Phlebotomy Technician Practice Exam
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?
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.
While performing a capillary stick on a six-month-old infant's heel, the lancet should be no longer than
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?
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 phlebotomist has received a requisiti
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?
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.
How long should pressure be applied on the venipuncture site for a patient on Coumadin therapy?
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.
Which of the following precautions should be used for a patient with pulmonary TB?
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.
A phlebotomist was collecting a CBC and BMP on a patient with a prominent vein, when the serum tube did not fill. After redirecting and trying another serum tube which did not fill, the phlebotomist went on to collect a PST tube and an EDTA tube and filled them completely. Which of the following is the MOST likely reason the serum tubes did not fill?
An expired tube was collected Rationale: Vacuum blood collection tubes have an expiration date beyond which the contents and their ability to fill can be compromised. In this case, both serum tubes may have been from the same lot. The PST and EDTA tubes were newer and the vacuum intact. It is incumbent on the phlebotomist to check the expiration dates and discard those that are outdated. This is good laboratory practice and quality control. The seal on the needle must be broken to remove the cap for use.
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?
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.
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?
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?
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).
An immunization is currently available for prevention of which of the following bloodborne diseases?
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 organizations makes on-site visits to inspect phlebotomy laboratories?
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).
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.)
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.
Which one of the following specimen types is primarily used to perform CLIA-waived point-of-care testing for glucose?
Capillary blood Rationale: Capillary blood from a dermal puncture is used with a glucometer to monitor glucose levels. A glucometer is considered a CLIA waived point of care instrument. Serum, plasma and venous blood are not used with these instruments.
Which of the following QC measures are within the phlebotomist's scope of practice? (Select the three (3) correct answers.)
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.
While obtaining blood during a venipuncture, the patient faints. Which of the following actions should the phlebotomist take initially?
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.
Which of the following actions is a HIPAA violation?
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.
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?
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.
An older adult patient arrives to have blood drawn. While assessing the arms for venipuncture, the phlebotomist notices scar tissue in the antecubital areas and is unable to palpate a vein. Which of the following is an appropriate alternative course of action?
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.
After the phlebotomist has introduced herself and identified the patient, she should NEXT
Explain 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.
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?
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 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?
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 minimum PPE requirement when drawing lab work on a patient with suspected HIV?
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.
Which of the following steps is completed FIRST in performing venipuncture?
Identify the pt 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 has collected an ammonia level. Which of the following should be done regarding transport of the specimen?
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 is the appropriate blood collection device for obtaining a blood spot collection on an infant?
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).
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?
Light blue and 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 (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.
Which of the following statements represents correct patient identification for a phlebotomist in an outpatient setting?
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.
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?
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?
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 an 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.
a patient has measles, which of the following is a required additional precaution?
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
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.
Which of the following standards are being violated when a phlebotomist fails to use proper handwashing technique?
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.
Commitment to privacy, continuity of care, advance directives, and the authority to refuse treatment are granted according to which of the following?
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.
While performing a venipuncture, immediately before removing the needle, the phlebotomist should
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.
Which task should a phlebotomist complete prior to daily use of a POC 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?
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.
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?
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).
When performing a venipuncture, sudden swelling is observed at the insertion site. Which of the following actions should the phlebotomist take?
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?
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 physician's 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 physician's 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?
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 should be included on a patient's laboratory requisition?
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.
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?
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.
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?
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?
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.
When performing a capillary puncture on an infant, which of the following is the reason for using the lateral heel instead of a finger?
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.
After centrifuging a blood specimen, the phlebotomist notes the serum has a reddish appearance. Which of the following has occurred?
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).
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
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 BEST describes the proper way to clean up a broken glass tube?
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 preps the median cubital vein for a venipuncture procedure. How should the phlebotomist prep the patient's skin?
Use back-and-forth friction, applied horizontally or vertically. 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 (use a nonalcohol-based cleanser if collecting a blood alcohol level). Use your facility's prescribed disinfectant for blood culture collections. Proper cleansing is necessary to prevent contamination. Back-and-forth friction has been shown to be more effective than concentric circles. Cleanser should be allowed to air dry before sticking the patient.
Before drawing a patient, the phlebotomist notices a droplet of dried blood on the arm of the phlebotomy chair. Which of the following should the phlebotomist do?
Use disinfectant to moisten the droplet, absorb with paper towel, then clean with disinfectant. Rationale: To clean small, dried blood spills, it is important to moisten the area with disinfectant so as not to create an aerosol and disperse infectious material into the air. With gloved hands, wipe up the blood or body fluid with paper towels and dispose of them in a biohazard waste container. Finally, reclean the area with disinfectant, allowing it to sit on the surface for several minutes before wiping with more paper towels. An alcohol pad, water or anti-microbial soap are not as effective against microorganisms as 10% bleach or commercial disinfectants.
When drawing a blood alcohol specimen, which of the following should be used to clean the arm?
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.
At which of the following times should a test tube be labeled with the patient's identification?
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.
Venipuncture should be avoided on an arm with
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).
Which of the following is a requirement for a healthcare facility to be in compliance with 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.
To help prevent a hematoma at the site after drawing blood, which of the following actions should the phlebotomist take?
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.
Capillary blood specimens are MOST likely to be successfully collected from patients that
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.
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?
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.
A phlebotomist must collect a specimen for a blood alcohol test on a patient who is allergic to shell fish. Which of the following antiseptics should the phlebotomist use?
benzalkonium chloride Rationale: For accurate results when preparing a venipuncture site to collect a blood alcohol level, the antiseptic used must not contain alcohol. It is important to be aware of the formulation of the antiseptic to be used. Chlorhexidine gluconate solutions may contain alcohol. If the patient is allergic to shellfish, any solution containing iodine is contraindicated. In this case, an aqueous solution of benzalkonium chloride may be the best choice.
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
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 specimens require the phlebotomist to follow chain-of-custody documentation procedures? (Select the two (2) correct answers.)
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 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.)
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.
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?
blood culture, red top, lavender top Rationale: To avoid cross-contamination.
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?
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.
Which of the following veins would generally be acceptable for routine blood collection by the phlebotomist?
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.
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?
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.
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?
contact and 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.
Which of the following is included in an exposure control plan?
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.
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?
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
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 is an appropriate draw site for an adult patient with a central line?
dorsal side of 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.
The rubber sleeve at the end of a ETS venipuncture needle allows for
drawing multiple tubes Rationale: The rubber sleeve maintains a closed system while switching tubes.
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
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.
A 17-month-old presents for a routine capillary stick to determine lead levels. The point of draw should be the
finger. Rationale: Dermal punctures are typically performed on the heels of neonates and children until approximately one year of age. Once the child begins to walk, the heel becomes too calloused to puncture safely. Therefore, the middle or index finger is used if a small amount of blood is required. The toe and thumb are not recommended.
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?
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. http://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf
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?
heel of 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.
The phlebotomist is instructed to perform a capillary stick for newborn screening. Which of the following collection devices should the phlebotomist use?
heel stick lancet Rationale: The heel stick lancet (e.g., Tenderfoot) is required for infants. If a heel stick 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?
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 is 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?
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
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.
A phlebotomist must follow transmission based precautions for which of the following patients?
patient with meningitis Rationale: Droplet precautions are used to reduce the transmission of diseases such as pertussis, meningitis, pneumonia, and rubella. These diseases can be transmitted through contact of the mucous membranes of the eye, mouth, or nose with large-particle droplets that occur through sneezing, coughing, or talking.
A 19-year-old patient offers her arm to the phlebotomist when she comes in with a venipuncture tray. This is an example of
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.
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.)
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 sites should the phlebotomist use for newborn screening blood collection?
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.
Which of the following is the CLSI recommended micro-collection order of draw for a BMP, CBC and bilirubin?
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.)
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 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?
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 phlebotomist receives an order to collect a cold agglutinin specimen. The phlebotomist should
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.
Negligence by a health care professional is considered which of the following?
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.
Which of the following information is required information on a laboratory test requisition for a blood specimen?
name of the physician Rationale: CLIA requires the name and address of the ordering physician on a laboratory test requisition so that the test results can be sent to the correct provider. Listing the patient's social security number and diagnosis would be considered a HIPPA infraction. The need for the source of the sample is defined by the test requested. Additional information includes: The patient's name or unique patient identifier, the sex and age or date of birth of the patient, the test(s) to be performed and the date and time of specimen collection, if appropriate.
Which of the following actions by the phlebotomist is the FIRST line of defense in preventing the spread of microorganisms?
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?
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
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
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 sharp may be disposed of following a venipuncture once the needle is
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.
When wearing the appropriate personal protective equipment for the particular task or duty, the phlebotomist is exercising
standard precautions Rationale: Standard precautions state that all blood and body fluids are potentially infectious and that appropriate PPE (personal protective equipment) must be worn when any possible contact may be made with these substances. These rules replaced universal precautions which mainly focused on blood borne pathogens. Medical asepsis is the act of sterilization and refers to equipment and surfaces, not patients. Work practice controls are safety measures involving medical equipment such as needle safety devices.
Instead of obtaining consent from a patient who is mentally competent, the phlebotomist obtains consent from a family member. This is a violation of
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.
The proper technique to anchor a vein is to use the non-dominant thumb
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.
When inserting a needle during venipuncture, the bevel should be in which of the following positions in relation to the vein?
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.
When performing a venipuncture, the phlebotomist is stuck with a bloody needle upon withdrawal from the patient. What is the FIRST thing the phlebotomist should do?
wash the exposed area with soap and water Rationale: The first step to take if injured by a contaminated needle is to wash the area thoroughly with soap and water. Then report to a supervisor who will oversee the incident. Immediate medical attention should be sought and the occurrence documented.
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?
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.
