Phlebotomy Practice Exam

The phlebotomist is drawing blood on an 88-year-old patient that has multiple skin tears. Which of the following should be used to secure the 2 x 2 gauze sponge? A. paper tape B. adhesive tape C. band aid D. Coban

Coban Rationale Coban or rolled gauze is the best method to secure 2 x 2 gauze sponge following a venipuncture on patients with existing skin tears as well as those with very fragile, thin skin. Paper tape, adhesive tape, and band aid all contain an adhesive that can tear the skin when removed. Skin tears, especially in elderly and other immunocompromised patients, pose a significant risk for infection. Phlebotomist must take great care to ensure patient safety and prevent susceptibility to infection whenever possible.

Which of the following actions should the phlebotomist take to decrease the potential for hemolysis of a blood specimen in an EDTA tube? A. Store the tube in the refrigerator after the specimen has been collected. B. Use a 25 gauge needle or smaller to collect the specimen. C. Allow the tube to stand for 20 minutes prior to processing. D. Gently invert the tube after collecting the specimen.

Gently invert the tube after collecting the specimen. Rationale Since an EDTA tube contains anticoagulant, it is important to immediately mix the blood as soon as it is collected to ensure that it doesn't clot. The phlebotomist should gently invert the tube after collecting the specimen to maintain specimen integrity and prevent rupture of RBC's in the sample. The smaller gauged needles would introduce a higher likelihood of hemolysis, not prevent it. Refrigerated storage would not necessarily prevent immediate hemolysis (but would slow down the breakdown of RBCs that would cause hemolysis over time). The tube should be gently mixed immediately after collection and can be processed and run as soon as needed (it does not need to stand for 20 minutes).

An immunization is currently available for prevention of which of the following bloodborne diseases? A. Hepatitis C B. HIV C. Herpes simplex D. Hepatitis B

Hepatitis B Rationale There is no cure (beyond supportive care) for a person who contracts acute Hepatitis B, and often leads to chronic infection, liver failure, and/or liver cancer. A safe an effective vaccine exists for the prevention of HBV.

Which of the following precautions should be used for a patient with pulmonary TB? A. airborne and standard B. standard and droplet C. contact and airborne D. droplet and contact

airborne and standard Rationale Tuberculosis (TB) is a worldwide health problem caused by Mycobacterium Tuberculosis, a type of bacteria. Patients with Pulmonary or Laryngeal TB may transmit the disease through airborne particles call "droplet nuclei" when they cough or sneeze (as examples) so airborne precautions are important. The particles are so small that normal air currents can keep them airborne making it easy to spread. Contact, Standard, and Universal Precautions alone are not sufficient as a mask is needed to keep from inhaling the organism through the respiratory tract.

To help prevent a hematoma at the site after drawing blood, which of the following actions should the phlebotomist take? A. ask the patient to make a fist B. clean the site with an alcohol prep C. apply direct pressure with cotton gauze D. have the patient bend the elbow to hold cotton gauze on the site

apply direct pressure with cotton gauze Rationale: To promote clotting and help prevent the leakage of blood outside of the vein (hematoma or bruise), the phlebotomist should apply direct pressure with cotton gauze. Asking the patient to make a fist, cleaning the site with an alcohol prep, or having the patient bend the elbow will not prevent a hematoma from forming.

Which of the following specimens require the phlebotomist to follow chain-of-custody documentation procedures? (Select the two (2) correct answers.) A. neonatal screening B. blood alcohol C. therapeutic drug monitoring D. drug testing E. maternal screening

blood alcohol, drug testing Rationale Blood alcohol and drug testing require the phlebotomist to follow strict and meticulous chain-of-custody documentation procedures in order to ensure integrity of legal proceedings. Chain-of-custody tracks the specimen from the time of collection to the reporting of results. Neonatal screening (newborn screening or PKU) is a test performed by capillary puncture within the first 48 hours after birth on all newborns across the United States. Neonatal screening is performed to detect any genetic disorders that may cause severe mental and physical disability if left undiagnosed and untreated. Therapeutic drug monitoring is used to evaluate physician prescribe medications with narrow therapeutic range. Medications with narrow therapeutic range can be toxic at elevated levels or not therapeutic at low levels. Maternal screening is a blood test performed on the mother during the second trimester of pregnancy to evaluate developing fetus for any congenital defects and determine if further testing is warranted.

The phlebotomist is about to perform a venipuncture procedure using a 21-gauge straight needle. At what angle should the phlebotomist position the needle prior to venipuncture? 15-30 degrees 5-10 degrees 35-40 degrees 40-45 degrees

15-30 degrees Rationale CLSI recommends the angle of insertion for a venpuncture using an ETS or syringe system to be 15 - 30 degrees. This allows the needle less room to miss the vein. When using a butterfly, a slightly lower angle may be used. Five to ten degrees is too low to adequately access the vein and higher (35-40 or 40-45 degrees) is too high and the needle may go through the vein and damage underlying tissue and nerves.

Which of the following would be considered a hospital acquired infection? A. a 72-year-old patient in the ER with flu-like symptoms B. an 8-year-old patient admitted with chicken pox C. a patient who contracts a MRSA infection from a venipuncture D. a healthcare worker that develops Hepatitis C

a patient who contracts a MRSA infection from a venipuncture Rationale A nosocomial infection is a "hospital-acquired" infection acquired by a patient who enters the hospital without any symptoms of it and appears to have acquired the infection during the hospital stay. A female patient who develops a urinary tract infection after having a urinary catheter inserted is a perfect example. The other patients were exposed prior to admission or were never admitted, in the case of the healthcare worker.

It is appropriate for the phlebotomist to use an alcohol-based hand rub as the only method of hand hygiene after which of the following activities? A. before entering the employee break room B. before putting on gloves prior to venipuncture C. after using the restroom D after removing soiled gloves

before putting on gloves prior to venipuncture Rationale In addition to when visibly soiled, hands should always be washed with an antimicrobial soap and water before eating and after using a restroom to reduce the incidence of health care environment related infections.

Which of the following must be included on a specimen label once it has been filled with blood? A. collector's identification B. ordered test C. physician's name D. patient's gender

collector's identification Rationale It is important to have a time, date, and initials on a tube label to ensure accuracy. The physician's name, ordered tests, and patient gender should all be on the testing requisition. Depending on the standard collection protocol of the medical practice, it may be required to label the tube with a sticker (that may or may not be pre-printed). It is important that the sample can be traced to the person who collected it (hence the initials), in addition to the time and date of collection.

A 19-year-old patient offers her arm to the phlebotomist when she comes in with a venipuncture tray. This is an example of A. parental consent. B. implied consent. C. informed consent. D. verbal consent.

implied consent. Rationale An implied consent is when a patient offers their arm, for B/P or phlebotomy, therefore, no written consent is necessary. Informed Consent is when the procedure is explained in detail to the patient and they consent to the procedure by signing a release. Verbal is when the patient speaks an assent (OK or Yes) after a procedure has been explained to them. Parental consent is required when the patient is under 18 years old and the procedure is ok'd by a guardian or parent.

Which of the following evacuated tubes should the phlebotomist draw first? A. lavender top B. light blue top C. light green top D. gold top

light blue top Rationale CLSI lists the order of draw as follows: 1. Blood cultures 2. Coagulation tube (e.g. blue closure) 3. Serum tube with or without clot activator, with or without gel (e.g. red closure, gold shield,etc.) 4. Heparin tube with or without gel plasma separator (e.g. green closure) 5. EDTA tube with or without gel separator (e.g. lavender closure, pearl closure) 6. Glycolytic inhibitor (e.g. gray closure) Other tube additives affect coagulation tests. Collecting the light blue top tube (for coagulation testing) in this scenario prevents contamination of the specimen with tissue thromboplastin (which will adversely affect the test).

Negligence by a health care professional is considered which of the following? A. battery B. non-maleficence C. malpractice D. assault

malpractice Rationale Malpractice occurs when a health care professional is negligent or fails to provide adequate treatment to the patient. Beneficence is the act of doing good, non-maleficence means to do no harm, and battery is unlawful physical contact. Assault is a threat to harm.

While obtaining blood during a venipuncture, the patient faints. Which of the following actions should the phlebotomist take initially? A. Reposition the needle slightly and obtain the ordered specimen. B. Discontinue the venipuncture and call for help. C. Apply direct pressure for five full minutes on the venipuncture site. D. Call the patient's emergency contact on file.

Discontinue the venipuncture and call for help. Rationale If the needle is still in the arm as the patient falls it could cause serious injury.

A patient shares with the phlebotomist the last time he was in the clinic to have his blood drawn, he "became very dizzy and felt like the room was spinning." Which of the following actions should the phlebotomist take? A. Ask the patient to lean slightly forward during the venipuncture. B. Reassure the patient the procedure will be over before dizziness occurs. C. Encourage the patient to lie down during the venipuncture. D. Encourage the patient to sit upright on the exam table during the venipuncture.

Encourage the patient to lie down during the venipuncture. Rationale To prevent syncope and maintain safety. Patients who are lying down rarely faint during venipuncture.

Venipuncture should be avoided on an arm with A. excessive hair. B. muscular hypertrophy. C. an elbow splint. D. alopecia.

an elbow splint. Rationale A patient with a cast/splint in place may have ongoing extremity swelling during the healing process. Use as a venipuncture site should be avoided. Though not always optimal, it is okay to collect from an arm with excessive hair, muscular hypertrophy (large muscles), or alopecia (hair loss).

Capillary blood specimens are most likely to be successfully collected from patients that A. are extremely obese. B. are dehydrated. C. have poor peripheral circulation. D. have peripheral edema.

are extremely obese. Rationale Capillary blood samples are advisable on patients when veins are not palpable, which includes patients who are morbidly obese, among others. A phlebotomist should never just "hope for the best" if a vein cannot be located.

he rubber sleeve at the end of a ETS venipuncture needle allows for A. faster draw of the specimen. B. drawing a single tube. C. slower draw of the specimen. D. drawing multiple tubes.

drawing multiple tubes. Rationale Maintains a closed system

A patient presents to have a diagnostic HIV test drawn. Which of the following forms of consent must the phlebotomist obtain prior to venipuncture? A. expressed B. implied C. informed D. verbal

informed Rationale Informed consent means the patient agrees to and signs a document in regards to a procedure after the provider explains the risks and consequences. Expressed consent is when the patient clearly gives permission to the procedure either verbally or non-verbally. Implied consent means consent is understood by the patient's actions even though the patient did not directly express consent. Verbal consent means the patient has said he/she agrees to the procedure even though it is not written down in contract.

Which of the following is the CLSI recommended micro-collection order of draw for a BMP, CBC and bilirubin? lavender, green, red green, lavender, red lavender, red, green red, green, lavender

lavender, green, red Rationale The recommended Order of Draw for capillary blood collection is different from blood specimens drawn by venipuncture. CLSI recommends the following order of draw for skin puncture: Blood gases, EDTA tubes, Other additive tubes, then Serum tubes.

A physician has ordered STAT hematology, chemistry, and coagulation tests on a patient. Which of the following tubes are needed for these procedures? (Select the three (3) correct answers.) A. lavender B. gray C. light blue D. green E. yellow

lavender, light blue, green Rationale The phlebotomist should draw the following tubes: Lavender for the Hgb, Hct - Red for serum chemistry test - Light blue for the PT - (Yellow is used for blood cultures and gray is generally used for glucose samples.) CLSI lists the order of draw as follows. 1. Blood culture tube 2. Coagulation tube (blue closure) 3. Serum tube with or without clot activator, with or without gel (red closure) 4. Heparin tube with or without gel plasma separator (green closure) 5. EDTA tube with or without gel separator (lavender closure, pearl closure) 6. Glycolytic inhibitor (gray closure)

The patient was sent to the lab to have lavender, light blue, green, and gray. Place the evacuated tubes in the correct order of draw. (Click and drag the options in the left column to their correct position in the right column.) light blue green lavender gray

light blue green lavender gray Rationale The evacuated tubes should be placed in order starting with the light blue tube, followed by the green tube, then lavender, and finally the grey tube. The PT/PTT tube needs to be drawn first to ensure it gets filled to the top since it contains so much of the additive sodium citrate. The order needs to be followed correctly or test results may be skewed due to cross-contamination of the additives in other tubes.

The phlebotomist has a requisition for chemistry and coagulation testing. Which of the following is the correct tube selection and order of draw? A. light blue, SST B. red, royal blue C. SST, royal blue D. red, light blue

light blue, SST Rationale The order of draw is designed to prevent carryover of additives from one tube to the next thereby affecting patient results. CLSI states the order of draw for ETS tubes to be: SPS (sterile), sodium citrate (blue, serum ( red or gold), heparin (green), purple (EDTA), oxalate / fluoride (gray). In this case the order would be light blue then SST (serum separator tube). Royal blue tubes are used for heavy metal screens and the red (serum tube) is never drawn before a light blue.

Which of the following is the maximum amount of time a phlebotomist can leave a tourniquet secured in place prior to venous access? A. thirty seconds B. three minutes C. two minutes D. one minute

one minute Rationale The advised time limit for having a tourniquet applied to an arm is one minute. This limit is in place to prevent flow constriction and increased risk of clotting during the venipuncture. Hemoconcentration, which may affect test results, can occur if the tourniquet is left on for more than one minute.

A phlebotomist must follow transmission based precautions for which of the following patients? A. patient with meningitis B. patient with diabetes C. patient with multiple sclerosis D. patient with lupus

patient with meningitis Rationale Airborne precautions must be followed for patients with Rubeola (measles) virus exhibiting maculopapular rash with cough, nasal mucosa secretions, and fever. A patient with a fever of unknown origin, rheumatic fever, or pneumonia requires standard precautions.

Which of the following is outside the scope of practice for a phlebotomist? A. verifying equipment function on point of care testing using a control. B. prioritizing collections based on order requests. C. recording quality control results on a log sheet. D. performing CLIA high complexity tests.

performing CLIA high complexity tests. Rationale CLIA refers to the Clinical Laboratory Improvement Amendment, which specifies personnel requirements for performing laboratory testing based upon their complexity. Moderate and high complexity testing are outside the scope of practice for a phlebotomist. Medical assistants may perform CLIA-waived testing, such as Point of Care Testing, with proper training.

The phlebotomist is drawing plain red, purple, green, and blue top tubes. Upon completion of the blood draw the phlebotomist noticed that he missed an order requiring an SST. The phlebotomist should share the A. red B. purple C. green D. blue

red Rationale A plain red tube and an SST tube both will yield serum once clotted and centrifuged. Therefore, it is possible to share the plain red top specimen for the SST test. There is no need to re-stick the patient. The lavender and blue top tubes both contain anticoagulant, thus they produce plasma (not serum) when centrifuged. They would not be good substitutes for an SST specimen.

The phlebotomist is asked to draw blood from a patient with an IV in the right arm whose left arm is inaccessible. The phlebotomist may draw without a physician's approval from the A. foot. B. IV line. C. right arm proximal to the IV site. D. right arm distal to the IV site.

right arm distal to the IV site. Rationale Collecting blood distal to the I.V. site prevents contamination of the sample by the intravenous solution. Medical assistants are not permitted to collect samples from an I.V. line and may not draw from an ankle vein without physician's approval.

A centrifuge functions in which of the following ways? A. slowly warms a refrigerated blood specimen to room temp B. magnifies cellular blood components C. measures the amount of glucose in a patient's blood D. rotates to separate components of a patient's blood

rotates to separate components of a patient's blood Rationale A centrifuge rotates to separate components of a patient's blood. Depending on specimen requirements for a particular test, certain samples must be processed by centrifugation to maintain the integrity for testing. A centrifuge does not serve as a specimen warmer, nor does it magnify sample components (microscopes are used for magnification). Glucose measurements are obtained by analyzing the sample on a glucose meter or designated laboratory instrument, not the centrifuge.

A sharp may be disposed of following a venipuncture once the needle is A. bent B. sheathed C. broken D. cut

sheathed Rationale Occupational Safety and Health Administration (OSHA) mandates that all needles must have a safety feature or be used with tube holder or syringe that has a safety feature. Needle must be sheathed immediately following a venipuncture in order to minimize the risk of accidental needlestick injuries and bloodborne pathogen exposure. Needles must never be bent, broken, cut, or removed from the tube holder following a venipuncture as this constitutes unsafe sharp practice.

The Needlestick Safety and Prevention Act exists to protect healthcare workers from accidental exposure to A. carcinogens. B. blood borne pathogens. C. hazardous chemicals. D. biologic toxins.

blood borne pathogens. Rationale The Needlestick Safety and Prevention Act requires reporting and documentation of all sharps injuries. In compliance with OSHA standards, log or report must be kept in the medical facility describing the incident, type of device, time, date, location, and follow up. This also includes minor incidents that do not result in injury or illness.

Which of the following organizations makes on-site visits to inspect phlebotomy laboratories? A. ASCLS B. DEA C. CLIA D. FDA

CLIA Rationale All laboratory testing in the United States that is performed on humans is highly regulated. The Centers for Medicare & Medicaid Services (CMS) governs laboratories via the Clinical Laboratory Improvement Amendments (CLIA).

The phlebotomist is preparing to remove her gloves after a venipuncture and notices blood on the gloves. Where should the phlebotomist dispose of her gloves? A. a biohazard waste container B. a red sharps container C. a regular trash container D. a specimen transport bag

a biohazard waste container Rationale Biohazard waste includes disposable items with visibly contaminated blood and/or body fluids, therefore the phlebotomist should dispose of her gloves in a biohazard container instead of the regular trash (could be an infection risk). A sharps container is for sharp objects (not soft gloves). A specimen transport bag would not be acceptable, because noticeably soiled gloves need to be properly disposed of in a biohazard waste container.

Which of the following is a requirement for a healthcare facility to be in compliance with OSHA? A. payment of annual dues B. current certificate of compliance on file C. annual employee safety training D. annual inspections conducted by OSHA

annual employee safety training Rationale In any Medical setting, they must be in compliance with OSHA guidelines, which include the following: a) A written exposure control plan, to be updated annually, Use of universal precautions, b) Consideration, implementation, and use of safer, engineered needles and sharps, c) Use of engineering and work practice controls and appropriate personal protective equipment (gloves face and eye protection, gowns), d) Hepatitis B vaccine provided to exposed employees at no cost, e) Medical follow-up in the event of an "exposure incident", f) Use of labels or color-coding for items such as sharps disposal boxes and g) containers for regulated waste and contaminated laundry.

When drawing a blood alcohol specimen, which of the following should be used to clean the arm? A. isopropyl alcohol B. Chloraprep C. benzalkorium choloride D. tincture of iodine

benzalkorium choloride Rationale When drawing blood for an alcohol level, it is crucial to avoid cleaning the venipuncture site with any solution containing alcohol. Doing so might contaminate the specimen and invalidate the results, especially in a court of law. Therefore isopropyl alcohol, tincture of iodine and solutions of chlorhexidine and alcohol (Chloraprep) should not be used.

A patient notices this symbol on a container in the room and asks what it means. The phlebotomist should tell the patient the symbol means A. isolation precautions required. B. radiation in use. C. emergency eye wash station. D. biohazard material present.

biohazard material present. Rationale This symbol accompanied by the term 'biohazard' serves as a warning that materials in or around the area constitute a health risk and could cause human disease or harm.

Which of the following statements by a new phlebotomist indicates the need for further education on standard precautions? A. "I will wear a gown, gloves, and mask for inpatient collections." B. "I will perform hand hygiene after removing gloves." C. "Sharps containers should be replaced when 2/3 full." D. "Antimicrobial wipes may be used for cleaning a collection area at the end of a shift."

"I will wear a gown, gloves, and mask for inpatient collections." Rationale In a healthcare setting, the staff wears Personal Protective Equipment (PPE), not the patients. The purpose of following contact-droplet isolation precautions are to contain the patient's environment and prevent the spread of infection. Since they have contact with multiple patients, medical professionals must wear proper PPE and perform proper hand hygiene when caring for every patient. Antimicrobial wipes can be utilized to clean exam rooms between patients. In order to limit potential for accidental exposure/puncture, Sharps containers should be replaced when 2/3 full.

While performing a capillary stick on a six-month-old infant's heel, the lancet should be no longer than A. 2.0 mm B. 2.0 cm C. 3.0 cm D. 3.0 mm

2.0 mm Rationale CLSI recommends that capillary blood collection on infants less than one year of age be performed on medial or lateral plantar surface of the heel and that the puncture must not exceed 2.0 mm. WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy recommends that the depth of heel punctures not exceed 2.4 mm as pain fibers/receptors significantly increase in abundance and the potential for bone injury also increases. Given the CLSI and WHO recommendations, 2.0 mm is the most appropriate answer. 2.0 cm and 3 cm are equal to 20 mm and 30mm, respectively, which is wider than the thickness of an average adult finger. It is important to note that units are very important (1.0 cm equals 10mm). 3.0 mm puncture may only be appropriate in performing capillary puncture on adults with excessive scarring and callouses on the fingers. Callouses are often the result of manual work and is also seen in musicians who play certain string instruments. In these situations, it is warranted to perform a deeper puncture in order to penetrate the callous and obtain blood from the capillary bed in the dermis, middle vascular layer of the skin located just deep to the epidermis.

Which of the following needle gauges is most commonly used for venipuncture? 24-25 21-23 18-20 16-17

21-23 Rationale The gauge of a needle refers to its outer diameter (smaller numbers= larger diameters and vice versa). The most commonly used needle for venipuncture is a 21-23 gauge. The needle size must be large enough to prevent hemolysis (break down of blood cells).

A CMP is ordered for an older adult patient whose veins continue to collapse despite drinking water. Which of the following is the best collection method for this patient? A. evacuated tube system B. 18-gauge needle and syringe C. capillary puncture D. 23-gauge butterfly needle and syringe

23-gauge butterfly needle and syringe Rationale A butterfly with a smaller gauge needle device is used for smaller veins, including fragile veins on all patients, elderly adults and small children. Other phlebotomy systems use larger gauge needles. The vacuum pressure in an evacuated tube system would collapse the vein. A needle and syringe provides better control than an evacuated tube. A capillary collection would be the last resort as it might not provide enough sample. An 18-gauge needle would be too large for this collection. The 23-gauge butterfly and syringe is the best initial choice in this case.

After selecting the appropriate location to collect a blood sample, how many inches above that location should the phlebotomist tie the tourniquet? A. 1 to 2 inches B. 3 to 4 inches C. 5 to 6 inches D. more than 6 inches

3 to 4 inches Rationale Tourniquets are used to make it easier to locate veins by causing them to become distended and easier to palpate. This occurs because the tourniquet impedes venous blood flow right (i.e., below the application site) but does not impede arterial blood flow. Most phlebotomy experts recommend a tourniquet be applied approximately 3 to 4 inches above the site of blood collection for optimum palpation in venipuncture. Placing a tourniquet too far away will not impede blood flow sufficiently to help with palpation, but too close may cause hemoconcentration, possibly affecting the ratio of cellular components to plasma and laboratory test results.

How long should pressure be applied on the venipuncture site for a patient on Coumadin therapy? A. 1 min B. 3 min C. 5 min D. 10 min

5 min Rationale It is the responsibility of the phlebotomist to assure that bleeding has entirely stopped after completion of the venipuncture before bandaging and releasing the patient. Those on anticoagulant therapy (coumadin) tend to require direct pressure at the site for a longer time - at least 5 minutes. A pressure bandage such as Coban is then applied. If bleeding continues longer than 10 minutes, medical assistance should be sought.

The phlebotomist is educating the patient on fasting diet requirements prior to a glucose tolerance test. Which of the following is the minimum time frame the patient must remain fasting before the start of the test? A. 12-24 hours B. 8-12 hours C. 1-2 hours D. 2-4 hours

8-12 hours Rationale To ensure accuracy of the blood test results. Gum chewing, eating mints, and/or smoking are not allowed. Sips of water may be permitted depending on provider NPO policy.

For which of the following tubes must the phlebotomist prep the site with povidone iodine or chlorhexidine? A. A lavender tube with EDTA B. A light blue tube with sodium citrate C. A yellow tube with ACD D. A yellow tube with SPS

A yellow tube with SPS Rationale Skin antisepsis is the most critical aspect of blood culture collection, which requires a higher degree of skin antisepsis than 70% isopropyl alcohol (isopropanol) is able to provide. Iodine, chlorhexidine gluconate (ChloraPrep), and benzalkonium chloride are acceptable forms of antisepsis for blood culture collection. If iodine is used, venipuncture site must be cleansed in concentric circles from the center (inside) to the periphery (outside) using three separate iodine swabs. Cleansing the site from clean to dirty allows for optimal antiseptic technique since the microbes are moved away from the venipuncture site. If ChloraPrep and benzalkonium chloride are used, the venipuncture site must be cleansed using 30-60 second friction scrub. Higher degree of skin antisepsis ensures that normal flora from the skin will not contaminate blood culture bottles and thus prevents false positive blood culture results. 70% isopropyl alcohol can be used to clean the venipuncture site prior to collecting a lavender tube, light blue tube, and yellow tube with ACD.

Which of the following actions should the phlebotomist take to make a vein more prominent when attempting to select a venipuncture site? A. Firmly tap the arm several times and palpate with a non-gloved finger. B. Apply a warm compress to the area for 5 minutes. C. Leave the tourniquet in place and ask the patient to dangle the arm for one minute. D. Apply firm pressure to the arm from the shoulder to the elbow.

Apply a warm compress to the area for 5 minutes. Rationale The phlebotomist should apply a warm compress to the area for 5 minutes. Warm moist heat promotes circulation and vasodilation and will help make the vein more visible. Tapping the arm or dangling the arm will not cause the vein to be as prominent as applying a warm compress. Applying firm pressure to the arm will occlude the blood flow and will not make the vein more prominent.

An infant is brought to the clinic for a CBC. After performing a heelstick, not enough blood is collected to perform the test. Which of the following actions should the phlebotomist take? A. Add one drop of diluent to the bottom of the microtainer. B. Use a deeper lancet. C. Apply a warm compress. D. Perform a fingerstick.

Apply a warm compress. Rationale The heat from a warm compress will encourage capillary vasodilation resulting in increased blood flow. Warming helps make blood collection easier and faster. Warm the heel for 3-5 minutes, which allows sufficient time for the capillaries to dilate. Squeezing can create discomfort and will not necessarily get more blood (it may also extract serous fluid that would dilute an already small amount of blood sample). The only content to be added to a microtainer collection tube is blood (adding a diluent would skew the results). The fingers of infants should not be used for collection since lancets are too long (and would puncture bones and nerves).

In the middle of a blood draw the patient experiences a seizure. Which of the following should the phlebotomist do after removing the tourniquet and withdrawing the needle? (Select the two (2) correct answers.) A. Call for help. B. Place gauze in the patient's mouth. C. Protect the patient's head and lower her to the floor. D. Place the patient in Trendelenburg position. E. Observe the patient in the chair for at least 45 minutes after the seizure.

Call for help Protect the patient's head and lower her to the floor. Rationale The phlebotomist must call for help and keep the patient safe from any injuries if the patient experiences a seizure during a venipuncture. Placing gauze into the patient's mouth may cause the patient to chock or inhibit effective breathing. Seizure causes the patient's muscles to contract involuntarily and thus the patient may unintentionally clench his/her jaw while the phlebotomist attempts to place anything in the mouth. Trendelenburg position is a position in which the patient is lying flat in supine position with the head tilted down and legs elevated. Patient experiencing a seizure must be kept safe by removing potentially hazardous objects from immediate area and protecting the patient's head without any forceful restraint. Patient after a seizure must be evaluated and observed by qualified healthcare professionals such as a physician.

A phlebotomist has completed a draw on a patient. After the blood is drawn the patient informed the phlebotomist that he tends to bleed longer. Which of the following is the next course of action the phlebotomist should take? A. Confirm hemolysis and have the patient elevate the arm for five minutes. B. Apply a cotton ball to the site with tape. C. Confirm hemostasis and apply gauze with a pressure wrap. D. Apply gauze with tape and tell patient to bend his arm for 20 minutes.

Confirm hemostasis and apply gauze with a pressure wrap. Rationale A proper phlebotomy procedure includes confirmation of hemostasis, regardless of whether or not a patient bleeds longer than normal. This definitely applies to this case when a patient admits a tendency to bleed longer than the average person.

The phlebotomist arrives at an inpatient room to collect a blood sample. There is an isolation cart located outside the room. The phlebotomist washes her hands and puts on the following personal protective equipment: gown, gloves, and mask. Which of the following types of precautions are being used for this patient? A. Contact Droplet Airborne B. Contact Droplet C. Standard Airborne D. Contact Airborne

Contact Droplet Rationale According to CDC and HICPAC Guideline for Isolation Precautions, Transmission-Based Precautions are all used in addition to Standard (hand hygiene and gloves). Therefore, Contact Isolation would require a gown in addition to gloves; Droplet Isolation would require a regular or surgical mask in addition to gloves. Reverse or Protective isolation would also require a gown and regular or surgical mask in addition gloves in order to protect immunocompromised patients. The need for gown, gloves and mask in this scenario indicates one of the following types of isolations: Contact-Droplet Isolation or Reverse/Protective Isolation. Reverse or Protective Isolation is not an option in the choices provided. Contact-Droplet-Airborne Isolation would require gloves, gown, and a N95 respirator mask. Standard-Airborne Isolation would require gloves and N95 respirator mask. Airborne Isolation is always used in addition to Standard Precautions. Contact-Airborne Isolation would require gloves, gown, and a N95 respirator mask. Contact-Airborne Isolation and Contact-Droplet-Airborne Isolation both require the same Personal Protective Equipment (PPE) because N95 mask will protect healthcare professionals against Airborne and Droplet transmission while the regular or surgical mask will only protect against Droplet transmission.

The phlebotomist is collecting a capillary sample from an infant. Following the collection, the phlebotomist holds firm pressure on the site until bleeding has stopped. How should the phlebotomist proceed? A. Put a cartoon character bandage on the site. B. Bandage with a pressure dressing. C. Tape a sterile gauze pad over the site. D. Do not bandage.

Do not bandage. Rationale If the child has shown evidence of wanting to touch everything in sight, the phlebotomist should not add a bandage to the list of things within his reach as a 2 year old could easily decide to put it in his mouth. Putting a smiley face on the bandage might make it even more enticing. A pressure dressing is unwarranted if firm pressure was held on the site until bleeding stopped. Bandages are not biohazards prior to being used, but only become so when in contact with blood.

The phlebotomist is performing a venipuncture on an apprehensive school age child. Which of the following approaches should the phlebotomist use to calm the child? A. Direct the child's questions to the parent and have the parent explain. B. Tell the child she has to do this, but it won't hurt. C. Explain the procedure and reassure the child that the parent can stay with her. D. Allow child to clean the puncture site and give her a sticker.

Explain the procedure and reassure the child that the parent can stay with her. Rationale Performing a venipuncture on a school age child requires age related competencies and understanding of the needs of various age groups. It is best to explain the procedure in simple terms and reassure the child that the parent can stay with her. It is important to always speak directly with the patient regardless of patient's age and status in order to demonstrate professionalism, respect and establish trust. Telling the child that she has to do this may make the child more apprehensive and more frightened. Never tell the child or any patient that the procedure will not hurt. Every patient experiences pain differently and has different pain tolerance. It is best to tell the child that they may feel a little pinch or relate the procedure to something a child might have experienced. Telling the child the procedure will not hurt will only lead the child to no longer trust the phlebotomist when it does hurt. It is acceptable to allow the child to handle or look at the tubes and packaged alcohol swabs before the procedure to become more comfortable, but it is imperative that any sharps are kept out of reach and that the phlebotomist performs the entire procedure.

If a phlebotomist has questions about disposing of outdated hazardous chemicals, where should she look to find this information? A. HIPAA B. MSDS C. CLIA D. NIOSH

MSDS Rationale A Material Safety Data Sheet (MSDS) is a hazardous chemical reference. It provides healthcare workers with procedures for working with substances safety to ensure regulatory compliance. Clinical Laboratory Improvement Amendments (CLIA) of 1988 are United States federal regulatory standards that apply to all clinical laboratory testing performed on humans in the United States, except clinical trials and basic research. HIPAA (Health Insurance Portability and Accountability Act) requires medical professionals to protect the confidentiality of patients' health information. The National Institute for Occupational Safety and Health (NIOSH) makes recommendations for preventing illness and injury acquired on the job.

If a patient has measles, which of the following is a required additional precaution? surgical mask N95 respirator fluid resistant apron double gloves

N95 respirator Rationale Airborne precautions are advised for patients with tuberculosis, measles, chickenpox and herpes zoster (until lesions are crusted over) and use of an N95 respirator is recommended as an additional precaution to standard precautions.

When disposing of hazardous materials, the phlebotomist must adhere to the guidelines and standards set forth by A. OSHA. B. CLIA. C. FDA. D. CMS.

OSHA Rationale In the United States, the treatment, storage and disposal of hazardous waste is regulated by the Hazardous Waste Operations and Emergency Response (HAZWOPER) standards set forth by the Occupational Safety and Health Administration (OSHA). The Clinical Laboratory Improvement Amendment (CLIA) regulates laboratories by providing a classification system based upon method complexity. The Federal Drug Administration regulates pharmaceuticals. Laboratory Managers merely enforce regulations as defined by the government and other regulatory agencies.

According to the American Hospital Association, if a Spanish-speaking patient is not provided a translator although one was requested. This would be considered a violation of A. protected health information B. Patient's Bill of Rights C. patient confidentiality D. Health Insurance Portability and Accountability Act

Patient's Bill of Rights Rationale It is within a patient's bill of rights to be provided a translator if one is available. If a patient requests a translator, that translator becomes a part of the health care team. By requesting a translator, the patient essentially agrees to the translator knowing private, confidential, protected medical information and therefore it would not violate HIPAA.

Which task should a phlebotomist complete prior to daily use of a POC instrument? A. Run the test patient sample. B. Perform QC on the instrument. C. Ensure that QC was performed within the last month. D. Calibrate the instrument.

Perform QC on the instrument. Rationale Each time a Point of Care (POC) testing instrument is used, both Quality Assurance and Quality Control procedures must be completed. This ensures the instrument and reagents are performing properly so test results can be validated. Without QA/QC, patient test results cannot be guaranteed. Although reading the operation manual is fine, it is not a substitute for training and need not be performed prior to each use. There would be no rationale for selecting "within the last month" as a time frame for completion of QA or QC, and certainly QC without QA is insufficient. Instrument calibration is generally necessary for an established timeframe (possibly after so many tests, with the change of reagents, after a certain length of time).

Which of the following actions should the phlebotomist take when disposing of a needle following a venipuncture? A. Recap the needle and place it immediately in a sharps container. B. Push the needle guard over the needle until it clicks and then place in a biohazard bag. C. Place the needle with safety device activated immediately in a sharps container. D. Recap the needle and place it on the blood collection tray.

Place the needle with safety device activated immediately in a sharps container. Rationale To minimize risk of needlestick exposure and/or injury, the phlebotomist should place the needle with safety device activated immediately in a sharps container. Recapping the needle increases the risk of an accidental needlestick and is not recommended (if the needle has a needle guard, it should be activated to minimize risk). All needles should be promptly disposed of in a sharps container, not in a biohazard bag or on the blood collection tray.

Which of the following should the phlebotomist do when collecting blood via finger stick? A. Position the lancet across the fingerprint lines. B. Wipe off any remaining alcohol from the finger before insertion. C. Disinfect the patient's finger with povidone-iodine. D. Milk the finger during the blood collection.

Position the lancet across the fingerprint lines. Rationale Capillary puncture can be performed on the palmar surface of the distal segment of the 3rd digit (middle finger) or 4th digit (ring finger). Lancet must be placed across (perpendicular) to the fingerprint whorls in order to allow blood to form round drops as it is collected. Placing the lancet along (parallel to) the fingerprint whorls will allow the blood to channel away from the puncture site into the grooves and make collection very difficult. Never wipe, fan or blow at a site that has been cleansed. Alcohol must air dry to allow time for it to work and inhibit bacteria. Wiping can prevents alcohol from work properly and can introduce more microbes. Fanning creates air turbulence and can introduce more microbes. Blowing introduces microbes from the mouth into the cleansed site. Capillary puncture does not require higher degree of antisepsis such as iodine. Iodine should not be used for capillary puncture as it can affect BURPP—bilirubin, uric acid, phosphorus and potassium tests. Milking is contraindicated during capillary puncture as it will increase specimen hemolysis and tissue fluid contamination.

A phlebotomist working in a hospital is collecting blood from a patient with very small, difficult veins. Three tubes of blood need to be collected. The blue and green tubes fill easily and completely, but the lavender tube fills incompletely. Changing the lavender tube using the same draw also results in an incomplete specimen. Which of the following should the phlebotomist do next? A. Re-position the needle and recollect the lavender tube. B. Re-draw the patient using a different site and obtain all three tubes. C. Submit the samples as drawn. D. Resubmit the draw order for the next round of draws.

Re-position the needle and recollect the lavender tube. Rationale It is possible for needle position to change during successive tube exchanges. In a patient will very small, fragile veins, the needle could have advanced further into the vein and possibly through the posterior wall or it could have been pulled more superficially and possibly through the anterior wall of vein. Re-positioning the needle may help reestablish blood flow in order to completely fill the lavender tube and ensure proper blood-to-additive ratio. It is unnecessary to re-draw all three tubes from the patient using a different site since the first two tubes filled successfully. If re-draw was necessary, only the under-filled or unfilled tubes should be collected. QNS (quantity not sufficient) is a specimen that does not have adequate volume for testing. Phlebotomist must not submit a known QNS specimen to the laboratory. Phlebotomist must notify the laboratory and ask for anther phlebotomist if he/she is not able to collect sufficient quantity for testing. Knowingly submitting QNS specimens will delay patient treatment. After two unsuccessful attempts, a phlebotomist can notify the laboratory (it should not be automatically assumed that the draw may be postponed for the next round of draws; if it is a STAT situation, the blood draw cannot wait).

A patient brings in written lab test results, including a mix of POC and higher complexity tests, and asks the phlebotomist for help with interpretation. Which of the following should the phlebotomist do? A. Explain the interpretation behind the POC tests, but let the patient read the directions with the higher level tests. B. Explain the interpretation behind the POC care tests, but refer the patient to the physician for the higher complexity tests. C. Refer the patient to the physician for interpretation of all results. D. Hand the patient pre-printed test explanations downloaded from the CDC web site.

Refer the patient to the physician for interpretation of all results. Rationale The phlebotomist is able to collect blood specimens via capillary puncture and venipuncture, process specimens and perform CLIA waived point of care tests. Phlebotomists are not able to interpret or analyze results whether the tests are categorized as waived, moderate or high complexity. It is always best to instruct the patient to consult with the physician for interpretation of the results.

Commitment to privacy, continuity of care, advance directives, and the authority to refuse treatment are granted according to which of the following? A. Americans with Disabilities Act B. The Patient's Bill of Rights C. Informed Consent D. Good Samaritan Law

The Patient's Bill of Rights Rationale Patients are guaranteed certain standards of care listed in this question by The Patient's Bill of Rights. In 2010, in conjunction with the Affordable Care Act, a new Patient's Bill of Rights was set forth to include protections associated with insurance companies. Patients do have a right to be fully informed of a procedure or treatment option and have the right to consent to it or refuse. The Americans with Disabilities Act (ADA) addresses discrimination of disabled individuals. The Good Samaritan Law protects individuals who are willing to help someone in an emergency situation.

Instead of obtaining consent from a patient who is mentally competent, the phlebotomist obtains consent from a family member. This is a violation of A. HIPAA. B. The Patient's Bill of Rights. C. CLIA Waived Testing. D. The Stark Law.

The Patient's Bill of Rights. Rationale Failure to obtain consent from the mentally competent patient is a violation of The Patient's Bill of Rights. The Patient's Bill of Rights states that a patient has the right to be informed of the treatment and the right to refuse the treatment. HIPAA protects the confidentiality of protected health information (PHI). CLIA Waived Testing refers to tests that are very simple and pose little or no risk to the patient if performed incorrectly. The Stark Law refers to limitations placed on physician referrals whenever a physician has a financial gain or incentive as a result of the referral.

A tourniquet was left on the arm for an extensive period of time before the performance of a venipuncture. Which of the following is most likely to occur? A. The patient will have excessive bleeding. B. The patient will develop a hematoma. C. The blood specimen will be hemolysed. D. The blood specimen will be hemoconcentrated.

The blood specimen will be hemoconcentrated. Rationale Hemoconcentration is decrease in the volume of plasma in relation to the number of red blood cells. Prolonged tourniquet use impedes circulation and will cause this to happen, but will likely not cause hemolysis or a hematoma. Hematocrit is a measure of the volume of red blood cells in a whole blood sample, and is not a physiological complication at all.

When performing a capillary puncture on an infant, which of the following is the reason for using the lateral heel instead of a finger? A. The tissue layers on the finger are more susceptible to permanent nerve damage. B. The finger produces a slower flow of blood, making it more difficult to obtain a specimen. C. The small amount of tissue between the skin and bone in the finger makes an injury to the bone likely. D. The blood in the fingertip has been found to contain a higher concentration of hemoglobin than the heel.

The small amount of tissue between the skin and bone in the finger makes an injury to the bone likely. Rationale Heel sticks are easily accessible and minimally invasive for capillary puncture. Fingers of infants are too small to tolerate the trauma of skin puncture.

Which of the following statements best describes the reason antecubital veins are most desirable to use when performing venipuncture? A. These veins are more flexible and allow for large bore needles. B. These veins have thin walls, making it easier to penetrate with the needle. C. The tissue surrounding these veins is less sensitive, making the procedure less painful. D. Better quality specimens are usually obtained from these veins.

The tissue surrounding these veins is less sensitive, making the procedure less painful. Rationale Of the three veins in the antecubital area acceptable for venipuncture, the median cubital vein (in the middle) is the vein of choice for four reasons: 1) it's more stationary; 2) puncturing it is less painful to the patient; 3) it's usually closer to the surface of the skin; and 4) it isn't nestled among nerves or arteries.

Which of the following best describes the proper way to clean up a broken glass tube? A. Use a paper towel to pick up the pieces of glass and place them in a trash can. B. Place the pieces of glass on a piece of paper and carry the paper to the red biohazard bag. C. Use a wet towel and wipe over the area so that minute fragments of glass may be picked up. D. Use a broom and dust pan to sweep up the glass and fragments and place in a sharps container.

Use a broom and dust pan to sweep up the glass and fragments and place in a sharps container. Rationale To prevent exposure to potentially infectious materials, a broom and dust pan should be used to sweep up the glass and fragments and then they should be placed in the sharps container (not a bag). This ensures that no one will touch the glass or any of the materials that were in the ampule. If a paper towel, piece of paper, or wet towel are used, the risk of coming into direct contact with the glass is increased.

The phlebotomist has an order to collect a complete blood count with differential, partial thromboplastin time, basic metabolic panel, and blood cultures. Place the collection tubes in the correct order of draw. (Click and drag the options in the left column to their correct position in the right column.) A. red B. lavender C. blood culture bottles D. light blue

blood culture bottles light blue red lavender Rationale: The phlebotomist would put the tubes in order starting with blood culture bottles, then PT (light blue), basic metabolic panel (red), and finally the CBC with diff (lavender). Most collection tubes contain an additive. If the additive is mixed with blood in the wrong order laboratory results could be affected. It is important to draw the samples in the correct order because failure to do so could result in inaccurate laboratory values.

Which of the following is an appropriate alternative to using a rubber tourniquet when attempting a venipuncture on a known patient who is difficult to obtain a sample from? A. blood pressure cuff B. non-adherent gauze C. hypoallergenic tape D. elastic bandage

blood pressure cuff Rationale The only acceptable choice among the listed options is the blood pressure cuff. Occlusion pressure may be adjusted as needed as an alternative to ensure circulation. In compliance with CLSI (Clinical and Laboratory Standards Institute) standards, the blood pressure cuff can provide uniform constriction, as long as the phlebotomist doesn't inflate the cuff beyond 40 mm of mercury.

While performing a venipuncture in the antecubital space, the patient verbalizes an extreme amount of pain and the blood in the collection tube is noted to be bright red. Which of the following sites is most likely to have been inadvertently punctured? A. brachial artery B. basilic vein C. cephalic vein D. ulnar artery

brachial artery Rationale The brachial artery is most likely punctured, because it is a large artery and the bright red bleeding and fast, pulsating movement indicates arterial blood flow and not venous. The brachial artery runs in the antecubital space, and would cause a lot of pain if it was punctured. The phlebotomist should apply pressure to the site for at least 5 minutes to ensure that clotting occurs.

When inspecting a patient's arm before performing a venipuncture, the most desirable site appears to be the back of the hand. Which of the following venipuncture methods is most appropriate in this situation? A. evacuated tube B. needle and syringe C. butterfly needle D. capillary puncture

butterfly needle Rationale The best choice in this situation is to use a butterfly needle, a winged needle with flexible tubing that is short in length. Butterfly needles are easier to insert into tiny, fragile, and/or rolling surface veins close to the skin. If a butterfly is not available, a needle and syringe would be the next choice. The vacuum pressure of evacuated tubes can collapse small or fragile veins such as those on the back of the hand. A capillary puncture would be the last option here, and would be used in the instance of a failed butterfly or syringe attempt (provided there are no other veins available).

Which of the following veins would generally be acceptable for routine blood collection by the phlebotomist? A. femoral B. subclavian C. dorsalis pedis D. cephalic

cephalic Rationale The most suitable veins for venipuncture are located in the antecubital fossa (region) of arm. The following veins are listed in order of preference: median cubital vein, cephalic vein, basilic vein. Femoral vein is located on the medial (inner) aspect of the thigh and must not be accessed by a phlebotomist. The subclavian vein is located just below the clavicle (collar bone) and must not be accessed by a phlebotomist. Dorsalis pedis are dorsal veins of the food and must not be accessed by a phlebotomist. Phlebotomists are able to access any vein on the upper extremities (arms), but do not have the right to access lower extremities (legs) unless explicitly permitted by a physician.

Which of the following QC measures are within the phlebotomist's scope of practice? (Select the three (3) correct answers.) A. checking the expiration dates of venipuncture supplies B. performing calibration on the chemistry analyzer C. monitoring temperatures of specimen refrigerators D. daily maintenance on the laboratory hematology instruments E. perform daily glucose meter control checks

checking the expiration dates of venipuncture supplies monitoring temperatures of specimen refrigerators perform daily glucose meter control checks Rationale A phlebotomist would perform QC measures on equipment and work surfaces they use regularly in collecting, processing, and storing samples. They are not responsible for performing calibrations or equipment checks on Chemistry or Hematology analyzers in the laboratory. Medical laboratory scientists would typically perform those functions.

Which of the following is included in an exposure control plan? A. dates of each employee's last tetanus booster B. maintenance of MSDS and incident report logs C. contaminated needlestick injury evaluation process D. emergency exit markings in compliance with OSHA standards

contaminated needlestick injury evaluation process Rationale It is important to document and make sure that all employees have annual training to be in compliance with OSHA regulations. According to the OSHA Bloodborne Pathogens Standard, an Exposure Control Plan must meet certain criteria: It must be written specifically for each facility, it must be reviewed and updated at least yearly (to reflect changes), list positions or technology used to reduce exposures to blood or body fluids and it must be readily available to all workers.

Which of the following specimens requires a heat block for transportation? A. ammonia B. cryofibrinogen C. lactic acid D. PSA

cryofibrinogen Rationale Some blood specimens require special treatment and handling to preserve the analyte while being transported to the lab for testing. Lactic acid and ammonia are chilled in ice slurries as they deteriorate very quickly at room temperature. Cryofibrinogen must be kept at body temperature (in a 37o C heat block) until analysis can begin. A blood sample for PSA analysis does not require a special temperature unless testing will be delayed, in which case the sample should be centrifuged, separated and the serum frozen.

A phlebotomist puts evacuated tubes filled with blood in plastic transport bags and places them in the physician office lock box for the reference lab courier who will pick them up in 1-2 hours. The lock box is outside and the temperatures are below freezing. How will freezing affect the test results? A. elevated hematocrit B. decreased red blood cell count C. elevated hemoglobin D. decreased calcium

decreased red blood cell count Rationale Specimen chilling can affect several blood test results such as red blood cell count, prothrombin time (PT), and potassium. Red blood cells count will decrease as a result of destruction of red blood cells in response to freezing. As cells freeze, the fluid inside will expand and rupture the cells, thereby decreasing the total viable number of red blood cells. Hematocrit is the percentage of total volume of red blood cells in total volume of blood. Hematocrit will decrease with decreased red blood cell count. Hemoglobin is the iron-containing molecule that carries oxygen and is found inside red blood cells. Potassium is found predominantly inside cells. Calcium levels are not affected by hemolysis.

Gray-topped sodium fluoride tubes should not be used to collect alanine aminotransferase (ALT) or aspartate aminotransferase (AST) because the anticoagulant A. destroys many enzymes. B. increases lipemia. C. prevents hemoconcentration. D. causes hemolysis.

destroys many enzymes. Rationale The sodium fluoride in gray-topped tubes can destroy many enzymes. Since ALT and AST are enzyme tests, sodium fluoride should be avoided.

Which of the following actions is a HIPAA violation? A. disposing of extra patient tube labels in a regular trash can B. shredding completed collection lists C. storing a fully stocked collection tray in the clinical laboratory D. putting a note in the laboratory reminding staff that a certain patient has a cold agglutinin

disposing of extra patient tube labels in a regular trash can Rationale HIPAA (Health Insurance Portability and Accountability Act) ensures that all patient information is kept private and confidential by safeguarding all protected health information (PHI). PHI is any information that can potentially identify the patient or the patient's medical condition or diagnosis. PHI includes, but is not limited to, the following: patient identification, demographics, diagnosis, financial information, tests and procedures. Disposing of extra patient tube labels in a regular trash constitutes HIPAA violation since these labels contain PHI. Care must be taken to dispose of any documentation containing PHI into an appropriate receptacle such as secured, locked recycle containers or shredders. Collection lists are preserved for hospital records and must not be shredded. Storing collection tray in the clinical laboratory is one of the duties of a phlebotomist. Placing a reminder for cold agglutinin is not a violation of HIPAA as it is placed in an area only for laboratory staff and is meant to improve patient care by ensuring collection of all specimens.

A phlebotomist has orders to collect blood specimens from a patient who has IVs in his right forearm and in the left antecubital area. Where should the phlebotomist collect a venous blood specimen? A. the middle or ring finger of right hand B. in the antecubital area of the right arm C. above the IV in the left arm D. distal to the IV in the left arm

distal to the IV in the left arm Rationale Drawing in the antecubital area of the right arm or above the IV in the left arm would lead to contamination of the sample with the fluid being administered. The test results would then reflect the contents of the fluid or dilute the analyte to be measured. Incorrect patient treatment might result. In this case, the safest place to draw would be distal to (away from) the IV left arm. The middle or ring finger could be used for a dermal puncture but not for venous blood.

Which of the following is an appropriate draw site for an adult patient with a central line? A. palmar side of the wrist. B. plantar surface of the heel. C. distal phalanx of the fifth finger. D. dorsal side of the hand.

dorsal side of the hand. Rationale Patients with central lines would be candidates for specimen collection from dorsal side of the hand. Venous samples are not collected from the palmar side of the wrist; veins are accessible from the dorsal side. Fingersticks are not performed on newborns as the blade depth could injure nerves in the fingertips and blood would be difficult to extract. Heel sticks may be performed on newborns, but not in the central section of the plantar surface. Nerve and/or tissue damage could result.

After the phlebotomist has introduced herself and identified the patient, she should next A. stabilize the vacuum tube setup. B. state the purpose for which the physician is ordering the test. C. reassure the patient that it will not hurt. D. explain the procedure.

explain the procedure. Rationale The phlebotomist must always explain the procedure to the patient before starting even when the patient appears to be unresponsive. Phlebotomists are rarely aware of the purpose the physician may be ordering the test. Phlebotomists must never speculate or assume the purpose based on tests ordered. If the patient asks for the purpose, then it is best to instruct the patient to consult with the physician. Phlebotomist must never tell the patient that the procedure will not hurt. Pain felt during the venipuncture is dependent on many variables that cannot be predicted: patient's sensitivity and tolerance, condition and disease processes, technique used, needle gauge, type and length used, and many more. It is best to notify the patient that they may experience a quick pinch or minor discomfort at the site of venipuncture. Once the needle is in the patient's arm, the vacuum tube setup can be stabilized.

Which of the following conditions may occur if a tourniquet is left in place on a patient's extremity for longer than 60 seconds? A. hemoconcentration B. venous insufficiency C. fibrinolysis D. hemangioma

hemoconcentration Rationale A tourniquet left in place for longer than 60 seconds predisposes the formation of blood clots due to slow blood flow (a.k.a. venous stasis). Venous insufficiency (VI) is a state in which the veins do not adequately send the blood from the extremities back to the heart. Fibrinolysis refers to the breaking down of a clot. Hemangioma is a term used to describe a condition in which blood vessels abnormally congregate in a place on the body, causing a non-cancerous tumor.

The phlebotomist applies the tourniquet, but then has trouble relocating the vein after several minutes of palpation. Which of the following is an expected outcome in these test results? A. falsely elevated K levels from tissue damage B. fibrinolysis from hemodilution C. falsely decreased iron levels from hemolysis D. falsely increased platelets from clotting

falsely elevated K levels from tissue damage Rationale The tourniquet should not be applied for longer than 1 minute. Prolonged tourniquet application can change the composition of blood collected due to hemoconcentration and potential tissue damage. Hemoconcentration is the concentration of blood components such as formed elements (red blood cells, white blood cell, and platelets) and analytes at the venipuncture site due to restriction of blood flow from a tourniquet. The liquid portion of the blood called plasma is 90% water by composition. Water molecules are small enough that they are able to flow through even when there is a constriction such as that caused by a tourniquet leaving behind larger molecules and cells that are not able to get through. Hemoconcentration can lead to erroneous test results including elevated potassium (K) level and glucose level. Hemoconcentration will also result in elevated, not lowered, hematocrit level. Fibrinolysis refers to the breaking down of a clot (which has not formed yet in this case). Clotting falsely decreases platelet count since platelets are used to form a clot.

Which of the following is the correct order of PPE removal prior to leaving the exam room of a patient who is in contact-droplet isolation? A. gloves, gown, mask B. gown, gloves, mask C. gown, mask, gloves D. gloves, mask, gown

gloves, gown, mask Rationale The term "don" means to put on. According to CDC and HICPAC Guideline for Isolation Precautions, the following PPE (personal protective equipment) donning (putting on/garbing) is recommended: Gown first, then Mask and Gloves last. All PPE must be donned in the appropriate aseptic manner. Gown must be put on in such a way as to only touch the inside surface and to avoid touching the outside of the gown. Mask must be donned so as to create protection around the airways including nose and mouth. Make sure to contour the upper portion of the mask around the nose bridge. Gloves must be donned over the cuff of the gown in order to create a seal and protect the wrist. The correct PPE doffing (taking off/removing) order is the following: Gloves first, then Gown and Mask last.

The physician orders a hemoglobin level to be checked on a 2-month-old patient. Which of the following sites should the phlebotomist use to obtain the specimen? A. lateral fingertip B. antecubital space C. heel of the foot D. superficial scalp vein

heel of the foot Rationale Recommended site to obtain a capillary sample on infants less than one year. The lateral (outside) or medial (inside) planter surface of the heel should be used for heel stick puncture. Never puncture other areas on the heel, as injury and /or nerve damage can occur. The heel of the foot is the recommended site to obtain a capillary sample on infants less than one year. The lateral (outside) or medial (inside) planter surface of the heel should be used for heel stick puncture. Never puncture other areas on the heel, as injury and /or nerve damage can occur.

A physician orders a CBC and glucose tolerance test. Which of the following is the correct tube selection and order of draw? A. red, lavender B. lavender, gray C. green, lavender D. lavender, yellow

lavender, gray Rationale 29. CBC (Complete Blood Count) is collected using Lavender/Purple tube containing anticoagulant Potassium EDTA. EDTA is ideal for whole blood testing such as CBC because EDTA prevents platelet aggregation and maintains the natural morphology (shape) of cells for analysis. Glucose tolerance test requires collection of glucose using Gray tube containing Potassium oxalate and Sodium fluoride. Oxalate is the anticoagulant. Fluoride is the antiglycolytic agent (glycolytic inhibitor) that prevents glucose breakdown in order to yield accurate glucose blood test results. The CLSI recommended Order of Draw is as follows: Sterile yellow, Light blue, Red, Gold/SST, Green/PST, Lavender/Purple, and Gray. According to the recommended Order of Draw, lavender/purple tube must be collected before gray tube. Red and green tubes should not be used to collect for glucose because they do not contain fluoride and the glucose levels will be inaccurate as a result. Red tube may be collected along with the Gray tube for glucose tolerance test if the physician orders the test for insulin in order to monitor insulin levels as blood glucose levels rise after ingestion of the glucose drink. Yellow tubes are normally used to collect for blood cultures to determine the presence of microbes in the blood.

Which of the following tube and additive combinations should be used for a PT/INR test? A. light blue, sodium citrate B. light blue, sodium heparin C. gray, sodium citrate D. gray, sodium heparin

light blue, sodium citrate Rationale An INR test refers to an International Normalized Ratio, which provides a standardized method of reporting prothrombin time results by comparing the ratio of the patient prothrombin time to the control prothrombin time. This, in turn, helps to standardize the method of reporting the effects of oral anticoagulant therapy on blood clotting. It uses the light blue tube with sodium citrate as it would for a regular prothrombin time (Pro Time) test.

A phlebotomist receives an order to collect a cold agglutinin specimen. The phlebotomist should A. keep the specimen at room temperature. B. maintain the specimen at 37 degrees Celsius. C. transport the specimen on ice. D. protect the specimen from light.

maintain the specimen at 37 degrees Celsius. Rationale 70. Cold agglutinin test requires that blood specimen be kept at 37 degrees Celsius (normal body temperature). Heel warmers and adult heat packs or blocks are utilized to maintain the specimen at normal body temperature of 37˚C in order to prevent agglutination (clumping) of substances such as cryofibrinogen and cold agglutinin. Chilling specimens by immersing them into slurry of ice and water aids in slowing down cellular metabolism and reduces evaporation. Cellular metabolism (breakdown of substances) in a specimen continues throughout and after collection. If the specimen is not handled properly during transport, red blood cells will continue to release waste and consume analytes in the liquid portion of the blood and falsely elevating or lowering certain analyte levels. Chilling helps prevent evaporation by keeping volatile substances dissolved in the liquid portion of the blood. Protecting the specimen from light by collecting it into an amber tube or wrapping the it in aluminum foil protect light sensitive specimens such as bilirubin and vitamins from being broken down by ultraviolet light. Most routine tests do not require special handling and are kept at room temperature during collection and processing, but are refrigerated after testing in order to preserve the specimen for any repeat, reflex or physician add-on tests.

For which of the following patients is the use of an adhesive bandage contraindicated? A. adult with hemophilia B. immunocompromised child C. adolescent with sickle cell anemia D. newborn with hyperbillirubinemia

newborn with hyperbillirubinemia Rationale The person collecting a blood sample from a newborn with hyperbilirubinemia would not use an adhesive bandage post-stick. Bleeding would be stopped by direct pressure and no bandage would be utilized. It is not recommended to use a bandage on children under two years of age because it could introduce a choking hazard if the child works the bandage loose. Bandaging a newborn's foot is a controversial issue because of skin sensitivity and potential bandage aspiration. Sensitivity is of particular concern in newborns with hyperbilirubinemia as they must endure multiple sample collections. Still, the incision should be monitored for bleeding and inflammation. It would be acceptable to use an adhesive bandage on the other patients in this example unless there was an indication specified, such as a latex allergy. After drawing an adult with hemophilia, the phlebotomist should monitor the venipuncture site to ensure a platelet plug has formed to stop bleeding before bandaging the patient. There are no additional requirements for using a sterile adhesive bandage on an immunocompromised child or an adolescent with sickle cell anemia.

Most laboratory testing errors occur during the A. analytical testing phase. B. data processing and record keeping phase. C. patient prep to lab arrival pre-analytical phase. D. post-analytical phase.

patient prep to lab arrival pre-analytical phase. Rationale Approximately 50-70% of all laboratory errors occur during the pre-analytical phase. The pre-analytical phase begins when the physician orders the tests and end just before specimen analysis (testing) begins. Patient preparation, specimen collection, handling and processing are all part of the pre-analytical phase. Specimen hemolysis, microclots formation and specimen mishandling are common sources of pre-analytical errors that can significantly alter test results. Analytical testing phase includes specimen testing by the Clinical Laboratory Technician or Clinical Laboratory Scientist. Post-analytical phase includes reporting of results and specimen storage for reflex testing or add-on testing (tests added on to the original specimen by physician request). Data processing and record keeping phase is not a laboratory phase.

Small red spots appear near the tourniquet on a patient's arm. This is most likely an indication of A. collapsed vein. B. a hematoma. C. petechiae. D. edema.

petechiae. Rationale Small red spots near the tourniquet on a patient's arm are most likely indicative of petechiae. Petechiae are small, red, non-raised spots that appear in response to pressure from the tourniquet. They do not pose a health risk to the patient. Petechiae may indicate poor capillary integrity and poor platelet function. A collapsed vein normally occurs in response to excessive vacuum in the evacuated tube or excessive pressure created with the plunger of a syringe during a venipuncture. A hematoma is a bruise under the skin resulting from blood pooling into the surrounding tissues during or after a venipuncture. Edema is swelling of tissues due to accumulation of interstitial (tissue) fluid.

When performing venipuncture on a patient with a left mastectomy, which of the following sites should the phlebotomist use? A. back of left hand B. right antecubital fossa C. right saphenous vein D. left basilic vein

right antecubital fossa Rationale Due to the mastectomy, avoid any left side sites. The right antecubital fossa is the best collection site. Blood samples should not be collected from the arm on any side a patient has had breast cancer surgery (a mastectomy or a lumpectomy with lymph node removal). The presence of lymph fluid dilutes the blood in this area, causing erroneous patient test results. The lymph fluid may also make the patient's arm swell, thus making tourniquet application painful. Additionally, all skin punctures should be avoided on the side of breast cancer surgery. Not only could test results be altered, but the performance of venipuncture, skin puncture, injections, etc. on breast cancer surgery patients may lead to the development of a bacterial infection. The right saphenous vein in the leg would not be a good choice (use the antecubital in the arm instead).

A phlebotomist must collect type and screen, STAT electrolytes, D-dimer, and estrogen. Which of the following correctly lists the appropriate additives for these tests in the CLSI recommended order of draw? A. sodium citrate, silica, sodium heparin, potassium EDTA B. sodium citrate, non-additive, lithium heparin, potassium EDTA C. non-additive, sodium citrate, lithium heparin, potassium EDTA D. silica, sodium citrate, sodium heparin, potassium EDTA

sodium citrate, non-additive, lithium heparin, potassium EDTA Rationale Blood collection tubes are color coded to indicate their chemical contents. The Clinical Laboratory Standards Institute (CLSI) defines the order of drawing these tubes to prevent carryover of the contents from one tube to the next. A small amount of the chemical may be retained on the inner needle or rubber sleeve of the ETS system and contaminate the next tube thereby affecting patient results. The order is sterile (blood cultures), sodium citrate (blue), serum (red or gold with or without clot activator or gel separator), heparin (green), EDTA (purple), sodium fluoride & potassium oxalate (gray). In this case, the light blue would be drawn first for the D-dimer, the non-additive (serum) tube second (estrogen), lithium heparin (STAT electrolytes) third and potassium EDTA (type & screen) last.

Which of the following POC laboratory tests is within the CLIA defined scope of practice for a phlebotomist? A. cell differential and urine sediment B. strep test and urine sediment C. urine dip and cell differential D. strep test and urine reagent strip

strep test and urine reagent strip Rationale CLIA (Clinical Laboratory Improvement Amendments of 1988) is a federal law that regulates all laboratory testing in the United States and sets the minimum requirements for laboratory practices to ensure the minimum standards of quality. The three categories of test complexity include waived, moderate complexity (which also includes provider performed microscopy procedures or PPMP), and high complexity testing. The FDA (Food and Drug Administration) determines test complexity based on the level of difficulty required to perform the test, level of skill required to perform the test, and the level of potential harm to the patient should the test be performed incorrectly. Waived test are considered to be simple tests with minimal risk of error requiring no or minimal education about the instrument. Therefore, waived test are within the CLIA defined scope of practice for a phlebotomist. Strep test and urine dip are very simple tests that require minimal training and have low risk of harm to the patient. Both tests are non-invasive and simple enough for a phlebotomist to perform. Strep test requires a throat swab and a urine dip test requires a urine reagent strip dipped into a urine cup. Cell differential and urine sediment are more complex and require microscopic analysis of the specimen, thus require higher skill level and can present greater risk to the patient if performed incorrectly.

Which of the following should be included on a patient's laboratory requisition? A. insurance information B. patient signature C. test priority D. chief complaint

test priority Rationale The exact information required on requisitions for testing by different laboratories may vary slightly. The common items always requested are: patient name, indication of insurance (id#/provider), testing requested, priority of the testing (STAT, routine, timed, etc.), and ordering physician. Many requisitions also ask for an indication for testing, ICD codes, patient diagnosis, etc. A patient signature, next of kin, and insurance contact number are not typically required.

When inserting a needle during venipuncture, the bevel should be in which of the following positions in relation to the vein? A. up B. down C. left D. right

up Rationale Positioning the needle bevel (slanted opening at the end of needle) up helps to maintain the integrity and position of the vein. If the bevel was down or to the left or right, it would not be as easy to hit the vein, and could cause damage to the tissue.

The phlebotomist needs to draw a blood culture, sedimentation rate, PTT, and a glucose test. Which of the following is the correct order of draw? A. red, yellow, light blue, lavender B. yellow, light blue, lavender, gray C. gray, light blue, lavender, red D. yellow, red, lavender, gray

yellow, light blue, lavender, gray Rationale Blood culture is collected using the Sterile yellow/Yellow tube containing anticoagulant SPS. SPS helps to facilitates bacterial growth. Sedimentation rate (ESR - erythrocyte sedimentation rate) is collected using the Lavender/Purple tube containing anticoagulant Potassium EDTA. EDTA is ideal for whole blood testing such as ESR because EDTA prevents platelet aggregation and maintains the natural morphology (shape) of cells for analysis. PTT (partial thromboplastin time) is collected using the Light blue tube containing anticoagulant Sodium citrate. Citrate is ideal for coagulation tests because it preserves clotting factors for testing. Glucose is collected using the Gray tube containing Potassium oxalate and Sodium fluoride. Oxalate is the anticoagulant. Fluoride is the antiglycolytic agent (glycolytic inhibitor) that prevents glucose breakdown in order to yield accurate glucose blood test results. The CLSI recommended Order of Draw is as follows: Sterile yellow, Light blue, Red, Gold/SST, Green/PST, Lavender/Purple, and Gray. According to the recommended Order of Draw, in order to prevent the effect of cross-contamination, the above tubes must be collected in the following order: Yellow, Light blue, Lavender, Gray.

Which of the following statements represents correct patient identification for a phlebotomist in an outpatient setting? A. "Is your name Evelyn Smith?" B. "May I have your name please?" C. "Is your name Ms. Smith?" D. "Ms. Smith, I need to see your driver's license."

"May I have your name please?" Rationale Proper patient identification is the most critical aspect of specimen collection and is one of the most important annual National Patient Safety Goals identified by the Joint Commission. Patients must be identified using at least two identifiers. The following identifiers are acceptable: full name, date of birth (DOB), and medical record number (MRN) for inpatients and social security number (SSN) for outpatients. In an outpatient setting, ask the patient to verbally state and spell his or her full name including first, last, middle and suffix and compare the name to the requisition. Never include any part of the patient's name when asking the patient to state and spell his or her name. Including the patient's name in the questions may prompt the patient to nod and not take an active role in patient identification and patient safety. Verbal identification helps reduce patient misidentification, specimen mislabeling and ultimately prevents patient mistreatment.

A phlebotomist has received a requisition to collect specimen for a Bilirubin from a premature newborn patient. Which of the following is the best device for this collection? A. a syringe and needle B. 1.00 mm lancet C. winged infusion set D. 3.00 mm lancet

1.00 mm lancet Rationale 66. CLSI recommends that capillary blood collection on infants less than one year of age be performed on medial or lateral plantar surface of the heel and that the puncture must not exceed 2.0 mm. WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy recommends that the depth of heel punctures not exceed 2.4 mm as pain fibers/receptors significantly increase in abundance and the potential for bone injury also increases. Given the CLSI and WHO recommendations as well as the consideration of a premature newborn and not a full term newborn, it is best to use 1.00 mm lancet to prevent bone injury and excessive discomfort. 3.00 mm lancet is much more likely to inflict unnecessary pain and discomfort to the infant. Syringe system and winged infusion set are contraindicated on premature or full term infants for bilirubin or other blood tests requiring minimum specimen due to increased risk for nerve damage, accidental arterial involvement, tissue damage and hematoma formation. Infants have very small veins, which can make successful venipuncture very difficult and painful. Due to the small size of the arm, structures are much closer together and thus increase the risk of nerve, artery or other tissues involvement and damage. Syringe system also requires for patient to stay perfectly still, which is not possible with infants.

Which of the following regulations set the minimum standards for medical laboratory practice and quality? A.HIPAA B. CLIA C. DEA D. OSHA

CLIA Rationale Clinical Laboratory Improvement Amendments (CLIA) are laws put in place to ensure quality assurance standards for medical laboratories, and enforced by the Department of Health and Human Services. HIPAA (Health Insurance Portability and Accountability Act) is a set of regulations put in place to ensure confidentiality of health insurance; also making it easier for a person to keep their health insurance if they change or lose jobs. The DEA is a United States federal law enforcement agency under the U.S. Department of Justice. OSHA standards are established minimum health and safety standards for workers and provides for the inspection of places of employment and the penalizing of employers who do not provide conditions that meet the established standards.

Which of the following actions is an example of compliance with Quality Control (QC) guidelines for phlebotomy? A. BCheck controls on urinalysis reagent strips daily. B. Ensure supplies in venipuncture trays are no more than one month beyond the expiration date. C. Ensure reusable supplies in venipuncture trays are recycled. D. Check glucometer controls monthly.

Check controls on urinalysis reagent strips daily. Rationale Proper Quality Control ensures accuracy and reliability of test results while detecting and eliminating errors. It is an important component of patient care to make sure results are accurate, therefore it is important to check controls on urinalysis dipsticks daily. Supplies (in venipuncture trays or anywhere) should never be used beyond the expiration date. Recycling is not a quality control measure. Glucometer controls should be checked at least daily (or more frequently). It is important to follow whatever quality control protocols are in place for each piece of equipment or manual test you perform. Always check to make sure quality control is up to date before running any patient samples.

When a phlebotomist enters a patient's room to collect a STAT blood sample, a sign above the bed states that all collections should be from the patient's central port. Which of the following should the phlebotomist do next? A. Proceed with sample collection from the central port and alert the nurse when finished. B. Communicate the test order to the nursing staff and wait for one of them to collect the sample. C. Identify the patient and ask for confirmation that the sign is accurate before proceeding with the collection. D. Exit the patient's room and proceed directly to the next patient on the collection list.

Communicate the test order to the nursing staff and wait for one of them to collect the sample. Rationale A central port is a central venous catheter inserted into a vein in the chest and threaded through until it reaches the heart. Central ports and other vascular access devices (VADs) provide direct access to patient's circulation in order to administer medication and fluids as well as to withdraw blood on routine basis. Any vascular access device poses an infection risk and every measure must be taken to reduce the risk of nosocomial/healthcare associated infections (HAIs). It is critical that only trained healthcare professionals withdraw blood from vascular access devices. Nurses and physicians are generally the ones to perform this task as they are trained to care for and maintain vascular access devices in order to maintain patency (prevent occlusion) in the catheter and reduce risk of infection. Therefore, it is best to communicate the test order to the nursing staff and wait for one of them to collect the sample. Orders must be confirmed with nurses and physicians, not the patient. Proper and effective communication is critical in a healthcare setting and is one of The Joint Commission's annual National Patient Safety Goals. Phlebotomists must communicate with the nursing staff before proceeding to the next patient.

An older adult patient arrives to have blood drawn. While assessing the arms for venipuncture, the phlebotomist notices scar tissue in the anticubital areas and is unable to palpate a vein. Which of the following is an appropriate alternative course of action? A. Draw blood from the hand using an evacuated tube system. B. Draw blood from the hand using a winged infusion set. C. Use a larger gauge needle to penetrate through the scar tissue. D. Perform a capillary puncture on the lateral thumb.

Draw blood from the hand using a winged infusion set. Rationale Areas with visible scar tissue should be avoided when selecting a site for venipuncture. Scarring can cause the area to be difficult to puncture and may obstruct blood flow. So, the best approach is to draw blood from the hand using a winged infusion set (a.k.a. butterfly). Use of an evacuated tube could collapse the vein due to the vacuum pressure. A capillary puncture would not be the best approach because a venous draw on the hand would give a superior specimen.

When drawing blood for a comprehensive metabolic panel (CMP) and a complete blood count (CBC), why is the CMP tube collected before the CBC tube? A. EDTA in the CBC tube can alter some of the test results in the CMP. B. The CMP requires a sterile specimen. C. The CBC tube will clot if it is collected before the CMP tube. D. Plasma tubes are drawn before serum tubes.

EDTA in the CBC tube can alter some of the test results in the CMP. Rationale A blood specimen will naturally clot (yielding a serum component) when collected in a tube without an additive to anticoagulate it and keep it whole blood (which has a plasma component). With the exception of blood cultures and coagulation tests (e.g. PT, PTT), serum tubes (for CMP, Lytes, etc.) should be collected before tubes with additives (e.g. lavender top for CBC) to avoid contamination of the serum tube with the additive (can cause erroneous results in the serum tube). CLSI lists the order of draw as follows: 1. Blood cultures 2. Coagulation tube (e.g. blue closure) 3. Serum tube with or without clot activator, with or without gel (e.g. red closure) 4. Heparin tube with or without gel plasma separator (e.g. green closure) 5. EDTA tube with or without gel separator (e.g. lavender closure, pearl closure) and 6. Glycolytic inhibitor (e.g. gray closure)

On the initial attempt the phlebotomist went through the vein, but was able to pull back on the needle and successfully collect the specimen. Which of the following should the phlebotomist do next? A. Explain to the patient that a bruise may be likely, but it should be gone within a few days. B. Apply a pressure dressing and instruct the patient to leave it on for 24 hours. C. Have the patient hold pressure on the site for at least 10 minutes and notify the nurse. D. Apply an ice pack to the site to minimize bleeding and prevent hematoma.

Explain to the patient that a bruise may be likely, but it should be gone within a few days. Rationale Phlebotomist must always inform the patient whenever a hematoma is anticipated in order to demonstrate professionalism and effective communication. This also establishes trust between the patient and the phlebotomist and facilitates position future interactions. Pressure dressing for an extended period of time can cause the arm to ache and can potentially impair normal circulation. If hematoma is anticipated, phlebotomist is responsible for applying firm and direct pressure to the site. Pressure should be applied for a full minute and five minutes for excessive bleeding. An ice pack will not minimize bleeding and will not prevent hematoma formation.

The phlebotomist has collected an ammonia level. Which of the following should be done regarding transport of the specimen? A. Maintain the specimen at room temperature. B. Wrap the specimen in a heel warmer to slow the metabolic process. C. Wrap the specimen in foil to protect from light. D. Immerse the specimen in an ice and water slurry.

Immerse the specimen in an ice and water slurry. Rationale Ammonia level must be transported immersed in a slurry of ice and water in order to slow down cellular metabolism and reduce evaporation. Cellular metabolism (breakdown of substances) in a specimen continues throughout and after collection. If the specimen is not handled properly during transport, red blood cells will continue to release ammonia into the liquid portion of the blood and falsely elevate ammonia levels. As a result, choice A is incorrect. Ammonia is also a volatile (evaporates easily) analyte (substance found in the plasma) and can easily evaporate during specimen processing and testing. Chilling helps prevent evaporation by keeping volatile substances dissolved in the liquid portion of the blood. Choice B is incorrect since heel warmer and heat blocks are utilized to maintain the specimen at body temperature of 37˚C in order to prevent agglutination (clumping) of certain substances being tested such as cryofibrinogen and cold agglutinin. Heat will also increase the rate of metabolic process. Choice C is incorrect since foil or amber tubes are used to protect light sensitive specimens such as bilirubin and vitamins from being broken down by ultraviolet light.

Which of the following standards are being violated when a phlebotomist fails to use proper handwashing technique? A. HIPAA B. OSHA C. CMS D. NAACLS

OSHA Rationale Proper hand washing violations are associated with OSHA standards. The Occupational Safety and Health Administration (OSHA) is the federal agency charged with the enforcement of safety and health legislation in the United States. The Clinical Laboratory Improvement Amendments (CLIA) is how the Centers for Medicare and Medicaid Services (CMA) regulates laboratory testing of human samples within the United States. The Joint Commission (JC- formerly JCAHO) sets performance and quality standards of health care organizations. The National Accrediting Agency for Clinical Laboratory Sciences (NAACLS) is associated with education program accreditation in the clinical laboratory. HIPAA is the Health Insurance Portability and Accountability Act of 1996 that was enacted to protect patient privacy of personal health information.

When performing a venipuncture, sudden swelling is observed at the insertion site. Which of the following actions should the phlebotomist take? A. Continue obtaining the blood sample. This is a localized reaction to the venipuncture. B. Release the tourniquet, remove the needle, and immediately apply pressure at the site. C. Apply firm pressure above the area of swelling to direct the blood flow into the collection device. D. Leave the tourniquet in place, immediately remove the needle, and apply pressure at the site.

Release the tourniquet, remove the needle, and immediately apply pressure at the site. Rationale The phlebotomist should release the tourniquet, remove the needle, and immediately apply pressure to the site. The sudden swelling is an indication that the needle has traumatized or penetrated through both sides of the vein. A hematoma is forming; this is also referred to as a "blown" vein. Though always a possibility, this is not a normal occurrence for a venipuncture. Pressure should be held directly on the site (not above it) because it is important to stop the bleeding.

While giving a patient an injection, the patient jumped, causing the phlebotomist to get stuck on the hand with a contaminated needle. After performing thorough hand washing, which of the following should the phlebotomist do first? A. Begin infectious disease prophylaxis. B. Complete an exposure incident report. C. Obtain patient consent for infectious disease testing. D. Report the incident to a supervisor.

Report the incident to a supervisor. Rationale If a healthcare worker is accidently stuck with a needle, there are specific OSHA guidelines to follow. The worker should immediately flush with water, then tell a supervisor of the incident. The worker would then be directed to confidentially seek a physicians care. Documents must be filed recording the incident date/time, patient if known, type of stick. The source individual should be tested for infectious diseases (HBV,HCV,HIV). OSHA requires that the employee be notified of the results. The exposed worker then needs to be tested for HBV, HCV, and HIV. The exposed employee must have a physicians written list of treatment options within 15 days.

Using the guidelines for any method of venipuncture, which of the following actions should the phlebotomist perform first? A. Explain the procedure to the patient. B. Review the requirements for collecting and handling the blood specimen. C. Apply the tourniquet and thoroughly palpate the selected vein. D. Position the patient's arm and cleanse the site with an antiseptic wipe.

Review the requirements for collecting and handling the blood specimen. Rationale To ensure accuracy and quality, it is important to anticipate your needs before beginning the actual venipuncture (i.e. tube color/size, minimum acceptable blood volume, whether or not the specimen needs to be placed on ice). Therefore, the phlebotomist would identify the patient and review the requirements for collecting and handling the blood specimen as ordered by the physician, then explain the procedure to the patient. Next, assemble the appropriate equipment and select the proper evacuated tubes for test to be performed. Then, apply the tourniquet and thoroughly palpate the selected vein. Finally, position the patient's arm and cleanse the site with an antiseptic wipe, then proceed with the venipuncture protocol.

Which of the following is the reason for wiping off the first drop of blood from the patient's finger with gauze when performing a capillary puncture? A. The first drop may be contaminated by the lancet. B. The first drop of blood may contain traces of tissue fluids. C. The first drop of blood contains more platelets and clots faster. D. The first drop of blood contains too much oxygen.

The first drop of blood may contain traces of tissue fluids. Rationale The first drop of blood should be wiped off the finger after the lancet puncture to remove any excess alcohol. The excess alcohol could compromise laboratory results. The first drop contains the same amount of hemoglobin (which carries oxygen in the red blood cells) as the rest of the patient's blood. Platelet concentration and lancet contamination are not issues in this scenario.

A phlebotomist has active symptoms of the common cold. Under which of the following conditions may he perform venipuncture? A. The phlebotomist may not perform venipuncture with an active cold. B. The phlebotomist may perform venipuncture provided the patient is wearing a mask. C. The phlebotomist may perform venipuncture provided he is wearing a mask and afebrile. D. The phlebotomist may perform routine venipuncture as usual.

The phlebotomist may perform venipuncture provided he is wearing a mask and afebrile. Rationale It is not uncommon for people to be able to work with the common cold. However, it is important for medical personnel to use good judgment and not transmit diseases to their patients. Medical personnel should take precautions and handle patient contact in a responsible manner. They should not have patient contact if they are febrile, since that is when colds are highly contagious. In this instance, the phlebotomist may perform venipuncture provided he/she is wearing a mask and afebrile. The phlebotomist should wear the mask to keep from transmitting the cold via coughing or sneezing on a patient.

After centrifuging a blood specimen, the phlebotomist notes the serum has a reddish appearance. Which of the following has occurred? A. The finding is normal. B. The specimen is contaminated with neutrophils. C. A buffy coat has formed and discolored the serum. D. The specimen is hemolyzed.

The specimen is hemolyzed. Rationale Normal serum should be amber-colored. If it's reddish in appearance, the specimen is hemolyzed. The reddish color is caused by broken red blood cells, not neutrophils (which are white blood cells). The buffy coat is the layer of white blood cells and platelets that forms in whole blood between the plasma and the red blood cells. This question eludes to serum, which is the liquid layer of clotted blood (the white blood cells/platelets would be contained within the clot).

The phlebotomist preps the median cubital vein for a venipuncture procedure. How should the phlebotomist prep the patient's skin? A. Use a circular motion, from the inside out. B. Use a circular motion, from the outside in. C. Wipe the area from top to bottom. D. Wipe the area from bottom to top.

Use a circular motion, from the inside out. Rationale A venipuncture is considered a minimally invasive procedure. The fact that the skin will be punctured leaves open the potential to introduce an infection. Therefore, proper care should be taken to minimize the risk of contamination (of the sample) and infection (to the patient). Prep the puncture site with an alcohol pad or equivalent by using a concentric (circular) motion, from the inside out. A basic rule of thumb is to use a "clean to dirty" approach. The circular motion is the appropriate prepping motion (instead of up and down or side to side).

The physician orders the following blood work to evaluate a patient for sepsis: CBC, Blood Culture, and BMP. When using the evacuated tube method for venipuncture, in which of the following orders should the tubes be drawn? A. red top, blood culture, lavender top B. lavender top, red top, blood culture C. blood culture, lavender top, gray top D. blood culture, red top, lavender top

blood culture, red top, lavender top Rationale To avoid cross-contamination.

During palpation of a large vessel in the forearm, the phlebotomist detects a vibration sensation. The phlebotomist should then A. use a syringe blood collection set up with minimal plunger pressure. B. select a smaller gauge needle for the draw site. C. choose a different collection site. D. use a lower angle of penetration with a butterfly.

choose a different collection site. Rationale The detection of a vibration sensation indicates the presence of an arteriovenous (AV) fistula. AV fistulas can develop almost anywhere in the body, but they are often created through a surgical procedure and are used for patients who require dialysis. AV fistula is a surgical fusion of an artery and a vein that allows for the vein to increase in diameter and develop thicker walls. Since veins have a tendency to develop scar tissues after repeated venipunctures, an AV fistula with thicker walls and larger size allows for easy needle entry even with repeated venipunctures. The AV fistula is considered to be the patient's "lifeline" as it allows for blood to be filtered through an "external kidney" machine called a hemodialyzer, which will maintain electrolyte balance, remove waste, and help maintain normal blood pressure. Only trained dialysis technicians and physicians are allowed to access the AV fistula. Phlebotomists must not access the AV fistula or any veins located on the same arm as the AV fistula. Instead, use the opposite arm for venipuncture.

While performing a venipuncture using an evacuated tube, a small amount of blood enters the tube and then stops. Which of the following conditions is most likely to have caused this? A. collapsing vein B. hematoma C. rolling vein D. sclerosed vein

collapsing vein Rationale When blood ceases to flow during the venipuncture process, the likely culprit is a collapsing vein. The walls of the vein lose tension, stopping blood flow. The sclerosed (scarred) vein would have been a tough stick, and blood flow likely would not have started. If a vein rolls, the needle generally misses the vein, resulting in no initial blood flow. A hematoma could form if the needle slips through the vein or if the bevel is only partially in the vein.

After performing a venipuncture on a patient the phlebotomist notices the patient is bending his elbow to hold the gauze in place. This action is contraindicated because bending the elbow is likely to A. create a hematoma. B. cause hemostasis. C. cause bacterial infection. D. result in hemorrhage.

create a hematoma. Rationale If adequate pressure is not applied following a venipuncture, a hematoma can form via the transfer of blood from the vein into the surrounding tissue. Proper procedure would be to keep the arm straight and apply direct pressure until bleeding stops.

An inpatient with a left-sided mastectomy has a hematoma in the left arm and an active IV in the right arm. Which of the following is an appropriate site for venipuncture? A. distal to the IV B. proximal to the IV C. distal to the hematoma D. proximal to the hematoma

distal to the IV Rationale Drawing from an arm on the side which has had a mastectomy may cause lymphadema and should not be used. If there is an active IV in the other arm, blood may be drawn as far below it as possible. If the IV is close to the hand, the phlebotomist may ask the nurse to turn it off for two minutes prior to the draw. Another option, if a small amount of blood is needed and the test requests allow, is a dermal puncture of one of the fingers of the right hand.

The phlebotomist applies pressure to the venipuncture site using gauze. After two minutes he observes that bleeding has not stopped. The next appropriate action would be to A. elevate the arm while applying pressure. B. wrap the arm with a pressure dressing. C. continue to apply pressure while bending D. the arm at the elbow. E. notify the physician immediately.

elevate the arm while applying pressure. Rationale Elevating the arm reduces the pressure from the flow of blood, i.e., the blood is flowing down the arm. The venipuncture wound will heal more easily without the pressure from the blood flow.

Which of the following is an example of negative nonverbal communication? A. maintaining eye contact B. folding the arms across the chest C. nodding the head D. taking notes

folding the arms across the chest Rationale There are numerous behaviors that project professionalism. Smiling, maintaining eye contact, listening with compassion (nodding the head and taking notes to demonstrate active listening), etc. are ways to let patients know they are being heard.

Which of the following is the minimum PPE requirement when drawing lab work on a patient with suspected HIV? A. gown, gloves, and mask B. gloves only C. mask only D. gloves and mask only

gloves only Rationale To prevent viral exposure and transmission, gloves are required when drawing lab work on a patient with suspected HIV. HIV can be spread through blood, so it is important that gloves be worn at all times when drawing lab work. Gowns and masks do not need to be worn when drawing lab work, because HIV cannot be spread through ordinary contact.

The phlebotomist is instructed to perform a capillary stick for newborn screening. Which of the following collection devices should the phlebotomist use? A. heel stick lancet B. butterfly needle and syringe C. evacuated tube D. finger stick lancet

heel stick lancet Rationale The heel stick lancet (e.g., Tenderfoot) is required for infants. If a heelstick in an infant is being performed, the phlebotomist should apply a warming device for approximately 3-5 minutes to the heel to increase blood flow to the area, which will facilitate the collection of the capillary specimen. The bones of the distal phalanx (located in the thickest part of the finger) may be injured or damaged by a traditional finger stick lancet puncture.

While performing a venipuncture, the phlebotomist removes the filled tubes, but forgets to remove the tourniquet prior to needle withdrawal. Which of the following is the most likely result? A. syncope B. hemoconcentrated specimen C. hematoma D. hemolyzed specimen

hematoma Rationale A hematoma is a large painful bruise at the puncture site, caused or created by blood seeping into the surrounding tissues, one of the causes is the delay in tourniquet release and pulling the vacuum tube out. Since the tourniquet is causing the veins to bulge this will prevent quick clotting, and cause bruising. Syncope is fainting; hemoconcentration is when the concentration of blood cells are increased. Hemolysis specimens indicate the destruction of red blood cells after drawing the specimen, or during the procedure.

Forceful shaking of blood in an evacuated collection tube will cause which of the following complications? A. hemostasis B. hemoconcentration C. hemolysis D. contamination

hemolysis Rationale Hemolysis is the breakdown/damage of blood cells and could end in an unusable specimen and costly re-draw for the patient. Hemostasis is when bleeding is stopped, hemoconcentration is the loss of plasma, and contamination is when something dirty causes the material to be unusable.

A phlebotomist has received a requisition for a blood draw on a patient with a coagulation disorder. The phlebotomist should be sure to A. hold pressure on the draw site until bleeding has stopped. B. call the doctor to confirm the collection site. C. collect the specimen from the hand to avoid a hematoma. D. use a blood pressure cuff to apply consistent pressure.

hold pressure on the draw site until bleeding has stopped. Rationale: Von Willebrand disease is an inherited condition that can cause extended or excessive bleeding. Those affected have deficient amounts or impaired von Willebrand factor, a protein important to the clotting process. Thus, the phlebotomist must hold steady pressure on the venipuncture site until all bleeding has stopped. The collection site does not need confirmation from anyone, as the disease would not affect site selection. Edema is not a problem, and use of a blood pressure cuff could force more bleeding if applied after the draw.

Which of the following steps is completed first in performing venipuncture? A. apply the tourniquet B. cleanse site with an alcohol wipe C. identify the patient D. arrange tubes in order of draw

identify the patient Rationale To prevent error and maintain a culture of safety, at least 2 identifiers (ex. full name and date of birth) must be verified prior to performing a procedure.

The phlebotomist is asked to draw blood on a non-responsive patient in an emergency department. This draw would be conducted under A. expressed consent. B. implied consent. C. informed consent. D. refusal of consent.

implied consent. Rationale Venipuncture on a non-responsive patient in an emergency department constitutes implied consent. Implied consent is not a verbal consent and is not explicitly given by the patient; instead it is implicitly given by the patient's body language, actions or situation. Non-responsive patient in an emergency department constitutes a situation where all measures are taken with the patient's best interests in mind and permission is assumed. Expressed consent is a consent that requires verbal and often written agreement to receive treatment involving high-risk surgeries and experimental medication after all the risks and benefits have been discussed with and understood by the patient. Informed consent is a consent that requires verbal agreement to receive treatment for a medical procedure or a treatment. Refusal of consent is an explicit denial to receive medical and is supported by the Patient's Bill of Rights.

The phlebotomist notes the patient's arm is scarred in the lateral aspect of the antecubital fossa, and the other arm is not available. The phlebotomist decides to use a more medial site in the in the fossa over the basilic vein. Which of the following make this a poor choice? (Select the two (2) correct answers.) A. increased risk of nerve damage B. increased risk of arterial involvement C. increased risk of hemolysis D. increased risk of an unsuccessful draw E. increased risk of specimen rejection

increased risk of nerve damage increased risk of arterial involvement Rationale The antecubital fossa—shallow depression anterior to the elbow—is the site of the main three veins for venipuncture: median cubital vein, cephalic vein, and basilic vein. The median cubital vein is found in the middle of the antecubital fossa. It is often superficial, well anchored and easy to palpate. Thus, the median cubital vein is the first choice for venipuncture. The cephalic vein is found in the lateral aspect (thumb side) of the antecubital fossa. It is often superficial, but less anchored than the median cubital vein and may be difficult to palpate. Thus, the cephalic vein is the second choice for venipuncture. The basilic vein is found in the medial aspect (pinky side) of the antecubital fossa. It is often superficial, easy to palpate, but is poorly anchored. The basilic vein also overlies a brachial artery and median cutaneous nerve and is thus the third choice for venipuncture. Performing venipuncture in the medial aspect of the arm over the basilic vein places the patient at risk for arterial puncture and nerve damage. Inadvertent arterial puncture can result in prolonged bleeding and hematoma. Inadvertent nerve puncture can result in temporary or permanent nerve damage leading to chronic pain in the arm.

Which of the following information is contraindicated for patient identification at the time of draw? A. insurance number B. social security number C. date of birth D. full name

insurance number Rationale An insurance number is not a common means of positive patient identification (entire families can share the same insurance policy number). Patients must be positively identified for medical services, whether they have insurance or not. Insurance information is necessary for billing purposes. The only true unique identifier listed among these choices is the social security number. Patient name and date of birth are also commonly used to confirm identification.

Which of the following is the appropriate blood collection device for obtaining a blood spot collection on an infant? A. syringe B. lancet C. micro-collection container D. evacuated tube

lancet Rationale PKU is a neonatal screening test collected on a blot card. The recommended method of blood collection on infants less than a year old is via capillary (thus eliminating the venipuncture choices). A capillary collection using heel puncture lancet would be the correct choice in this situation. The heel puncture lancet would go the proper depth on an infant (there are even different sizes of lancets available for premature vs. term infants).

Which of the following sites should the phlebotomist use for newborn screening blood collection? A. lateral or medial plantar surface of the heel B. antecubital fossa C. superficial scalp vein D. lateral surface of the great toe

lateral or medial plantar surface of the heel Rationale a heel stick should be performed on the lateral or medial portions of the plantar surface of the heel-skin surface (left and right). Never stick the center area of heel, the arch, or the back of the heel. Avoid puncturing the bone by targeting the plantar surface. Draw an imaginary line starting in the middle of the big toe to the back of the heel. Then draw another imaginary line between the small toes to the back of the heel. The proper collection sites will be the fleshy portions outside those lines and below where the arch meets the heel. The anteromedial aspect, lateral surfaces and plantar curvature do not provide good flesh for a proper collection.

The patient on hemodialysis with a left AV shunt has undergone a right sided mastectomy and has an order for a STAT glucose. After consulting with the physician the phlebotomist is told to perform a capillary draw. Which of the following sites should the phlebotomist use? A. right middle finger B. left ring finger C. left thumb D. right little finger

left ring finger Rationale Venipunctures or capillary punctures must not be performed on the same side as the mastectomy unless ordered by the physician. Mastectomy procedures often involve lymph node removal and make that side more prone to lymphedema and infection. Right-sided mastectomy will prevent the phlebotomist from collecting blood from the right middle or right little finger. Little fingers should not be used for capillary puncture due to presence of little tissue and thus increased risk for bone damage and injury. It is acceptable to perform a capillary puncture, but not venipuncture, on the same side as the AV shunt. Thumb has a pulse, which indicates presence of an artery and thus must never be used for capillary puncture to prevent arterial involvement. Left ring finger is the most appropriate choice for this patient.

A patient on coumadin therapy is at the lab for a weekly coagulation test. Which of the following tubes should the phlebotomist collect for this test? A. red top B. lavender top C. light blue top D. green top

light blue top Rationale Sodium citrate (light blue top tube) is the anticoagulant of choice for coagulation studies such as PT/INR (Protime/International Normalization Ratio) because it does not bind to calcium or inactivate heparin, which may be required to be present in such testing. Lavender top tubes contain EDTA as the anticoagulant, which does bind calcium. Green top tubes contain heparin and could lead to inaccurate coagulation studies.

A phlebotomist is using an evacuated tube holder and multi-sample needle to collect a CBC, PT, and BUN. The correct order of draw for this collection is A. light blue, green, lavender. B. green, lavender, light blue. C. lavender, light blue, green. D. green, light blue, lavender.

light blue, green, lavender. Rationale The correct order of draw would be: two light blue top tubes (one waste and one for PT which is a coagulation test), green top tube (for the Chem 7), and the lavender top tube (for the CBC).

The physician has ordered a prothrombin time (PT) and complete blood count (CBC) for an adult patient with a diagnosis of thrombophlebitis. The phlebotomist should collect the evacuated tubes in which of the following orders? A. lavender, light blue B. light blue, red C. light blue, lavender D. red, light blue

light blue, lavender Rationale In the past, there was concern that the first blood collected into a tube or syringe was contaminated with tissue thromboplastin resulting from the entry of the needle into the skin. The presence of tissue thromboplastin in a blue top tube could alter the results of the routine coagulation tests, protime (PT) and activated partial thromboplastin (aPTT). Therefore, it was necessary to collect a small quantity of blood in another tube to assure that no tissue thromboplastin would contaminate the blue top tube. Research now indicates that the amount of tissue thromboplastin generated from a venipuncture today is minimal and will not affect the results of PT and aPTT testing. However, studies have not been performed for other coagulation tests so a discard tube should be filled with a small volume of blood prior to collecting blood into a blue top tube. NOTE: The "no discard tube needed" policy applies only when using a routine venipuncture with needle/tube holder or needle/syringe. A lavender (EDTA) tube is the appropriate tube to collect for a CBC test. CLSI (Clinical and Laboratory Standards Institute) lists the order of draw as follows: 1. Blood culture tube 2. Coagulation tube (eg, blue closure) 3. Serum tube with or without clot activator, with or without gel (eg, red closure) 4. Heparin tube with or without gel plasma separator (eg, green closure) 5. EDTA tube with or without gel separator.

Keeping contaminated equipment and supplies away from the phlebotomist's clothing to prevent pathogen transmission to the next patient is an example of which of the following? A. medical asepsis B. surgical asepsis C. sanitization D. disinfection

medical asepsis Rationale Medical asepsis is the prevention of direct effect of cross contamination from ourselves to another patient. Medical asepsis is the destruction of disease causing pathogens. Surgical asepsis is the destruction of all microorganisms. Sanitization is the cleaning process that reduces the number of organisms. Disinfection is the process of killing pathogenic organisms making them inactive, not effective for all spores.

A patient with an order for a blood draw presents with burns covering both arms. Which of the following is the phlebotomist's best option for collecting the largest amount of blood for this patient? A. microcollection container B. capillary tube C. filter paper (PKU) card D. evacuated tube

microcollection container Rationale A microtainer tube would be the best choice in this case. If a patient has burns covering both arms, a routine venipuncture from a brachial vein is not an option. The person collecting the blood will have the best chance at getting the highest volume of blood from a smaller vein using a microtainer tube (has less vacuum pressure than a regular sized tube). There are many ways to collect blood, and using a evacuated tube is the generally the best. But in case of a burn, you can do a capillary finger stick and then use a microtainer tube which works on the same principle. A PKU is collected on a Guthrie blot card and is only for newborn screening.

Which of the following actions by the phlebotomist is the first line of defense in preventing the spread of microorganisms? A. wear non-sterile gloves when performing venipuncture B. perform regular hand hygiene C. wear sterile gloves when changing a dressing D. use aseptic technique when drawing up a medication

perform regular hand hygiene Rationale: Performing regular hand hygiene is the first of preventative measure against disease transmission in caring for patients. According to the CDC, the simple act of hand washing is the single most important means of preventing the spread of viral and bacterial infections.

Which of the following is a site preparation solution required for collecting blood cultures and blood alcohol levels? A. povidone-iodine B. soap and water C. hydrogen peroxide D. isopropyl alcohol

povidone-iodine Rationale Skin antisepsis is the most critical aspect of blood culture collection, which requires a higher degree of skin antisepsis than 70% isopropyl alcohol (isopropanol) is able to provide. Iodine, chlorhexidine gluconate (ChloraPrep), and benzalkonium chloride are acceptable forms of antisepsis for blood culture collection. If iodine is used, venipuncture site must be cleansed. Friction and letting the site air dry are important factors. If ChloraPrep and benzalkonium chloride are used, the venipuncture site must be cleansed using 30-60 second friction scrub. Higher degree of skin antisepsis ensures that normal flora from the skin will not contaminate blood culture bottles and thus prevents false positive blood culture results. Antiseptic used to clean venipuncture site for blood alcohol level collection cannot contain any alcohol. ChloraPrep contains alcohol. Benzalkonium chloride does not contain alcohol and would be an appropriate antiseptic to collect both Blood Cultures and Blood Alcohol level. Iodine comes in two formulations: one is alcohol based and the other is aqueous (water) based. Tincture of iodine is made by dissolving iodine in alcohol, while povidone-iodine (PVP or Betadine) is made by dissolving iodine in water. The most appropriate antiseptic used to collect both Blood Cultures and Blood Alcohol level is povidone-iodine.

A phlebotomist has received a requisition to draw a bilirubin on an infant with jaundice. The phlebotomist should A. protect the specimen from light. B. invert the specimen immediately. C. transport the specimen on ice. D. draw a waste tube.

protect the specimen from light. Rationale Bilirubin is a photo-sensitive analyte (can degrade by as much as 50% with an hour of light exposure). A specimen submitted for bilirubin testing should be collected in an amber tube which will protect it from light (a regular tube wrapped in aluminum foil could also be acceptable). It is not necessary to keep the specimen warm with a heel warmer, nor is it necessary to chill the specimen to slow metabolism and stabilize the specimen. As long as the specimen is properly collected, protected from light, and handled according to normal serum protocol, it can be run as routine, thus Stat analysis is not necessary.

Which of the following techniques should the phlebotomist use when performing a venipuncture on a geriatric patient with loose skin? A. a tighter tourniquet to anchor more fragile veins B. vigorous massaging of the arm to increase blood flow in the veins C. pulling the skin taut using gentle and sufficient pressure to anchor the vein D. using a sharper angle and slower needle insertion to decrease rolling

pulling the skin taut using gentle and sufficient pressure to anchor the vein Rationale Blood collection from a geriatric patient can be more difficult due to fragile skin and poorly anchored veins. The best technique for a successful venipuncture on a geriatric patient is to pull the skin taut and firmly anchor the vein. Pulling the skin taut helps stretch the skin and tissues underneath, which in turn stabilizes the vein and allows the needle to enter the skin more easily. A tighter tourniquet will only cause more discomfort, potential bruising and skin tearing, as well as hemoconcentration of the blood specimen. Vigorous massaging of the arm can cause bruising and hemoconcentration of the blood specimen. The needle angle used during venipuncture is directly related to the depth of the vein. Deep veins require a steeper angle, while superficial veins require a shallower angle.

The phlebotomist received a requisition for blood test on a 70-year-old female patient with diabetes and a mastectomy of the left breast. Upon entering the room the phlebotomist notices a PICC line in the patient's right arm. For this specimen collection, the phlebotomist should A. draw above the PICC line. B. draw from the left arm. C. refer the draw to the nurse. D. draw directly from the PICC line.

refer the draw to the nurse. Rationale This scenario is a scope of practice example. The phlebotomist should ask a nurse to draw the sample. PICC line draws are outside an entry level phlebotomist's scope of practice. It should be noted that a facility may offer special training for PICC line draws, but specific training must be completed and competency assessed before any personnel collect such specimens. Performing a venipuncture in the left arm is not an option because the patient's left breast has been removed (it is not advisable to draw blood from an arm on the same side of a mastectomy). It is easier on the patient to have a nurse collect the specimen from the PICC line instead of enduring a venipuncture in an ankle.

While performing a venipuncture, immediately before removing the needle, the phlebotomist should A. activate the needle safety mechanism. B. release the tourniquet. C. gently invert the evacuated tubes. D. apply a gauze pressure dressing.

release the tourniquet. Rationale Right before the phlebotomist removes the needle, he/she should release the tourniquet. If the tourniquet is left on for too long, blood flow to the extremity could be impaired. Activating the needle safety mechanism, inverting the evacuated tubes, and applying a gauze dressing are all actions that need to be taken after the tourniquet is released and the needle is removed.

A phlebotomist collects a cryofibrinogen specimen, places the specimen in a biohazard specimen bag, then onto slurry of ice and water and transports it to the laboratory in a timely manner. In this case the phlebotomist A. performed proper specimen handling. B. should have protected the specimen from light. C. should have kept the specimen at 37˚C. D. should have aliquoted the specimen before transport.

should have kept the specimen at 37˚C. Rationale Many types of specimens are required to be kept at certain temperatures for accurate test results to be obtained by the laboratory. Cryofibrinogen, cryoglobulin and cold agglutinins must be kept at 37o C (body temperature). Tests requiring protection from light include: bilirubin, carotene, porphyrins and vitamins A, B2, and C. Specimens that require chilling on an ice slurry are ammonia, lactic acid, pH & blood gases among others. Consult your facility's policies for the correct procedures to follow. Aliquoting of the specimen (dividing it into parts) is done during or after processing in the laboratory.

A finger stick capillary puncture should be performed at which of the following sites to prevent injury? A. at the most distal end of the fingertip B. slightly to the side of the center of the fingertip C. directly in the center of the fingertip D. proximal to the skin crease located at the first joint on the fingertip

slightly to the side of the center of the fingertip Rationale Capillary blood from the finger is one of the best sources from which to obtain certain samples, such as those needed for blood sugar readings. To ensure adequate blood flow and prevent injury, the proper approach is to utilize the middle or ring finger of the patient's non-dominant hand; the sides of the finger have better blood flow and are not as painful as the pad (center) or the actual distal end of the finger. The skin crease at the first joint would not provide adequate blood and could cause more pain and/or injury, therefore this area should be avoided during a finger stick.

What does the color of an evacuated collection tube represent? A. a visual identifier for tests expected to be above or below normal range B. the minimum volume of blood to be obtained C. the personal protective equipment required for collection D. the type or absence of an additive

the type or absence of an additive Rationale There are a variety of blood collection tubes. The colors of the caps indicate the presence or absence of additive. Particular laboratory tests may require a specific additive. For instance, if a test requires serum, a red top tube that allows the blood to clot would suffice. A lavender/purple top tube contains K3 EDTA anticoagulant that will keep blood from clotting, allowing for whole blood testing such as a CBC and Differential. Depending upon the type of tube and additive therein, a minimum blood volume may be required.

The proper technique to anchor a vein is to use the non-dominant thumb A. to pull the skin toward the wrist. B. and forefinger to stretch the skin above and below the site. C. to apply direct downward pressure. D. and forefinger to apply direct downward pressure above and below the site.

to pull the skin toward the wrist. Rationale Using the thumb of the non-dominant hand to anchor the vein before inserting the needle for venipuncture not only keeps the vein from rolling but stretches the skin and helps make the puncture less painful. Using the thumb and the forefinger (C or window hold) leaves the forefinger in line for a possible needlestick injury. Just enough pressure should be applied to keep the vein still.

While performing a venipuncture to obtain a CBC and PTT, the phlebotomist punctures the skin, advances the needle, inserts the tube, but does not see a blood return. The phlebotomist should next A. adjust the bevel up. B. release the tourniquet. C. try another tube. D. advance the needle further.

try another tube. Rationale To establish blood flow in a failed venipuncture, the first step is to replace the tube as it may not have a good vacuum. If this does not work, the needle may be adjusted slightly forward or backward until centered in the vein. Releasing the tourniquet will not help as the vein may collapse. The needle should be inserted bevel up and is never turned while in the vein.

Which of the following is a CLIA waived test that can be performed by the phlebotomist? A. differential B. urine reagent strip analysis C. Gram stain analysis D. crossmatch

urine reagent strip analysis Rationale A phlebotomist can perform a chemical urinalysis test, which shows if the patient has protein or glucose in their urine, but would require intervention by the primary care provider. A chemical urinalysis can also tell what the specific gravity of the urine, meaning how diluted or concentrated it is. The test is done with a small dipstick that changes color when it comes into contact with urine. The phlebotomist then compares the stick to a chart to see what is in the urine and if anything is abnormal. A differential is done by a laboratory technician. It is done by drawing blood and then placing the blood on a glass slide to look for any signs of infection or anemia. A Gram stain analysis is also done in the lab under a microscope when a bacterial or viral infection is suspected. Cross-matching is a test administered before a blood transfusion to ensure the donor's blood is compatible with the recipient. This test is performed by a certified laboratory technologist.

At which of the following times should a test tube be labeled with the patient's identification? A. before entering the patient's room B. after leaving the patient's room C. while in the patient's room, before drawing the blood D. while in the patient's room, after drawing the blood

while in the patient's room, after drawing the blood Rationale Three crucial identification steps in phlebotomy must be performed in this sequence without interruption—(1) positively identifying the patient, (2) collecting the patient's blood into tubes, and (3) labeling the tubes immediately afterward. Any change in this sequence or any significant interruption between steps has been linked to significantly increased chances for error.