50 mesh/inch at the center of the image and
____ c. 50 mesh/inch at the center of the image and
____ d. 40 mesh/inch at the center of the image and
37. How often should the processor crossover racks be
cleaned?
____ a. daily
____ b. weekly
____ c. biweekly
____ d. monthly
38. The film transport time should not exceed ____% of the
recommended manufacturer’s processing time.
____ a. 1 ____ c. 3
____ b. 2 ____ d. 4
39. The test for illuminator uniformity should be per-
formed:
____ a. weekly
____ b. monthly
____ c. semiannually
____ d. annually
40. For general radiography, the acceptable parameters for
contrast index are:
____ a. ± 0.10
____ b. ± 0.15
____ c. ± 0.5
____ d. none of the above are acceptable
176 Post-test
41. When storing unexposed radiographic film, the relative

humidity should be between:
____ a. 20 to 30 %
____ b. 30 to 50 %
____ c. 40 to 60 %
42. The manufacturer’s recommended developer tempera-
ture for your processor is 92˚F. Which of the following
values is an acceptable temperature?
____ a. 98˚F
____ b. 97˚F
____ c. 87˚F
43. When using the wire-mesh tool to check for screen-
film contact, the technologist should view the results
from a distance of ____ away from the viewbox.
____ a. 2 to 3 m
____ b. 3 to 4 m
____ c. 4 to 5 m
44. For general radiography, the acceptable repeat rate
should be less than:
____ a. 10%
____ b. 7%
____ c. 5%
____ d. 4%
45. Which of the following is not needed to perform
processor QC monitoring?
____ a. sensitometer
____ b. step wedge
____ c. densitometer
____ d. thermometer
46. What is the proper corrective action when the speed
index is too high?
____ a. check developer thermostat setting
____ b. check replenishment rates
____ c. check processor overflow drain
____ d. add developer starter solution
Post-test 177
47. The ACR suggests that sensitometers be recalibrated

every:
____ a. year
____ b. 18 months
____ c. 2 years
____ d. there is no recommendation for periodic
recalibration of sensitometers
48. Lead protective devices should be tested for cracks and
other defects:
____ a. weekly
____ b. monthly
____ d. annually
49. A safelight test has resulted in an unacceptable level of
film density. What might cause this result?
____ a. a crack in the filter
____ b. wrong wattage of bulb in the safelight
____ c. improper processing
50. The mid-range density of the processor control strip
reflects the ____ index.
____ a. speed
____ b. contrast
____ c. density
51. For mammography, a repeat analysis should be per-
formed:
____ a. monthly
____ b. quarterly
____ d. annually
52. The digital thermometer used to measure the develop-
er temperature must be accurate to at least ±:
____ a. 0.03˚F
____ b. 0.3˚F
____ c. 0.05˚F
____ d. 0.5˚F
178 Post-test
53. The sensitometer used for mammography QC

programs should have _____ steps.
____ a. 21
____ b. 18
____ c. 15
____ d. 10
54. To minimize artifacts on mammography images, dark-
room overhead air vents and safelights should be
wiped or vacuumed:
____ a. daily
____ b. weekly
____ c. monthly
____ d. quarterly
55. When establishing processor QC operating levels, the
mid-density is determined by selecting the step having
an average density closest to but not less than:
____ a. 1.00
____ b. 1.10
____ c. 1.20
____ d. 1.50
56. When establishing processor QC operating levels, the
high density is determined by selecting the step having
an average density closest to:
____ a. 3.00
____ b. 2.70
____ c. 2.20
____ d. 2.00
57. Recommended performance criteria for the analysis of
mammography processing control charts call for MD
and DD to be within ± ____ for no action to be taken.
____ a. 0.10
____ b. 0.01
____ c. 0.15
____ d. 0.50
58. A crossover should be performed whenever:
____ a. a new box of film is opened
____ b. developer is replaced with unseasoned
chemistry
Post-test 179
____ c. establishing operating values for processor

QC
59. The device used to confirm that the generator is pro-
ducing the kVp as indicated on the control panel is a:
____ a. step wedge
____ b. copper step meter
____ c. R-meter
____ d. digital kVp meter
60. When performing an exposure-time accuracy test with
a digital x-ray timer, it is important to do a minimum
of ____ exposures for each selected time station.
____ a. 2
____ b. 3
____ c. 5
____ d. no minimum is required
61. The mammographic phantom used for QC tests
should be approximately equivalent to a 4.2 cm thick
compressed breast consisting of what percentage of
glandular tissue?
____ a. 10
____ b. 30
____ c. 50
____ d. 60
62. Mammographic phantom images should have a back-
ground density measurement never less than:
____ a. 1.0 ± 0.1
____ b. 1.0 ± 0.2
____ c. 1.2 ± 0.2
____ d. 1.2 ± 0.1
63. What equipment is needed when performing an AEC
backup time test?
____ a. AEC test phantom and stopwatch
____ b. lead apron and stopwatch
____ c. lead apron and AEC test phantom
____ d. densitometer and AEC test phantom
180 Post-test
64. Film illuminators used to view radiographs should

have a brightness level of:
____ a. 1500 nit
____ b. 1200 nit
____ c. 1000 nit
____ d. 800 nit
65. The ACR requires that both the sensitometer and den-
sitometer be recalibrated every:
____ a. year
____ b. 18 months
____ c. 2 years
____ d. none of the above are correct
66. Star test patterns are used to measure:
____ a. film resolution
____ b. filament bloom
____ c. focal spot size
____ d. linearity
67. When performing a test to confirm that the small and
large focal spots are within the tube manufacturer’s
stated specifications, the test instrument should be
placed:
____ a. on the faceplate of the collimator
____ b. on the image receptor
____ c. on the radiographic table
____ d. more than one but not all are acceptable
68. The most important QC area in the overall quality
assurance program is the:
____ a. darkroom
____ b. record-keeping process
____ c. collection and analysis of data
____ d. medical physicist’s assessment
69. What tools are required for processor monitoring?
I. thermometer
II. sensitometer
III. densitometer
IV. QC film
____ a. II and III
____ b. I, II, and III
____ c. II, III, and IV
____ d. I, II, III, and IV
Post-test 181
70. Processor control strips should be kept as part of the

permanent record for at least:
____ a. 6 months
____ b. 12 months
____ c. 18 months
____ d. 24 months
71. When testing with a digital kVp for kVp accuracy at the
70, 90, and 100 kVp stations meter, you obtained 68
kVp, 94 kVp, and 100 kVp. Are the kVp values within
acceptable parameters?
____ a. yes
____ b. no
____ c. more information needed
72. How often should the fluoroscopic exposure repro-
ducibility be checked?
____ a. weekly
____ b. monthly
____ d. annually
73. When testing with a digital kVp meter for fluoroscopic
kilovoltage accuracy at 80, 90, and 100 kV, you
obtained 85 kVp, 94 kVp, and 100 kVp. Are the kVp
values within acceptable parameters?
____ a. yes
____ b. no
____ c. more information needed
74. In the manual fluoroscopic exposure mode, the maxi-
mum exposure rate should be ≤ ____ mC/kg/min.
____ a. 0.10
____ b. 1.0
____ c. 1.3
____ d. 1.5
75. In the automatic fluoroscopic exposure mode, the max-
imum exposure rate should be ≤ ____ R/min.
____ a. 5
____ b. 2.5
____ c. 15
____ d. 10
182 Post-test
76. What holes should be clearly visualized with the low-

contrast fluoroscopic test?
____ a. 1/4 and 3/16 inch
____ b. 1/8 and 3/16 inch
____ c. 1/8 and 1/4 inch
____ d. 1/16 and 1/8 inch
77. The low-contrast fluoroscopic test should be performed
for the:
I. TV monitor
II. Spot film device
III. Linearity
____ a. I only
____ b. II only
____ c. I and II
78. Which of the following recognizes variation over a
period of time and encourages evaluation of the pat-
tern of variation so that actions toward betterment can
be initiated?
____ a. QC
____ b. QA
____ c. QI
79. Choose the nonstatistical tool used to generate a large
volume of ideas for the list below:
____ a. flowchart
____ b. matrix
____ c. brainstorming
80. This chart is used to monitor one or more processes
over time to determine if there are shifts or trends:
____ a. flowchart
____ b. run chart
____ c. Pareto chart
____ d. central tendency chart
Post-test 183
81. A QI team brainstormed to identify factors that produced

variability in a process. Team members categorized
these variables as to equipment, process, manpower,
materials, and methods. What tool would they use to
visually display the results of the brainstorming session?
____ a. flowchart
____ b. Pareto chart
____ c. cause and effect diagram
____ d. control chart
82. For the following data, calculate the median:
14, 9, 36, 3, 98, 105, 18
____ a. 18
____ b. 27
____ c. 40
____ d. 50
83. If the causes of variation in a process are constant,
then measuring the outcomes will produce a set of
data points that have a predictable spread that can be
mathematically modeled. This spread is called the:
____ a. average
____ b. mode
____ c. standard deviation
____ d. skew
84. FOCUS-PDCA is an organized problem-solving
process that yields an avenue for continuous improve-
ment. What does the C in FOCUS represent?
____ a. causes for process variation are identified
____ b. clarify the problem and current knowledge
of the process
____ c. collect data
85. Which of the following methods is used to narrow
down options without discouraging specific team
members who espouse various hypotheses?
____ a. checksheets
____ b. multivoting
____ c. regression analysis
184 Post-test
86. Control charts are popular forms of presentation items

for quality improvement teams. Upper and lower con-
trol limits for these charts are typically set at sigma.
What is another name for this term?
____ a. standard deviation
____ b. coefficient of variation
____ c. spread
____ d. highest and lowest range
87. An alternative to the FOCUS-PDCA model is the:
____ a. seven-step model
____ b. statistical tools model
____ c. Deming’s principles
88. This analysis tool is designed to determine whether
there is a relationship between two variables. It can be
used to examine the relationship between a key quality
characteristic and potential process variables. What is
this tool?
____ a. storyboard
____ b. scatter plot
____ c. Pareto chart
____ d. cause and effect diagram
89. The symbolic representation of standard deviation is:
____ a. s
____ b. s
____ c. sd
____ d. ss
90. A bar graph describing a monitored event in descend-
ing order from left to right is termed a:
____ a. Pareto chart
____ b. histogram
____ c. matrix
____ d. distribution chart
91. What is the standard deviation for the following set of
numbers?
2, 8, 22, 36, 50, and 72
____ a. 31.7
____ b. 29
____ c. 25
____ d. 24.2
Post-test 185
92. The SX of a group of numbers is 480. The n equals 14.

What is the mean?
____ a. 34.29
____ b. 17.14
____ c. 68.57
____ d. more information is needed
93. This tool represents the easiest and fastest method for
documenting information about a process.
____ a. pie chart
____ b. check sheet
____ c. run chart
____ d. matrix
94. Which of the following measures is not a statistical
tool?
____ a. frequency distributions
____ b. central tendency
____ c. spread
____ d. survey
95. In the evaluation of a run chart, seven or more consec-
utive points above or below the center line indicates a
____ exists.
____ a. trend
____ b. controlled process
____ c. shift
____ d. pattern
96. What is the one sigma rule?
____ a. occurs when eight or more consecutive
points are within one standard deviation
from the center line
____ b. occurs when four or five consecutive points
are one standard deviation on the same side
as the center line
____ c. occurs when two or three consecutive points
are one standard deviation on the same side
as the center line
97. Health status and disability represent:
____ a. a structure
____ b. a process
____ c. an outcome
____ d. a concept
186 Post-test
98. A central aspect for applying quality improvement

relies on identifying and monitoring:
____ a. outcome indicators
____ b. process limitations
____ c. system components
99. Choose an example of an indicator from the following
list:
____ a. infection rates
____ b. timeliness of diagnostic test
____ c. accuracy of payroll
____ d. all of the above are indicators
100. When beginning a quality improvement project, it is
only after the process in question is understood that
data about process variables can be collected to
determine if the process is in control. Which of the
following tools is used to gain an understanding of
the process?
____ a. run chart
____ b. flowchart
101. This tool presents measurements in a way that
displays the nature of the distribution. The chart
represents the frequency distribution of a set of data.
What is this tool?
____ a. histogram
____ b. pie chart
____ c. run chart
____ d. control chart
102. From the list below, choose a model of data analysis.
____ a. research
____ b. benchmarking
____ d. neither a nor b
103. When assessing patient satisfaction, data may include:
____ a. surveys of current patients
____ b. telephone response time
____ c. waiting time studies
____ d. a, b, and c are correct
Post-test 187
104. A process is defined as:

____ a. a defined set of causes and conditions that
transforms inputs into outputs
____ b. components of inputs only
____ c. actions which produce outputs
105. What is another name for an Ishikawa diagram?
____ a. flowchart
____ b. cause control diagram
____ c. fishbone diagram
106. In the analysis of a run chart, at least ____ points are
needed to be valid.
____ a. 35
____ b. 10
____ c. 20
____ d. 25
107. A method of displaying the data, analyses, conclusions,
and decisions made during the phases of a process
improvement project is termed a:
____ a. project notebook
____ b. process accounting
____ c. storyboard
____ d. story notebook
108. The x-ray tube of a mobile fluoroscopic C-arm unit
should maintain a SOD of:
____ a. ≤ 15 inches
____ b. ≤ 12 inches
____ c. ≥ 15 inches
____ d. ≥ 12 inches
109. What is the mode of the following group of numbers?
4, 10, 33, 51, 3, 17, 55, 3, 21, 92
____ a. 3
____ b. 19
____ c. 29
____ d. 92
188 Post-test
110. Which of the following statements is true?

____ a. upper and lower limits are not part of a run
chart
____ b. a run chart is used to map a process
____ c. the center line of a run chart represents the
median
____ d. another name for a run chart is a shift chart
111. What tool does this figure represent?
100%
82% 95%
89%
30
68%
50%
20
26%
10
____ a. bar graph ____ c. histogram

____ b. Pareto chart ____ d. none of the above
112. In the following data set, what does N represent?
X = 45 N = 16 s = 12.3
____ a. raw score or number
____ b. mean
____ c. sample size
____ d. coefficient of variation
113. What is the coefficient of variation for five exposures
using the following exposure factors? The exposures
conveyed mR readings of 210, 235, 221, 212, and 208.
100 mA @ 0.1 sec and 80 kVp.
____ a. 0.0469
____ b. 0.178
____ c. 27
____ d. 33.7
114. A method used to reduce the possibility of skewing
during sample selection is:
____ a. selection of a large sample ≥ 25
____ b. randomization
____ c. selection of a diverse sample
Post-test 189
115. Frequency distributions depict data by how often an

event or situation occurs.
____ a. true
____ b. false
116. When analyzing data dispersion, the percentiles often
used are:
____ a. 15, 25, 75
____ b. 25, 75, 95
____ c. 25, 50, 75
____ d. 50, 75, 95
117. In the analysis of artifacts, lines that are parallel to the
direction of film travel are most often caused by:
____ a. crossovers
____ b. guide shoes
____ c. entrance rollers
118. In the analysis of artifacts, artifacts with evenly spaced
intervals of 1 inch are most often caused by:
____ a. crossovers
____ b. guide shoes
119. In the analysis of artifacts, plus-density bands 1/8 inch
wide are most often caused by:
____ a. crossovers
____ b. guide shoes
120. Common perpendicular processing artifacts are
referred to as:
____ a. pi lines
____ b. roller marks
____ c. streaks
____ d. stub lines
121. NCRP Report #99 states that the fluoroscopic image
should not be less than ____ centimeter ____ than the
specified diameter.
____ a. 1, smaller
____ b. 1, larger
____ c. 0.5, smaller
____ d. 0.5, larger
190 Post-test
122. NCRP Report #99 states that fluoroscopic beam

limitation be no greater than ____ of the SID at
any tower height.
____ a. 12%
____ b. 10%
____ c. 5%
____ d. 3%
123. NCRP Report #99 states that the difference between
the fluoroscopic image and the spot film image be no
greater than ____ of the SID.
____ a. 12%
____ b. 10%
____ c. 5%
____ d. 3%
124. NCRP Report #99 states that the minimum HVL at 90
kVp is ____ mm AL.
____ a. 2.3
____ b. 2.5
____ c. 2.7
____ d. 3.0
125. The annual occupational exposure recommended by
the NCRP is:
____ a. 50 mSv
____ b. 5000 mrem
____ c. 10 mSv
126. The annual effective dose for children under the age of
18 years recommended by the NCRP is:
____ a. 1 mSv
____ b. 5 mSv
____ c. 10 mSv
127. The total effective dose for the embryo-fetus recom-
mended by the NCRP is:
____ a. 0.5 mSv
____ b. 5 mSv
____ c. 10 mSv
____ d. 50 mrem
Post-test 191
128. Report #99 by the NCRP states that the exposure

reproducibility variance for an AEC device should
be ± ____.
____ a. 12%
____ b. 10%
____ c. 5%
____ d. 3%
129. Which of the following is not a required QC test to be
performed by the radiologic technologists?
____ a. radiation output rate
____ b. analysis of fixer retention in film
____ c. screen-film contact
____ d. phantom images
130. Visual checks of the equipment should be performed:
____ a. daily
____ b. weekly
____ c. monthly
____ d. annually
131. The mammography technologist should evaluate
darkroom fog:
____ a. daily
____ b. weekly
____ d. annually
132. The recommended performance criteria for fixer
temperature for processing mammographic film is:
____ a. ± 3˚ F of the developer temperature
____ b. ± 5˚ F of the developer temperature
____ c. ± 2˚ C of the developer temperature
____ d. ± 5˚ C of the developer temperature
133. The recommended performance criteria for mammo-
graphic compression device performance is that a
force of at least ____ pounds shall be provided.
____ a. 10
____ b. 15
____ c. 25
____ d. 45
192 Post-test
134. When analyzing fixer retention in mammographic

film, residual fixer should be less than:
____ a. 5 micrograms per square centimeter
____ b. 2 micrograms per square centimeter
____ c. 0.5 micrograms per square centimeter
____ d. 0.05 micrograms per square centimeter
135. OSHA recommends that a worker with occupational
risk to ____ should be vaccinated.
____ a. HBV
____ b. HIV
____ c. ACI
136. A worker at risk for contracting a bloodborne pathogen
should practice:
____ a. universal precautions
____ b. blood and body fluid precautions
____ c. body substance isolation
137. When referring to an MSDS, the term chemical means
any:
____ a. chemical compound
____ b. mixture of elements
____ c. mixture of compounds
138. Employers shall develop, implement, and maintain at
each workplace, a/an ____ that includes policies for
labeling and other forms of warning, material safety
data sheets, and employee information and training.
____ a. written hazard communication program
____ b. department safety program
____ c. infection control program
____ d. department policy manual
Post-test 193
139. The Safe Medical Device Act of 1990 requires that

medical device users report to the ____ incidents that
reasonably suggest that there is a probability that a
medical device has caused or contributed to the death
of a patient, serious injury or illness or a patient.
____ a. manufacturer
____ b. F.D.A.
____ c. both a and b are correct
140. Serious illness or injury as defined by the Safe Medical
Device Act of 1990 is an illness or injury that:
____ a. is life threatening
____ b. results in permanent impairment of bodily
function
____ c. necessitates immediate medical or surgical
intervention to preclude permanent impair-
ment of a bodily function
____ d. a, b, and c are correct
194 Post-test
ANSWERS TO
1. c. characteristic
2. a. increases, increases
3. a. luminesce
4. d. space charge
5. b. off-focus radiation
6. d. protective layer
7. a. screen efficiency
8. d. more than one but not all of the above
9. b. silver halide and gelatin
10. c. silver halide crystals
11. a. cracking artifacts
12. d. glutaraldehyde
13. a. brown films
14. d. specific gravity
15. c. both a and b
16. a. bromide
17. c. effective use of people
18. a. dryer exhaust
19. a. chemical oxidation
20. a. annually
21. b. faulty rectification
22. b. semiannually
23. b. .96 inches
24. c. 4 kVp
25. c. 10%
26. c. 13.44 mR/mAs
27. a. annually
28. b. no
29. c. half-value layer
30. b. acceptance testing, routine performance monitor-
ing, and maintenance
Post-test 195
31. a. is not producing artifacts

32. b. center, decreasing
33. a. annually
34. d. 1.2 inches
35. b. semiannually
36. d. 40 mesh/inch at the center of the image and 35
mesh/inch at the edge
37. a. daily
38. b. 2
39. c. semiannually
40. b. ± 0.15
41. b. 30 to 50 %
43. a. 2 to 3 m
44. a. 10%
45. b. step wedge
46. a. check developer thermostat setting
47. b. 18 months
48. d. annually
50. a. speed
51. b. quarterly
52. d. 0.5˚F
53. a. 21
54. b. weekly
55. c. 1.20
56. c. 2.20
57. a. 0.10
58. a. a new box of film is opened
59. d. digital kVp meter
60. c. 5
61. c. 50
62. c. 1.2 ± 0.2
63. b. lead apron and stopwatch
196 Post-test
64. a. 1500 nit

65. b. 18 months
66. c. focal spot size
67. a. on the faceplate of the collimator
68. a. darkroom
69. d. I, II, III, and IV
70. b. 12 months
71. a. yes
72. c. semiannually
73. a. yes
74. c. 1.3
75. d. 10
76. a. 1/4 and 3/16 inch
77. c. I and II
78. c. QI
79. c. brainstorming
80. b. run chart
81. c. cause and effect diagram
82. a. 18
83. c. standard deviation
84. b. clarify the problem and current knowledge of the
process
85. b. multivoting
86. a. standard deviation
87. a. seven-step model
88. b. scatter plot
89. a. s
90. a. Pareto chart
91. d. 24.2
92. a. 34.29
93. b. check sheet
94. d. survey
95. c. shift
Post-test 197
96. b. occurs when four or five consecutive points are

one standard deviation on the same side as the
center line
97. c. an outcome
98. a. outcome indicators
99. d. all of the above are indicators
100. b. flowchart
101. a. histogram
102. c. both a and b
103. d. a, b, and c are correct
104. a. a defined set of causes and conditions that trans-
forms inputs into outputs
105. c. fishbone diagram
106. d. 25
107. c. storyboard
108. c. ≥ 15 inches
109. a. 3
110. a. upper and lower limits are not part of a run chart
111. b. Pareto chart
112. c. sample size
113. a. 0.0469
114. b. randomization
115. a. true
116. c. 25, 50, 75
117. b. guide shoes
118. b. guide shoes
119. c. entrance rollers
120. a. pi lines
121. a. 1, smaller
122. d. 3%
123. d. 3%
124. b. 2.5
126. a. 1 mSv
198 Post-test
127. b. 5 mSv
128. c. 5%
129. a. radiation output rate
130. c. monthly
131. c. semiannually
132. b. ± 5˚ F of the developer temperature
133. c. 25
134. a. 5 micrograms per square centimeter
135. a. HBV
137. d. all of the above
138. a. written hazard communication program
139. c. both a and b are correct
140. d. a, b, and c are correct

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QUALITY

Elwin R. Tilson, Ed.D., RT(R)(QM)(M)(CT)

Richard R. Carlton, M.S., R.T.(R)FAERS

Australia Canada Mexico Singapore Spain United Kingdom United States

Business Unit Director: Executive Marketing Manager: Production Coordinator:

For more information contact Delmar, Library of Congress Cataloging-in-Publication Data

Or find us on the World Wide Web at

ALL RIGHTS RESERVED. No part of this work covered

NOTICE TO THE READER

Chapter 2 Program Standards/Mammography Criteria 29

Chapter 3 Quality Improvement Concepts 55

Chapter 4 Quality Improvement Data 93

Chapter 5 Physical Principles 115

Chapter 6 Test Instrumentation 153

Suggested Readings 165

USING THIS TEXT TO THE

ABOUT THE AUTHORS

research interests include Gerontology, Quality Management,

Dr. Elwin R. Tilson is Professor and Clinical Coordinator of

Richard R. Carlton is an Assistant Professor of Radiologic

One of the most important challenges in studying for the QM

This book is an excellent overview of quality control (Chap-

Note: The proper term DLOGE curve is used throughout this

Government Regulations and Accreditation Guidelines

pages 533–537, is also useful. Other good QM philosophy and

BASIC MATERIAL YOU NEED TO KNOW

NCRP #105 (Sections 1, 2, 6, 7, 8)

KNOWLEDGE POINT 1.1:

KNOWLEDGE POINT 1.2:

KNOWLEDGE POINT 1.3:

KNOWLEDGE POINT 1.4:

KNOWLEDGE POINT 1.5:

Time, Distance, Shielding

KNOWLEDGE POINT 1.6:

KNOWLEDGE POINT 1.7:

● Store materials in secured locked area.

KNOWLEDGE POINT 1.8:

● Segregate radioactive and infectious wastes from ordi-

KNOWLEDGE POINT 1.9:

This is probably the most important section to know

● Be aware of approximate personnel radiation exposure.

● When using mobile equipment, set safety standards,

KNOWLEDGE POINT 2.1:

KNOWLEDGE POINT 2.2:

● Most darkrooms will fog film; small amounts of dark-

KNOWLEDGE POINT 2.3:

3. Average gradient (slope of straight line of DLOGE

KNOWLEDGE POINT 2.4:

● Less than 2µg/cm2 thiosulfate ion (fixer) should remain

KNOWLEDGE POINT 2.5:

KNOWLEDGE POINT 2.6:

KNOWLEDGE POINT 2.7:

KNOWLEDGE POINT 2.8:

KNOWLEDGE POINT 2.9:

uniform within ±0.10 OD side-to-side (preferably

KNOWLEDGE POINT 2.10:

KNOWLEDGE POINT 2.11:

KNOWLEDGE POINT 2.12:

KNOWLEDGE POINT 2.13:

KNOWLEDGE POINT 2.14:

KNOWLEDGE POINT 2.15:

KNOWLEDGE POINT 2.16:

● Density controls should represent equal percentage