Chapter 9: Preexamination//Preanalytical Considerations
100. This illustrated situation would cause the tube to make a hissing sound and it would fail to fill with blood. a. B b. C c. E d. F
100. Answer: b WHY: This illustration shows that the needle has not penetrated the skin all the way (Fig. 9-13 C. Needle bevel partially out of the skin; tube vacuum will be lost.) and consequently is not seated in the lumen of the vein where it should be. A characteristic "hissing" sound should tell the phlebotomist immediately that the vacuum is pulling air into the tube, which means the vacuum pull of the tube will be lost. The corrective action is to push the needle into the vein and exchange the tube for a new one with vacuum.
101. The specimen processor asks you if you verified that the patient was fasting for a specimen you drew earlier that morning. The processor most likely asked this question because the specimen was: a. clotted. b. icteric. c. lipemic. d. pinkish
101. Answer: c WHY: A lipemic specimen appears milky (cloudy white) or turbid (cloudy) instead of normal transparent light yellow. Fatty foods like butter contain lipids. Lipids do not dissolve in water so they can appear in serum or plasma shortly after eating. Consequently, a lipemic specimen is a clue that the patient may not have been fasting. Thus, the processor wanted to know if the phlebotomist had verified that the patient was fasting.
102. Even if patients have never fainted during a blood draw before, you should a. ask how they are doing during the draw. b. be prepared to protect them from falling. c. not turn your back on them while labeling. d. All the above.
102. Answer: d WHY: Just because patients haven't fainted in the past does not mean they won't faint during a current blood draw. The phlebotomist can be prepared for fainting episodes, by asking patients how they are doing during the draw, being prepared to protect them from falling if they do faint, and never turning away from the patient (e.g., after the draw while labeling tubes), because in doing so they will be unable to see the signs that precede fainting.
103. The best specimens to use for establishing inpatient reference ranges for blood tests are a. basal state specimens. b. fasting specimens. c. postprandial specimens. d. steady-state specimens.
103. Answer: a WHY: Inpatient reference ranges for laboratory tests are typically established using basal state specimens to eliminate the effects of diet, exercise, and other factors on results. Basal state refers to the resting metabolic state of the body early in the morning after fasting for approximately 12 hours. Basal state specimens are also fasting specimens, but a fasting specimen is not necessarily a basal state specimen. A postprandial specimen is not a basal state specimen because it is collected a certain amount of time after a meal. Steady state is a stable condition, but it can be at other times of the day and is not usually a fasting state.
104. The ratio of blood to anticoagulant is most critical for which of the following tests? a. Alkaline phosphatase b. Complete blood count c. Glycohemoglobin d. Prothrombin time
104. Answer: d WHY: A prothrombin time is a coagulation test. The ratio of blood to anticoagulant is most critical for coagulation tests because a ratio of nine parts blood to one part anticoagulant must be maintained for accurate test results. The excess anticoagulant in a tube that does not fill to the correct level dilutes the plasma portion of the specimen used for testing, causing falsely prolonged test results.
105. A patient who has had a mastectomy is most likely to have a. hyperglycemia. b. lymphedema. c. seizure disorder. d. thrombocytopenia.
105. Answer: b WHY: Lymph node removal, which is typically part of a mastectomy procedure, may cause lymphostasis (obstruction or stoppage of normal lymph flow). The impaired lymph flow makes the arm susceptible to swelling, called lymphedema.
11. A hematoma is a a. blood clot inside of a vein. b. pool of fluid from an IV. c. swelling or mass of blood. d. symptom of nerve injury.
11. Answer: c WHY: Hematoma (Fig. 9-1) is the medical term for a swelling or mass of blood under the skin caused by leakage of blood from a blood vessel. A hematoma can occur during or after venipuncture or arterial puncture, often because of poor technique. A blood clot within a vein is called a thrombus. A pool of fluid from an IV would cause localized edema. A hematoma is not a symptom of nerve injury, but pressure from the pooling of blood in the tissue could injure a nerve.
12. Mastectomy is the medical term for breast a. biopsy. b. reduction. c. removal. d. surgery.
12. Answer: c WHY: The surgical removal of a breast, which is sometimes done in the treatment of breast cancer, for example, is called a mastectomy. It is derived from the Greek word mastos which means "breast." The suffix -tomy means "incision or cutting."
13. Exsanguination is a. autologous donation of blood. b. iatrogenic depletion of blood. c. life-threatening loss of blood. d. therapeutic removal of blood.
13. Answer: c WHY: Exsanguination is massive blood loss or removal of blood to a point where life cannot be sustained. Autologous donation of blood is giving blood for one's own use. Iatrogenic is an adjective used to describe an adverse condition brought on as a result of treatment. Blood depletion because of blood being removed for testing is called iatrogenic blood loss. Iatrogenic blood loss often leads to anemia, and could threaten life if more than 10% of a patient's blood volume is removed at one time or over a short period. Blood is sometimes removed for therapeutic purposes, such as, when treating polycythemia, but not in quantities that would cause exsanguination.
14. Which of the following is a product of the breakdown of red blood cells? a. Bilirubin b. Creatinine c. Glucagon d. Lipid (fat)
14. Answer: a WHY: Bilirubin is a yellowish pigment that is the product of the breakdown of red blood cells by the body. High levels of bilirubin in the blood lead to deposits of the pigment in the skin, mucous membranes, and sclera (whites of the eyes), a condition called jaundice.
15. A vein that is thrombosed is a. clotted. b. patent. c. scarred. d. swollen.
15. Answer: a WHY: Thrombosed means "clotted." A thrombosed vein is not necessarily scarred or swollen. A patent vein is a vein that is freely open, not clotted.
16. A patient experiences a momentary loss of consciousness or a miniseizure while you are drawing his blood. The last tube has just started to fill. All of the following are correct actions to take EXCEPT a. Complete the draw as quickly as you can. b. Immediately discontinue the blood draw. c. Notify the appropriate first aid personnel. d. Prevent the patient from injuring himself.
16. Answer: b WHY: Do not attempt to complete the draw on a patient who has a seizure or even a miniseizure during venipuncture. Continuing the draw is dangerous and could result in injury to the patient. In addition, you could receive an accidental needlestick. Discontinue the draw immediately and remove, shield, and discard the needle as soon as possible. Try to prevent the patient from injuring himself or herself and notify the appropriate first aid personnel as soon as possible.
17. The patient has an IV in the left forearm and a large hematoma in the antecubital area of the right arm. The best place to collect a specimen by venipuncture is the a. left arm above the IV entry point. b. left arm below the IV entry point. c. right arm distal to the hematoma. d. right arm in the antecubital area.
17. Answer: c WHY: When one arm has an IV it is preferred that the specimen be collected from the other arm if possible. Never collect a blood specimen above an IV or a hematoma. When there is no alternative site, perform the venipuncture below or distal to the hematoma. Venipuncture through or close to a hematoma is painful to the patient and can result in collection of blood from outside the vein that is hemolyzed or contaminated by the IV, and unsuitable for testing. Going below (distal) to the hematoma ensures collection of blood that is free-flowing and unaltered by the effects of the clotting and hemolysis in the area.
18. Which of the following conclusions is probable? Figure 9-1 (refer to #11) shows an arm with a. bruising that was most likely caused by a reflux reaction. b. discoloration from prolonged application of a tourniquet. c. evidence of partial exsanguination of the antecubital area. d. the results of hematoma blood moving after venipuncture.
18. Answer: d WHY: A hematoma is a swelling or mass of blood that can be caused by blood leaking from a blood vessel during or immediately after a venipuncture. A bruise eventually spreads into the surrounding area. The bruising in Figure 9-1 most likely resulted from a very large hematoma that formed during a venipuncture. After the venipuncture the pool of blood apparently migrated to low areas of the arm while the patient was in a resting position in the hospital bed.
19. Hemoconcentration from prolonged tourniquet application increases a. blood plasma volume. b. nonfilterable analytes. c. pH and oxygen levels. d. specimen hemolysis.
19. Answer: b WHY: Hemoconcentration is a condition in which plasma and small, filterable components of the blood pass through the walls of the blood vessels into the tissues, decreasing blood plasma volume and concentrating and therefore increasing nonfilterable or suspended blood components such as red blood cells. Oxygen and pH are usually tested on arterial blood and a tourniquet is not used in collection. Hemoconcentration does not cause specimen hemolysis.
2. Most reference ranges are based on laboratory test values for a. fasting patients. b. healthy people. c. ill individuals. d. treated patients.
2. Answer: b WHY: Most tests are performed to screen for, diagnose, or monitor disease. To be properly evaluated, test results need to be compared with test result values expected of healthy individuals. Therefore, values for most tests are established using specimens from healthy individuals. Because results vary somewhat from person to person, the results used for comparison become a range of values with high and low limits, commonly called a reference range. Most reference ranges are given for fasting patients, established using specimens from healthy, fasting individuals. Fasting patients, however, are not always healthy individuals. Some tests do have reference ranges for patients who are ill or are being treated for certain disorders, such as diabetes, but these reference ranges are less common.
20. Which of the following is the medical term for fainting? a. Sclerose b. Stasis c. Supine d. Syncope
20. Answer: d WHY: Syncope is the temporary loss of consciousness and the ability to maintain an upright position as a result of inadequate blood flow to the brain, and is the medical term for fainting. Sclerose means "to harden." Stasis is stagnation of blood or other fluids. Supine means "lying on the back, face up."
22. A vein that is occluded is a. fragile. b. inflamed. c. obstructed. d. resilient.
22. Answer: c WHY: The definition of occluded is obstructed. Occluded veins are not necessarily fragile, and they lack resiliency because of the obstruction. The obstruction is sometimes the result of inflammation, but an occluded vein is not necessarily inflamed.
23. Which test requires the patient's age when calculating results? a. Cold agglutinin titer b. C-reactive protein c. Creatine kinase MB d. Creatinine clearance
23. Answer: d WHY: Some physiologic functions, such as kidney function, normally decrease with age. Creatinine is removed (cleared) from the blood plasma by the kidneys. The amount removed is measured by the creatinine clearance test. Since kidney function declines with age, the patient's age is required when calculating the results of the creatinine clearance test.
32. When a patient is on drug therapy, a test result can be false positive if a. a prescribed drug acts to enhance the desired test reaction. b. an analyte and the drug compete for the reaction test sites. c. anticoagulant reflux occurred during specimen collection. d. serum used for the test came from a partially filled tube.
32. Answer: a WHY: When a prescribed drug acts to enhance the desired test reaction, the results will be falsely elevated. If the substance tested (analyte) is competing for the same test sites in the testing process as the drug, the results will be falsely decreased. Reflux of anticoagulant during specimen collection may cause an adverse patient reaction, but does not affect the specimen being collected. Testing serum obtained from a partially filled red top should not affect test results if there is enough specimen to perform the test.
33. Which of the following analytes can remain elevated for 24 hours or more after exercise? a. CK b. CO2 c. K+ d. pH
33. Answer: a WHY: Exercise elevates blood levels of a number of components, including skeletal enzymes such as creatine kinase (CK) and lactate dehydrogenase (LDH), which may stay elevated for 24 hours or more. CO2 and pH levels decrease with exercise. Potassium (K+) levels increase with exercise, but usually return to normal levels after several minutes of rest.
52. A type of line commonly used to monitor blood pressure and collect blood gas specimens. a. A-line b. CVC c. IV d. PICC
52. Answer: a WHY: An arterial line (A-line) (Fig. 9-8) or catheter is most commonly located in the radial artery and is used to provide continuous measurement of a patient's blood pressure. It is also commonly used for collection of blood gas specimens.
37. What changes occur in the bloodstream when a patient goes from supine to standing? a. Nonfilterable elements increase. b. Red blood cell counts decrease. c. The level of calcium decreases. d. Volume of plasma is increased.
37. Answer: a WHY: When a patient stands up after being supine (lying down), blood plasma filters into the tissues, decreasing plasma volume and increasing nonfilterable or suspended elements such as calcium, iron, proteins, and red blood cells.
45. Drawing blood from an edematous extremity may cause a. erroneous specimen results. b. hemolysis of the specimen. c. premature specimen clotting. d. rapid formation of petechiae.
45. Answer: a WHY: Edema is swelling caused by the abnormal accumulation of fluid in the tissues. Specimens collected from edematous areas may yield erroneous test results due to contamination with the fluid in the tissue or altered blood composition related to the swelling and impaired circulation in the area.
46. If you have no choice but to collect a specimen from an arm with a hematoma, collect the specimen a. above it. b. beside it. c. distal to it. d. through it.
46. Answer: c WHY: If you have no other choice, it is acceptable to collect a blood specimen distal, or below a hematoma, where blood flow is least affected by it. A venipuncture in the area of a hematoma, including above, beside, or through it, is painful to the patient, and can yield erroneous results related to the obstruction of blood flow by the hematoma. It can also result in collection of contaminated and possibly hemolyzed blood from the hematoma, instead of blood from the vein.
57. The way to bandage a venipuncture site when the patient is allergic to the glue in adhesive bandages is to a. apply a bandage that is latex-free. b. wait 5 minutes to apply a bandage. c. wrap a warm wash cloth around it. d. wrap it with self-adhering material.
57. Answer: d WHY: Some patients are allergic to the glue used in adhesive bandages. Using a latex-free bandage is not an option because the patient is allergic to the adhesive used for the bandage, not necessarily latex. A good option is to cover the site with a clean folded gauze square and wrap it with bandaging material such as Coban that sticks to itself, not the skin. Another option if the patient is alert and competent is to ask him or her to hold pressure over the site until bleeding stops in lieu of bandaging. Waiting 5 minutes before applying a bandage does not correct the adhesive allergy issue. Wrapping the site with a warm wash cloth would increase blood flow and could make the site take longer to stop bleeding.
58. You may have to be careful about what type of equipment is brought into the room if a patient is severely allergic to a. adhesive. b. iodine. c. latex. d. perfume.
58. Answer: c WHY: Increasing numbers of individuals are developing allergies to latex. Some allergies are so severe that being in the same room where latex materials are used can set off a life-threatening reaction. If an inpatient is known to have a severe allergy to latex, there is typically a warning sign on the door to the room. It is important that no items made of latex be brought into the room. Fortunately, manufacturers have come up with latex-free alternatives to many items commonly used in healthcare, but other items still contain latex parts and many nonmedical items such as balloons, rubber bands, and even the soles of shoes may have latex in them.
63. If an outpatient tells you before a blood draw that she is feeling nauseated, you should a. advise her to begin slow, deep breathing. b. draw the specimen; watching her closely. c. have her lie down until she feels better. d. suggest that she come back another day.
63. Answer: a WHY: A feeling of nausea often precedes vomiting, so it is a good idea to give the patient an emesis basin to hold as a precaution. Apply a cold, damp washcloth or other cold compress to the patient's forehead and ask him or her to breathe slowly and deeply. Do not attempt blood collection until the nausea subsides. Drawing the specimen regardless of her nausea may stimulate her to vomit. The nausea will not necessarily subside if you have her lie down. Coming back another day will not solve the problem if this is a reaction to the thought of having blood drawn. In addition, returning another day may be an imposition to the patient, especially if she is from out of town or has otherwise traveled some distance to get to the lab. It may also delay any treatment if the physician is waiting for results to decide on a course of action.
64. Pain associated with venipuncture can be minimized by a. desensitizing the site by rubbing hard with alcohol. b. putting the patient at ease with a little small talk. c. tying the tourniquet tight enough to numb the arm. d. warning the patient that the draw might hurt a lot.
64. Answer: b WHY: Engaging in small talk before venipuncture can put patients at ease and help them relax. A relaxed patient is less likely to feel as much pain associated with the draw as someone who is anxious and tense. Rubbing with alcohol can abrade the skin and can be painful rather than desensitizing. Tying the tourniquet too tight can make the arm feel numb, but numbness is a sign of nerve compression and is never recommended. A venipuncture should not "hurt a lot." Telling patients that the draw might be painful can increase their anxiety and make them more tense. The patient should be warned just before the needle enters the arm, however, to prevent a startle reflex.
65. A site could potentially be used for venipuncture even if a. petechiae appear below the tourniquet. b. scarring from a deep burn is present. c. the arm appears slightly edematous. d. the only vein feels hard and cordlike.
65. Answer: a WHY: Petechiae (Fig. 9-4) are small red, purple, or brownish, nonraised spots that appear with tourniquet application on some patients with platelet or capillary defects. They do not compromise test results and may not be avoidable because they will probably occur at any site that is chosen. Sites with massive scarring, or edema, and veins that feel hard and cordlike should be avoided.
72. Infection of a venipuncture site can result from a. following the wrong order of draw. b. leaving the tourniquet on too long. c. touching the site after cleaning it. d. using an unsterile ETS tube holder.
72. Answer: c WHY: Infection at the site following venipuncture is rare but not unheard of. Using proper aseptic technique, including not touching the site after it has been cleaned, minimizing the time between removing the needle cap and venipuncture, not opening adhesive bandages ahead of time, and reminding the patient to keep the bandage on for at least 15 minutes after specimen collection, should minimize the risk of infection. The wrong order of draw or leaving a tourniquet on too long can affect the specimen but does not cause infection of the site. ETS tube holders are not normally sterile because they do not touch the venipuncture site.
73. Blind or deep probing for a vein can result in a. accidental arterial puncture. b. impairment of vein patency. c. permanent nerve injury. d. All the above.
73. Answer: d WHY: Blind or deep probing during venipuncture is usually painful and can result in the accidental piercing of nerves and arteries and the possibility of permanent damage. Lawsuits have been filed over permanent nerve injuries caused directly by needles or indirectly by compression of the nerves by hematomas that resulted from inadvertent arterial sticks. Patency is the state of being freely open. Probing can damage veins and make them less patent.
67. A phlebotomist has tried twice to collect a light blue top tube on a patient with difficult veins. Both times the phlebotomist has been able to collect only a partial tube. What should the phlebotomist do? a. Collect the specimen by a skin puncture b. Have someone else collect the specimen c. Pour the two tubes together and mix well d. Send one to the lab marked "difficult draw"
67. Answer: b WHY: There is no skin puncture container for collecting plasma specimens for coagulation tests because, except for coagulation tests that can be performed with special point-of-care instruments, coagulation tests cannot be performed by skin puncture. Partially filled coagulation tubes have an incorrect blood-to-additive ratio and are unacceptable for testing. Pouring two partially filled tubes together also results in an improper ratio of blood to additive and is unacceptable. A phlebotomist should never make more than two attempts at venipuncture on a patient at one time. After the second attempt, another phlebotomist should be asked to collect the specimen.
68. Pseudoanemia can be caused by a. being stressed before a blood draw. b. going from standing to lying down. c. leaving the tourniquet on too long. d. smoking a cigarette before a draw.
68. Answer: b WHY: A condition called postural pseudoanemia (posture-related false anemia) can be caused by going from standing to lying down. The change in position causes an increase in plasma volume that decreases hematocrit values that could be mistaken for blood loss or acute anemia.
69. Which of the following is the best indication that you have accidentally punctured an artery? a. A hematoma starts to form. b. Blood obtained is dark red. c. Blood pulses into the tube. d. There isn't any way to tell.
69. Answer: c WHY: Arterial blood is under more pressure than venous blood and will normally pulse or spurt into the tube. Consequently, blood pulsing or spurting into the tube is the best indication that you may have accidentally hit an artery. A hematoma will not necessarily form when you hit an artery instead of a vein if the needle bevel is completely within the artery and adequate pressure is held over the site after the needle is removed from it. Hematomas can also form during venous blood collection. Color is not a good way to identify arterial blood. Normal venous blood is typically dark red. Arterial blood in normal individuals is bright red, but it may look as dark as venous blood if the patient has a pulmonary problem.
74. A patient complains of marked pain when you insert the needle. The pain radiates down his arm and does not subside. What should you do? a. Ask him if he wants you to stop the draw. b. Collect the specimen as quickly as you can. c. Discontinue the venipuncture immediately. d. Say "Hold on or I'll have to stick you again."
74. Answer: c WHY: Marked (extreme or significant) pain, numbness of the arm, and pain that radiates up or down the arm are signs of nerve involvement and any one of them requires immediate removal of the needle. A patient may not understand the significance of the symptoms or may act stoic to not appear weak. It is up to the phlebotomist to recognize the signs of nerve injury and discontinue the venipuncture immediately. Continuing the draw can worsen the damage.
71. If you suspect that you have accidentally collected an arterial specimen instead of a venous specimen a. apply a pressure bandage to the site immediately. b. ask another phlebotomist to recollect the specimen. c. check to see if arterial blood can be used for the test. d. discard it and collect a new one from another site.
71. Answer: c WHY: An inadvertently collected arterial specimen can usually be submitted for testing, rather than redrawing the patient. However, the specimen should be labeled as arterial because some test values are different for arterial specimens. If you suspect that you have accidentally punctured an artery, you must hold pressure over the site for 3 to 5 minutes. Do not have the patient hold pressure or apply a pressure bandage in lieu of holding pressure.
75. A stinging sensation when the needle is first inserted is most likely the result of a. an imperfection in the needle bevel. b. not letting the alcohol dry thoroughly. c. tying the tourniquet excessively tight. d. pushing down during needle insertion.
75. Answer: b WHY: Performing venipuncture before the alcohol has dried completely is the most common cause of a stinging sensation to the patient. Blood collection needles are used only once and are not likely to be dull or flawed, but they should be examined when first opened to detect defects that could cause pain or injure the patient. Pushing down on the needle as it is inserted can be painful but does not normally produce a stinging sensation. A tourniquet that is tied too tightly is typically described as a pinching sensation.
28. A 12-hour fast is normally required when testing for this analyte. a. Bilirubin b. Calcium c. Electrolytes d. Triglycerides
28. Answer: d WHY: Triglycerides are a type of lipid. A 12-hour fast is required to remove the effects of food ingestion on the triglyceride content of the blood (see answers to questions 26 and 27).
48. Which of the following veins is often the easiest to feel on obese patients? a. Basilic b. Brachial c. Cephalic d. Median
48. Answer: c WHY: Veins on obese patients can be deep and difficult to find. The cephalic vein is sometimes the easiest vein to palpate. To locate it, rotate the patient's arm so that the hand is prone. In this position, the weight of excess tissue often pulls downward, making the cephalic vein easier to feel and penetrate with a needle.
49. The serum or plasma of a lipemic specimen appears a. cloudy white. b. dark yellow. c. foamy and pink. d. red and turbid.
49. Answer: a WHY: An abnormally high concentration of lipids (fatty substances) in the blood is called lipemia. Lipemia can persist for up to 12 hours. Because lipids are insoluble in water they make serum or plasma look milky (cloudy white) or turbid and the specimen is described as being lipemic.
5. Lipemia results from a. high fat content of the blood. b. improper specimen handling. c. increased number of platelets. d. specimen hemoconcentration.
5. Answer: a WHY: The term "lipemia" comes from the word root "lip," which means "fat." Lipemia is the presence of increased fats (lipids) in the blood. Lipids do not dissolve in water and thus high levels of lipids are visible in the serum or plasma causing it to look cloudy or milky white.
50. A phlebotomist must collect a hemoglobin specimen from a patient in ICU. There is an IV in the patient's left wrist. There is no suitable antecubital vein or hand vein in the right arm. What should the phlebotomist do? a. Ask another phlebotomist to collect it. b. Collect it from a leg, ankle, or foot vein. c. Draw it from a hand vein below the IV. d. Perform a finger stick on the right hand.
50. Answer: d WHY: The most expedient thing to do in this situation is to collect the specimen by finger stick. A capillary specimen can be collected and on its way to the lab in the time it would take to call another phlebotomist to come and collect the specimen, the IV to be shut off for 2 minutes to collect the specimen below it, or permission obtained to collect the specimen from a leg, ankle, or foot vein.
51. If a CBC is collected from a screaming infant the a. chance of hemolysis is increased. b. platelets are more likely to clump. c. specimen may be hemoconcentrated. d. WBCs may be temporarily elevated.
51. Answer: d WHY: Studies performed on crying infants have demonstrated significant increases in white blood cell (WBC) counts, which are a part of a complete blood count (CBC). Counts returned to normal within 1 hour after crying stopped. For this reason, it is best if CBCs or WBC specimens are obtained after the infant has been sleeping or resting quietly for at least 30 minutes. Because an infant usually cries during blood collection, the specimens should be collected as quickly as possible. If a specimen must be collected while an infant is crying, it should be noted on the report.
76. Which is the best way to avoid reflux? a. Draw the specimen while the patient is supine. b. Follow correct order of draw when filling tubes. c. Keep the tourniquet on until the last tube is full. d. Make certain that tubes fill from the bottom up.
76. Answer: d WHY: "Reflux" is a term used to describe the backflow of blood from a collection tube into a patient's vein during venipuncture. Reflux can happen if there is a pressure change in the vein that occurs normally or when the tourniquet is released. It can only occur if blood in the tube is in contact with the needle during venipuncture. Reflux of blood mixed with an additive such as EDTA can cause an adverse patient reaction. Keeping the arm in a downward position so that tubes fill from the bottom up (Fig. 9-12), and avoiding back-and-forth movement of tube contents during blood collection, prevent blood in the tube from being in contact with the tube holder end of the needle and therefore prevent reflux.
78. Prolonged tourniquet application can affect blood composition because it causes a. delayed hemostasis. b. dilution of plasma. c. hemoconcentration. d. specimen hemolysis.
78. Answer: c WHY: Prolonged tourniquet application causes stagnation of blood flow (venous stasis), which causes the plasma portion of the blood to filter into the tissues. This decreases blood plasma volume and increases nonfilterable blood components, a condition called hemoconcentration. To minimize the effects of hemoconcentration, the tourniquet should be released within 1 minute of application and the patient should not be allowed to continuously make and release (or pump) a fist.
79. The serum or plasma of a slightly hemolyzed specimen appears a. clear yellow. b. cloudy white. c. greenish yellow. d. pink to reddish.
79. Answer: d WHY: Hemolysis is the destruction of red blood cells and the liberation of hemoglobin into the serum or plasma portion of the specimen, causing it to appear pink to reddish depending on the degree of hemolysis. The specimen is described as being hemolyzed.
8. This is the medical term for a nervous system response to abrupt pain, stress, or trauma. a. Circadian response b. Iatrogenic reflux c. Vasovagal syncope d. Venous stagnation
8. Answer: c WHY: Vasovagal means "relating to vagus nerve action on blood vessels." Syncope is the medical term for fainting. Vasovagal syncope is sudden faintness or loss of consciousness resulting from a nervous system response to abrupt pain, stress, or trauma. Circadian means "having a 24-hour cycle." Iatrogenic means "an adverse condition brought on by the effects of treatment," and reflux means "backflow," as in the backflow of blood into a patient's vein during venipuncture. Venous stagnation or stasis is the stoppage of normal venous blood flow.
80. Which action is least likely to cause specimen hemolysis? a. Drawing a large tube using a small needle b. Mixing a blood specimen too vigorously c. Pulling back a syringe plunger too quickly d. Using a transfer device for a syringe draw
80. Answer: d WHY: Mixing tubes vigorously instead of gently inverting them, pulling blood into a syringe too quickly, and using a small-bore needle to collect blood into a large-volume tube can all result in hemolysis of the specimen. Transferring blood from a syringe to a tube using a transfer device should not cause hemolysis if done correctly.
96. Which illustration depicts what can happen if the vein is not anchored well? a. A b. H c. I d. J
96. Answer: d WHY: If a vein is not firmly fixed in the tissue or anchored well by the phlebotomist, the needle could slip to the side of the vein instead of into it (Fig. 9-13 . J. Needle beside the vein; caused when a vein rolls to the side.).
97. This illustration is an example of a situation that is the most likely to lead to legal issues. a. C b. E c. G d. J
97. Answer: b WHY: This illustration shows a needle that has passed partway through the vein (Fig. 9-13 E. Needle bevel partially through the vein; causes blood leakage into tissue.) and is allowing a hematoma to form beneath the vein. The nerve below the vein could be hit, which means there would be a sharp pain felt by the patient and the venipuncture would have to be immediately discontinued. Even if the underlying nerve is not hit by the needle, the blood pooling beneath the vein could cause a compression injury to the nerve. Both situations, if not handled appropriately, could lead to injury of the patient and possible legal action.
85. A needle that has gone through the back wall of the vein may cause a. a hissing sound when you engage the tube. b. blood to enter the tube slowly or not at all. c. reflux of specimen into surrounding tissue. d. the tube to fill with air that is in the tissues.
85. Answer: b WHY: If the needle penetrates part way through the bottom wall of the vein (Fig. 9-13 E. Needle bevel partially through the vein; causes blood leakage into tissue.), blood will enter the tube more slowly than usual because it is leaking into the tissues at the same time. If the needle bevel has penetrated all the way through the bottom wall (Fig. 9-13 F. Needle bevel completely through the vein; no blood flow obtained.), there may be no blood flow at all. Pulling back on the needle slightly is necessary to establish proper flow. A hissing sound indicates that the vacuum escaped from the tube, which can happen if the needle bevel backs out of the skin slightly, not when it goes through the vein. A needle penetrating through the back wall of a vein is not known to cause reflux of specimen into the tissues nor does it cause the tube to fill with air.
9. Small nonraised red or purple spots appear on the patient's skin below where the tourniquet has just been tied. What are they and what causes them? a. A rash from tying the tourniquet too tightly b. Bilirubin spots because the liver is diseased c. Dermatitis from an allergy to the tourniquet d. Petechiae due to capillary or platelet defects
9. Answer: d WHY: Petechiae (Fig. 9-4) are small, nonraised red-, purple-, or brownish-colored spots that appear on a patient's skin when a tourniquet is applied. The spots are due to a defect in the capillary walls allowing blood to leak into the skin. Some of the causes for petechiae are certain medications like aspirin, prolonged straining of the capillaries when vomiting or prolonged tourniqueting, and even some infectious diseases, such as strep throat.
94. The phlebotomist is quite certain the needle is in the vein, but there is no blood flowing to the tube. He can sense a slight needle vibration or quiver which reminds him of another time this happened. Which illustration shows what has happened? a. A b. G c. H d. I
94. Answer: d WHY: This illustration shows that the needle has become stuck in one of the valves in the vein (Fig. 9-13 I. Needle bevel penetrating a valve prevents blood flow.). Valves can cause an unusual problem for the phlebotomist if, in fact, the needle should pierce the valve tissue in the middle of the lumen.
60. Which patient should be asked to lie down during a blood draw? A patient with a a. central venous catheter. b. coagulation disorder. c. history of syncope. d. severe latex allergy.
60. Answer: c WHY: Syncope means "fainting." A patient with a history of fainting during blood collection should be asked to lie down during a blood draw.
1. The Preexamination/preanalytical phase of the testing process begins when a a. blood or body fluid specimen is collected. b. label is applied after specimen collection. c. specimen is submitted for processing. d. test is ordered by a patient's physician.
1. Answer: d WHY: Preexamination/Preanalytical means "prior to analysis." The preanalytical phase of the testing process includes all the steps taken before a specimen is analyzed. Consequently, it begins when the test is ordered and ends when testing begins.
10. Venous stasis is a. backflow of tissue fluid into a vein. b. stage 1 of the coagulterm-99ation process. c. stoppage of the venous blood flow. d. vein collapse from excess pterm-98ressure.
10. Answer: c WHY: Venous stasis (also called venostasis) is a condition in which the normal flow of blood through a vein is stopped or slowed. Stasis means "stopping, controlling, or standing." Venous means "relating to a vein."
24. Which of the following tests is most affected by altitude? a. Cholesterol b. Electrolytes c. Magnesium d. RBC count
24. Answer: d WHY: Red blood cells carry oxygen to the tissue cells. The oxygen content of the air decreases as the altitude increases. The decrease in oxygen content at higher altitudes causes the body to produce more red blood cells in order to fulfill the body's oxygen requirements.
25. Persistent diarrhea in the absence of fluid replacement may cause a. hemoconcentration. b. iatrogenic anemia. c. petechiae formation. d. red cell destruction.
25. Answer: a WHY: Persistent diarrhea without fluid replacement leads to dehydration, which is a decrease in total body fluid, including blood plasma. Blood components become concentrated in the smaller plasma volume, a condition called hemoconcentration.
26. You must collect a protime specimen from a patient with IVs in both arms. The best place to collect the specimen is a. above one of the IVs. b. below one of the IVs. c. from an ankle vein. d. from one of the IVs.
26. Answer: b WHY: It is preferred that blood specimens not be drawn from an arm with an intravenous (IV) line (Fig. 9-5). However, according to CLSI, a specimen can be drawn below an IV after it has been shut off for a minimum of 2 minutes. (A phlebotomist should never shut off an IV. It must be shut off by the patient's nurse.) It should be noted on the requisition that the specimen was drawn below an IV after it was shut off. The type of IV fluid should also be noted. Never draw above an IV because the specimen may be contaminated with IV fluid. Drawing blood specimens from ankle veins requires permission from the patient's physician and is not recommended for protimes or other coagulation specimens, or patients who have coagulation problems. Only nurses and other specially trained personnel are allowed to collect specimens from an IV.
29. This blood component exhibits diurnal variation, with peak levels occurring in the morning. a. Cortisol b. Creatinine c. Glucose d. Phosphate
29. Answer: a WHY: Diurnal variations are normal fluctuations throughout the day. Cortisol levels exhibit diurnal variation with highest levels occurring in the morning. Creatinine, glucose, and phosphate also exhibit diurnal variation; however, blood levels of these analytes are lowest in the morning.
3. Diurnal variations associated with some blood components are a. abnormal changes that occur once a day. b. changes that follow a monthly cycle. c. normal fluctuations throughout the day. d. variations that occur on an hourly basis.
3. Answer: c WHY: Diurnal means "happening daily." The levels of many blood components exhibit diurnal variations, or normal fluctuations or changes throughout the day. These normal variations are typically greatest between early morning and late afternoon.
30. Tests influenced by diurnal variation are typically ordered a. fasting. b. preop. c. STAT. d. timed.
30. Answer: d WHY: For consistency in evaluating or comparing results, tests that exhibit diurnal variation or fluctuations throughout the day are often ordered for a specific time of day. The requested time of collection is typically a time when the highest level of the analyte is expected.
31. A drug known to interfere with a blood test should be discontinued for how many hours before the test specimen is collected? a. 1 to 3 b. 4 to 24 c. 25 to 30 d. 48 to 72
31. Answer: b WHY: According to College of American Pathologists (CAP) guidelines, drugs known to interfere with blood tests should be stopped or avoided for 4 to 24 hours (depending on the drug) before specimens for the affected tests are collected. Drugs that interfere with urine tests should be stopped 48 to 72 hours before specimen collection.
34. Which hormone is most affected by the presence of a fever? a. Insulin b. Melatonin c. Testosterone d. Thyroxine
34. Answer: a WHY: Hypoglycemia caused by fever increases insulin levels followed by a rise in glucagon levels. Melatonin levels are affected by light, increasing at night when it is dark and decreasing during daylight hours. Testosterone exhibits diurnal variation with highest levels occurring in the morning. Thyroxine is a hormone that is secreted by the thyroid and increases the metabolic rate.
35. Which analyte has a higher reference range for males than for females? a. Cholesterol b. Hematocrit c. Magnesium d. Potassium
35. Answer: b WHY: A patient's sex has a determining effect on the concentration of some blood components. These differences are reflected in separate male and female reference ranges for certain analytes. For example, males tend to have greater muscle mass and normally have higher red blood cell counts to supply the muscles with oxygen. Consequently, red blood cell counts and related tests such as hematocrit and hemoglobin have higher reference ranges for males. The hematocrit is a measure of the percentage of a specimen that is red blood cells.
36. An icteric blood specimen indicates a. bilirubin test results could be elevated. b. it probably was not a fasting specimen. c. the collection procedure was incorrect. d. the blood could be hemoconcentrated.
36. Answer: a WHY: Icterus (also called jaundice) is a condition characterized by increased bilirubin in the blood and other body fluids and deposits of the yellow pigment in the skin, mucous membranes, and sclera (whites of the eyes), giving the patient a yellow appearance. Body fluid specimens with high bilirubin levels have an abnormal deep yellow to yellow-brown color, and are described as being icteric. The presence of icterus is not related to a patient's fasting state, the collection procedure, or hemoconcentration.
38. Why do pregnant patients have lower reference ranges for red blood cell (RBC) counts? a. Frequent bouts of nausea lead to hemoconcentration. b. Increased body fluids result in dilution of the RBCs. c. Poor appetite results in a temporary form of anemia. d. The growing fetus uses up the mother's iron reserves.
38. Answer: b WHY: Normal body fluid increases in pregnancy include an increase in blood plasma levels. The increased volume of plasma has a dilution effect on the red blood cells (RBCs), reducing RBC count results. Consequently, the reference ranges for RBC counts on pregnant women are lower than for women who are not pregnant. Hemoconcentration would elevate RBC counts. Anemia from poor appetite or inadequate iron reserves represent situations that typically result in abnormal patient results that are lower than reference ranges.
39. Which of the following analytes is typically increased in chronic smokers? a. Bicarbonate b. Hemoglobin c. O2 saturation d. Vitamin B12
39. Answer: b WHY: Chronic smokers have impaired ability to transport oxygen to the cells because as much as 10% of their hemoglobin is bound to carbon monoxide acquired from cigarette smoke. The body compensates for this by increasing the number of red blood cells. Consequently hemoglobin, which is a component of red blood cells, typically increases also. Bicarbonate, O2 saturation, and vitamin B12 levels are usually decreased in chronic smokers.
41. Of the following factors known to affect basal state, which is automatically accounted for when reference ranges are established? a. Diurnal variation b. Drug interferences c. Effects of exercise d. Geographic locale
41. Answer: d WHY: Reference ranges for specimens are established using basal state specimens. Environmental factors associated with geographic location do affect basal state. However, because all the specimens used to calculate reference ranges come from individuals in that location, geographical factors are usually automatically reflected in the reference range values.
4. A patient's arm is swollen. The term used to describe this condition is a. cyanotic. b. edematous. c. sclerosed. d. thrombosed.
4. Answer: b WHY: Edema is the accumulation of fluid in the tissues, characterized by swelling. An extremity with edema is described as being edematous. Cyanotic means "marked by cyanosis, or bluish in color from lack of oxygen." Sclerosed means "hardened." Thrombosed means "clotted." Sclerosed and thrombosed are terms used to describe damaged veins.
42. Temperature and humidity control in a laboratory is important because it a. ensures the test results will be normal. b. maintains the integrity of specimens. c. prevents any interference from drugs. d. reduces the chance of aerosol release.
42. Answer: b WHY: Temperature and humidity are known to affect test values. Closely controlling these environmental factors in a clinical laboratory standardizes the test environment, and helps ensure specimen integrity and proper functioning of equipment. Controlling temperature and humidity can help ensure accuracy of test results. It does not ensure that test results will be normal or lessen drug interference in testing. Aerosol release usually results from improper stopper removal technique.
43. Scarred or burned areas should be avoided as blood collection sites because a. analytes are diluted in such areas. b. circulation is possibly impaired. c. specimens tend to be hemolyzed. d. veins are most likely thrombosed.
43. Answer: b WHY: Scarred and burned areas should be avoided as blood collection sites because circulation in these areas could be impaired. This can result in hemoconcentration, which can concentrate, not dilute analytes. Veins do not normally become sclerosed or thrombosed due to scarring or burns. Hemolyzed specimens typically result from collection errors, not from scars or burns on the arm.
44. A vein that feels hard, cordlike, and lacks resiliency is most likely a. an artery. b. collapsed. c. sclerosed. d. superficial.
44. Answer: c WHY: The word root scler means hard. A vein that feels hard, cordlike, and lacks resiliency is said to be sclerosed. An artery has a pulse that can be felt, which easily distinguishes it from a vein since a vein has no pulse. A collapsed vein typically cannot be felt at all even if it is superficial which means close to the surface of the skin.
53. This is a permanent vascular access pathway that is surgically created to provide access for dialysis. a. AV shunt b. CVC c. Saline lock d. PICC
53. Answer: a WHY: The surgically created connection of an artery and a vein in the forearm is called an AV shunt (Fig. 9-6 refer to #40) and is most commonly created to provide access for dialysis. A dialysis shunt created by direct permanent fusion of the artery and vein is called a fistula (Fig. 9-6A) and is visible as a large bulging section of vein. If the shunt was created using a piece of vein or tubing to form a loop from the artery to the vein that can be seen under the skin it is called a graft (Fig. 9-6B). A central venous catheter (CVC) is a line inserted into a large vein and advanced into the superior vena cava proximal to the right atrium (Fig. 9-9). It is used to administer medications and sometimes draw blood specimens. A saline lock (Fig. 9-7 refer to #47) is a special winged needle set or cannula that can be left in a patient's arm for up to 48 hours and used to administer medications and draw blood. A peripherally inserted central catheter (PICC) (Fig. 9-10 A. Peripherally inserted central catheter (PICC) placement. B. Power PICC®.) is inserted into the peripheral venous system (veins of the extremities) and threaded into the central venous system (main veins leading to the heart).
54. Collecting blood specimens from an arm on the same side as a mastectomy without permission from the patient's physician is prohibited because a. results on that arm will be elevated. b. that arm is susceptible to infection. c. there is a lot less feeling in that arm. d. veins in that arm will collapse easily.
54. Answer: b WHY: Blood should never be collected from an arm on the same side as a mastectomy (breast removal) without first consulting the patient's physician. Lymphostasis (stoppage of lymph flow) that can occur when lymph nodes have been removed leaves the area susceptible to infection. It is thought that test results could be affected by lymphedema due to lymphostasis, but not necessarily elevated. The patient won't necessarily have less feeling in that arm. Veins in that arm do not necessarily collapse readily.
59. What is the best thing to do if a venipuncture site continues to bleed after 5 minutes? a. Have the patient hold pressure until it stops. b. Make a note of the problem on the lab slip. c. Report it to the patient's physician or nurse. d. Wrap the site with a tight pressure bandage.
59. Answer: c WHY: A site that continues to bleed 5 minutes after venipuncture is not normal. The patient's nurse or physician must be notified so the situation can be addressed. Continue to apply pressure and do not dismiss an outpatient or leave an inpatient until bleeding has stopped or the appropriate personnel have taken charge of the situation. Never wrap a pressure bandage around a site in lieu of holding pressure. Always check the site before applying a bandage. Otherwise you will not know if bleeding has stopped.
6. A patient with a high degree of jaundice typically has a. bruising and petechiae. b. edematous extremities. c. hemolyzed specimens. d. yellow skin and sclera.
6. Answer: d WHY: Jaundice, also called icterus, is a condition characterized by increased bilirubin (a product of the breakdown of red blood cells) in the blood, leading to deposits of yellow bile pigment in the skin, mucous membranes, and sclera (whites of the eyes), giving the patient a yellow appearance.
61. During a blood draw an outpatient says he feels faint. What should the phlebotomist do? a. Ask him if it is OK to continue the draw. b. Discontinue the draw and lower his head. c. Keep him upright and complete the draw. d. Use an ammonia inhalant to revive him.
61. Answer: b WHY: If an outpatient feels faint during blood collection, discontinue the draw immediately and lower his or her head. Do not ask the patient if you should continue. You should not continue the draw, even if the patient wants you to do so. The use of ammonia inhalants is not recommended as they can have adverse side effects such as respiratory distress in asthmatic individuals.
62. An outpatient becomes weak and pale after a blood draw. What should the phlebotomist do? a. Accompany the patient to his or her car. b. Have the patient lie down until recovered. c. Offer the patient a glass of water to drink. d. Tell the patient to go get something to eat.
62. Answer: b WHY: An outpatient who becomes weak and pale following a draw may faint and should be asked to lie down until he or she recovers. If the patient cannot be moved from the chair, lower his or her head and apply a cold compress or wet washcloth to the back of the neck. Do not allow the patient to leave until 15 minutes after recovery. The patient should not drive for at least 30 minutes.
66. Which of the following situations is least likely to cause contamination of the specimen? a. Cleaning a finger stick site with isopropyl alcohol b. Drawing the median vein when the hand has an IV c. Touching the filter paper while collecting a PKU d. Using povidone-iodine to clean a heel puncture site
66. Answer: a WHY: Cleaning a skin puncture site with isopropyl alcohol is the accepted technique. Collecting blood from the median vein above an IV may contaminate or dilute the specimen with IV fluid. Touching the filter paper while collecting a phenylketonuria (PKU) specimen can be a source of contamination that leads to erroneous results. Povidone-iodine should not be used to clean skin puncture sites because it interferes with phosphorus, potassium, and uric acid test results.
7. Lymphostasis is a. impaired secretion of lymph fluid. b. obstruction of the flow of lymph. c. reduced lymphocyte production. d. stoppage of lymphoid functions.
7. Answer: b WHY: Stasis means "stopping, controlling, or standing." Lymphostasis is defined as the obstruction or stoppage of the flow of lymph (lymph fluid).
70. A term used to describe anemia brought on by withdrawal of blood for testing purposes is a. hemolytic. b. iatrogenic. c. icteric. d. neutropenic.
70. Answer: b WHY: Iatrogenic is an adjective used to describe an adverse condition brought on by the effects of treatment. Blood loss as a result of removal for testing purposes is called iatrogenic blood loss. Removal of blood on a regular basis or in large quantities can lead to anemia in some patients, especially infants.
77. Which of the following is least likely to impair vein patency? a. Improperly redirecting the needle b. Leaving a tourniquet on too long c. Multiple draws to the same vein d. Probing to locate a missed vein
77. Answer: b WHY: Leaving the tourniquet on too long is not likely to impair vein patency (state of being freely open). It may, however, lead to erroneous test results caused by hemoconcentration brought on by prolonged blockage of blood flow. Improperly redirecting the needle, probing for deep veins, and performing numerous venipunctures in the same area are all actions that can damage veins and impair vein patency.
81. Which of the following can cause a hematoma to form because of a blood draw? a. Entering the lumen of the vein without hesitation b. Failing to apply adequate pressure after the draw c. Mixing the first tube while collecting the second d. Removing the tourniquet as the first tube is filling
81. Answer: b WHY: Hematoma formation can be caused by several different errors in phlebotomy technique, including failure to apply adequate pressure to the site after a blood draw, leakage of blood from a vein because the needle is only partly inserted in the vein (Fig. 9-13 D. Needle bevel partially into the vein; causes blood leakage into tissue.), and leakage of blood from a hole made by a needle that penetrated through the back wall of the vein (Fig. 9-13 F. Needle bevel completely through the vein; no blood flow obtained.) during needle entry or the collection process. A needle bevel that enters the lumen of the vein is right where it should be (Fig. 9-13. A. Correct needle position; blood can flow freely into the needle.) and would not be the cause of hematoma formation. Mixing one tube while filling another, and removing the tourniquet as the first tube is filling are accepted procedures and would not cause a hematoma.
82. You are in the process of collecting a blood specimen on a patient with difficult veins. You had to redirect the needle, but it is now in the vein, and the first tube has just started to fill. The blood is filling the tube slowly. The skin around the venipuncture site starts to swell. You have several more tubes to fill. What should you do? a. Ask the patient if it hurts; if not, continue the draw b. Continue the draw after pushing the needle in deeper c. Pull back on the needle slightly and finish the draw d. Stop the draw at once and apply pressure to the site
82. Answer: d WHY: Blood filling the tube slowly is a sign that the needle bevel is not completely within the vein (Fig. 9-13 D. Needle bevel partially into the vein; causes blood leakage into tissue., E. Needle bevel partially through the vein; causes blood leakage into tissue. Refer to #83.), which allows blood to leak into the tissues. A hematoma, the most common venipuncture complication, is caused by blood leaking into the tissues and identified by swelling at or near the venipuncture site. It is painful to the patient, results in unsightly bruising (Fig. 9-1), and can cause compression injuries to nerves and lead to lawsuits. If a hematoma starts to form during blood collection, immediately release the tourniquet, withdraw and discard the needle, and hold pressure over the site for a minimum of 2 minutes.
83. A vein with walls that have temporarily drawn together and shut off blood flow during venipuncture is called a(an) a. blown vessel. b. collapsed vein. c. reflux reaction. d. inactive fistula.
83. Answer: b WHY: A vein is said to be collapsed (Fig. 9-13 K. Collapsed vein prevents blood flow despite correct needle position.) when its walls temporarily retract, cutting off blood flow. A vein can collapse if the tube being drawn has too much vacuum, a syringe plunger is pulled back too quickly, or the tourniquet is tied too tightly or too close to the site. It can also collapse when the tourniquet is removed during the draw, especially if the tourniquet was too tight and inflated the vein excessively. A blown vein results from a small tear or enlarged hole at the site of needle entry that causes blood to escape quickly and the vein to collapse as a result. A reflux reaction is a patient reaction to the backflow of a tube additive into his or her vein during venipuncture. The type of fistula of importance to phlebotomists is the artificial connection between an artery and a vein. An AV fistula can last for many years, but occasionally they get plugged or clotted and will not function. If not fixable, a new one will be created and the old one will become inactive, and may be left in place.
84. You are collecting a blood specimen. The needle is in the vein and blood flow has been established. As the tube is filling, you hear a hissing sound, there is a spurt of blood into the tube, and blood flow stops. What most likely happened is the a. bevel came out of the skin and the tube vacuum escaped. b. needle went all the way through the back wall of the vein. c. patient had a sudden and dramatic drop in blood pressure. d. tube had a crack in it and there was no more vacuum left.
84. Answer: a WHY: When the vacuum escapes from an evacuated tube during blood collection, it typically makes a hissing sound. This can happen if the needle bevel backs out of the skin even slightly (Fig. 9-13 C. Needle bevel partially out of the skin; tube vacuum will be lost.), allowing the tube to draw air instead of blood. If the needle penetrates all the way through a vein, the tube will not draw blood but the vacuum will still be intact because the bevel is under the skin. A drop in a patient's blood pressure would not cause a hissing sound. A tube with a crack in it and no vacuum would not draw blood or make a hissing sound because the vacuum was gone before the draw was even started.
86. When a vein rolls, the needle typically a. ends up in the lumen of the vein. b. goes all the way through the vein. c. lands against an inside vein wall. d. slips beside instead of in the vein.
86. Answer: d WHY: Healthy vein walls are sturdy. If a vein is not anchored well, it may roll (move away) slightly and the needle may slip beside the vein (Fig. 9-13 J. Needle beside the vein; caused when a vein rolls to the side.) instead of going into it. The lumen of a vein is the hollow portion through which the blood flows. A needle bevel should end up in the lumen of the vein during venipuncture (Fig. 9-13 A. Correct needle position; blood can flow freely into the needle.). A needle can go through a vein (Fig. 9-13 E. Needle bevel partially through the vein; causes blood leakage into tissue., F. Needle bevel completely through the vein; no blood flow obtained.) if it is inserted too quickly or deeply, and if the tube holder is not held securely during the draw (e.g., when pushing a tube onto the needle). The needle bevel can end up against an inside wall of the vein if the needle enters it at an angle that is too shallow, if there is a bend in the vein (Fig. 9-13 G. Needle bevel against the upper vein wall prevents blood flow.), or if the bevel is down (Fig. 9-13 H. Needle bevel against the lower vein wall prevents blood flow.) instead of up when it enters the vein.
87. You are in the process of collecting a blood specimen. The needle is inserted but the tube is filling very slowly. A hematoma starts forming rapidly. What has most likely happened is the a. needle is only partly in the vein. b. needle is up against a vein wall. c. patient has a clotting disorder. d. tube is slowly losing vacuum.
87. Answer: a WHY: If the needle bevel is only partially inserted in the vein during blood collection (Fig. 9-13 D. Needle bevel partially into the vein; causes blood leakage into tissue. ), the tube will fill very slowly and blood will leak into the tissue around the vein, causing a hematoma.
88. You are performing a multitube blood draw. You collect the first tube without a problem. The second tube fails to fill with blood. You pull the needle back and nothing happens. You push the needle a little deeper and nothing happens. You remove the tube, pull back the needle a little, rotate the bevel, and reset the tube. Still nothing happens. Which of the following actions should you take next? a. Discontinue the draw and try at another site. b. Let someone else take over and give it a try. c. Redirect the needle until you get blood flow. d. Try a new tube in case it is a vacuum issue.
88. Answer: d WHY: Failure to achieve blood flow in a second tube after the first tube filled without a problem initially suggests that the needle position could have changed slightly when the tube was removed and replaced. If this had been the case, however, blood flow would have been reestablished with slight manipulation of the needle. This suggests there could be a problem with the tube. Always try a new tube before giving up on a blood draw. Further redirections of the needle amount to probing and should not be done.
89. You insert the needle during a venipuncture. You engage the tube in the tube holder, but do not get blood flow. You determine that the needle is beside the vein. You redirect it two times and still do not get blood flow, even after trying a new tube. What should you do next? a. Anchor the vein and redirect the needle again. b. Ask a coworker to redirect the needle for you. c. Discontinue the draw and try again at a new site. d. Try pushing the needle deeper and then redirect.
89. Answer: c WHY: Multiple redirections of the needle while attempting venipuncture amount to probing, which is dangerous and should not be done, even if a second phlebotomist takes over the draw for you. If you cannot obtain blood flow with one or two redirections of the needle, discontinue the draw and try again at a new site.
90. Which of the following is most apt to be the cause of vein collapse during venipuncture? a. Several large-volume tubes have been collected. b. Tourniquet application has exceeded 1 minute. c. Tourniquet pressure is below diastolic pressure. d. Tube vacuum is too much for the size of the vein.
90. Answer: d WHY: A vein may collapse (Fig. 9-13 K. Collapsed vein prevents blood flow despite correct needle position.) if the tube being drawn has too much vacuum for the size of the vein. Tourniquet application exceeding a minute is not good for the specimen, but does not normally cause the vein to collapse. Tourniquet pressure is not usually measured, but when a blood pressure cuff is used as a tourniquet it should be maintained below diastolic blood pressure. Filling several large volume tubes should not cause a normal vein to collapse if proper procedures were followed for equipment selection and vein selection.
91. A bariatric tourniquet is used for a. ABG collection. b. difficult draws. c. obese patients. d. All the above.
91. Answer: c WHY: Bariatric means pertaining to the treatment of obesity, but the term is also used as a polite way to refer to individuals and items for individuals who are extremely overweight whether or not they are actually being treated for obesity. Consequently, a bariatric tourniquet is an extra-large size tourniquet designed for use on obese patients. A tourniquet is not used for arterial blood gas (ABGs) or any other arterial specimens. Obese patients may be difficult draws but not all difficult draws are obese patients.
92. An injury referred to as "Claw hand" can be caused by a. arterial thrombosis. b. infection of a vein. c. ulnar nerve injury. d. vasovagal syncope.
92. Answer: c WHY: Nerve injury is a serious phlebotomy complication that can result in permanent damage to motor or sensory nerve function of the arm or hand. The condition referred to as "Claw hand" (Fig. 9-14) can be caused by a direct or compression injury to the ulnar nerve. Nerve compression injuries can occur from blood pooling and clotting beneath the vein because of accidental arterial puncture or blood leaking from the vein because the needle went all the way through it on initial needle entry.
93. A quadriplegic patient a. can feel pain if there is no sensory damage. b. cannot speak due to upper body paralysis. c. is paralyzed only from the waist down. d. must have blood drawn by a physician.
93. Answer: a WHY: A person who is paralyzed in both arms and legs is called a quadriplegic. Paralysis is the loss of muscle function. A person who is paralyzed can feel pain if there is no sensory damage. Quadriplegics can speak if the paralysis is only from the neck down. Phlebotomists can draw quadriplegic patients although the loss of muscle function can result in stagnation of blood flow and an increased chance of vein thrombosis that is magnified by venipuncture. Consequently, strict venipuncture procedures must be followed (e.g., no probing or lateral needle redirection) and firm pressure must be held over the site after the draw until it is certain that blood flow has ceased.
98. Correcting the situation in this illustration involves slowly pulling back the needle until blood flow is established. a. B b. G c. J d. K
98. Answer: b WHY: The veins in our arms are not predictably straight. This illustration shows the needle bevel up against an unexpected bend in the vein (Fig. 9-13 G. Needle bevel against the upper vein wall prevents blood flow.). (In this case the needle bevel could also end up slightly in the vein wall.) This means that there may be very little or no blood entering the needle. The phlebotomist must first release the tube so there is no vacuum pull on the vein that could damage it. Then slowly pull back the needle until the bevel is in the center of the vein and blood flow is established.
99. If what this illustration depicts starts to happen, the venipuncture should be terminated immediately. a. D b. F c. H d. I
99. Answer: a WHY: A swelling or lump on the outside of the arm around the needle indicates that the needle is not all the way in the vein and a hematoma is forming (Fig. 9-13 D. Needle bevel partially into the vein; causes blood leakage into tissue.). This means that the needle must be withdrawn immediately, pressure applied, and the hematoma treated.
