NCCT Phleb. Review Answers

NCCT Phleb.
Review Answers PG 1
Preliminary Exam - 150 Q’s Answers
1. Biohazard waste container
a. 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.
2. Identify the patient
a. 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.
3. SST, royal blue, gray
a. Rationale: Blood collection tubes are color coded to indicate their chemical
contents. The Clinical Laboratory Standards Institute (CLSI) defines the order of
drawing these tubes to prevent carryover of the contents from one tube to the
next. A small amount of the chemical may be retained on the inner needle or
rubber sleeve of the ETS system and contaminate the next tube thereby affecting
patient results. The order is (for the most commonly used tubes): sterile (blood
cultures), sodium citrate (blue), serum ( red or gold with or without clot activator
or gel separator), heparin (green), EDTA (purple), sodium fluoride & potassium
oxalate (gray). It is also important to know the order of draw by the contents of
the tubes as there are many infrequently used colors that may use the same
anticoagulants as more common ones. As an example, pink, tan and royal blue
tubes contain EDTA. In this case, the phlebotomist should draw an SST (serum
separator) for the calcium, royal blue (EDTA) for the lead and gray (sodium
fluoride & potassium oxalate) last. Lead levels can also be drawn in a tan top
tube. Lead levels can also be drawn in a tan top tube (use royal blue or tan in
accordance with the testing laboratory requirements).
4. Light blue
a. Rationale: A light blue top tube contains buffered sodium citrate, an additive that
removes calcium to prevent blood from clotting.
5. The Patient's Bill of Rights.
a. 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.
6. The phlebotomist may perform venipuncture provided he is wearing a mask and afebrile.
NCCT Phleb. Review Answers PG 2
a. 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.
7. Light blue top
a. Rationale: Sodium citrate (light blue top tube) is the anticoagulant of choice for
coagulation studies such as PT/INR (Protime/International Normalization Ratio)
because it does not bind to calcium or inactivate heparin, which may be required
to be present in such testing. Lavender top tubes contain EDTA as the
anticoagulant, which does bind calcium. Green top tubes contain heparin and
could lead to inaccurate coagulation studies.
8. Communicate the test order to the nursing staff and wait for one of them to collect the
sample.
a. Rationale: A central port is a central venous catheter inserted into a vein in the
chest and threaded through until it reaches the heart. Central ports and other
vascular access devices (VADs) provide direct access to a patient's circulation in
order to administer medication and fluids as well as to withdraw blood on a
routine basis. Any vascular access device poses an infection risk and every
measure must be taken to reduce the risk of nosocomial/healthcare associated
infections (HAIs). It is critical that only trained healthcare professionals withdraw
blood from vascular access devices. Nurses and physicians are generally the
ones to perform this task as they are trained to care for and maintain vascular
access devices in order to maintain patency (prevent occlusion) in the catheter
and reduce risk of infection. Therefore, it is best to communicate the test order to
the nursing staff and wait for one of them to collect the sample. Orders must be
confirmed with nurses and physicians, not the patient. Proper and effective
communication is critical in a healthcare setting and is one of The Joint
Commission’s annual National Patient Safety Goals. Phlebotomists must
communicate with the nursing staff before proceeding to the next patient.
9. Gently invert the tube after collecting the specimen.
a. Rationale: Since an EDTA tube contains anticoagulant, it is important to
immediately mix the blood as soon as it is collected to ensure that it doesn't clot.
The phlebotomist should gently invert the tube after collecting the specimen to
maintain specimen integrity and prevent rupture of RBCs in the sample. The
smaller gauged needles would introduce a higher likelihood of hemolysis, not
prevent it. Refrigerated storage would not necessarily prevent immediate
hemolysis (but would slow down the breakdown of RBCs that would cause
hemolysis over time). The tube should be gently mixed immediately after
collection and can be processed and run as soon as needed (it does not need to
stand for 20 minutes).
10. Distal to the IV
a. Rationale: Drawing from an arm on the side which has had a mastectomy may
cause lymphedema and should not be used. If there is an active IV in the other
arm, blood may be drawn as far below it as possible. If the IV is close to the
hand, the phlebotomist may ask the nurse to turn it off for two minutes prior to the
draw. Another option, if a small amount of blood is needed and the test requests
allow, is a dermal puncture of one of the fingers of the right hand.
11. Yellow, light blue, lavender, gray
a. Rationale: Blood culture is collected using the Sterile yellow/Yellow tube
containing anticoagulant SPS. SPS helps to facilitate 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.
12. Chain-of-custody
a. Rationale: A Chain-of-custody form is used to maintain a legal record of
individuals who have had physical possession of the specimen. It prevents the
possibility of tampering. An Advance Directive is a legal document that allows
someone to spell out medical decisions about end-of-life care ahead of time.
Informed Consent recognizes the need of a patient to know about a procedure,
surgery, or treatment, before deciding whether to have it. No medical information
may be released without proper authorization (Medical Release form) from the
patient or legal guardian, currently dated and signed.
13. Throw the entire assembly into a sharps container.
a. Rationale: The evacuated tube system (ETS) or syringe system with attached
needle and safety device are designed for a single use and are to be placed as a
unit into a sharps container upon the completion of the venipuncture procedure.
Needles should not be removed from ETS holders. The needle may be removed
from the syringe only after the needle safety device has been activated to allow
for the attachment of a transfer device. None of this equipment is to be placed
into a biohazard bin or bedside trash.
14. Disposing of extra patient tube labels in a regular trash can
a. 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 a 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.
15. .0.5% chlorhexidine
a. Rationale: To minimize the risk of contamination by normal skin flora, sites for
blood culture collection require a 30 – 60 second scrub to access the bacteria
beneath the dead skin cells in the area. Although not appropriate for infants
under 2 months of age, chlorhexidine gluconate has become the antiseptic of
choice. Isopropyl alcohol may be used but requires a longer scrub with at least
two pads. Isopropyl alcohol is used to clean the tops of the cultures bottles before
inoculation with blood. Preparations of iodine such as 2% povidone should not be
used on those sensitive to iodine as they may provoke allergic reactions.
Hydrogen peroxide is not considered effective for blood culture site cleansing.
Whichever antiseptic is used, it is important to allow the area to air dry and not to
retouch the site before performing the venipuncture.
16. Before putting on gloves prior to venipuncture
a. 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.
17. 15-30 degrees.
a. Rationale: The correct angle of insertion for venipuncture is 15 to 30 degrees
regardless of the size of the patient. 10 degrees is too low and risks missing the
vein, while 45 degrees is too high and might allow the needle to go through the
vein. If the vein is very deep, as is often the case in obese patients, the
phlebotomist might have to go farther into the arm but the angle remains the
same.
18. Checking expiration dates, recording refrigerator temperatures, running controls on POC
testing
a. Rationale: Quality control procedures are used to verify that equipment is within
certain criteria to ensure accurate specimen collection, testing and patient
results. If expiration dates on ETS tubes are exceeded, adequate vacuum and
viable contents cannot be guaranteed. Refrigerator temperatures must be within
range to keep reagents and specimens at correct temperatures. Controls must be
run in the same manner as patient tests on POC test processes to ensure these
systems are performing correctly. All QC results must be clearly documented and
any outliers investigated and corrective action taken. Calibration of lab equipment
and recording abnormal patient results is the job of technologists.
19. Gloves, gown, mask
a. 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.
Gowns 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
20. Use a broom and dustpan to sweep up the glass and fragments and place in a sharps
container.
a. Rationale: To prevent exposure to potentially infectious materials, a broom and
dustpan 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.
21. 2.0 mm or less
a. 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, 2.4 mm or less is the most appropriate response. 2.5 cm and
2.4 cm are equal to 25 mm and 24 mm, 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). Deeper puncture may only be appropriate in
performing capillary puncture on adults with excessive scarring and calluses on
the fingers. Calluses are often the result of manual work and are 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.
22. Granted implied consent.
a. Rationale: Informed consent is the agreement of the patient to a medical
procedure after having the procedure explained and being given the chance to
ask questions. The patient must be competent and consent voluntarily. Implied
consent is given by a patient’s actions – such as extending the arm, or if the
situation is an emergency. In the above case, the patient has legally granted
implied consent. However, if further explanation or questions arise, a trained
medical interpreter must be found. Expressed consent is permission for
something that is given specifically, either verbally or in writing and would be
documented in the chart or medical record.
23. Falsely elevated K levels from tissue damage
a. 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
decreased platelet count since platelets are used to form a clot.
24. 23 g Vacutainer and a lavender top tube
a. Rationale: A 23-gauge needle is preferred for pediatric patients. Avoid gauges of
25 or more because these may be associated with an increased risk of
hemolysis. Lavender tops indicate a CBC draw.
25. Choose a different collection site.
a. Rationale: The detection of a vibration sensation indicates the presence of an
arteriovenous (AV) fistula. AV fistulas can develop almost anywhere in the body,
but they are often created through a surgical procedure and are used for patients
who require dialysis. AV fistula is a surgical fusion of an artery and a vein that
allows for the vein to increase in diameter and develop thicker walls. Since veins
have a tendency to develop scar tissues after repeated venipunctures, an AV
fistula with thicker walls and larger size allows for easy needle entry even with
repeated venipunctures. The AV fistula is considered to be the patient’s “lifeline”
as it allows for blood to be filtered through an “external kidney” machine called a
hemodialyzer, which will maintain electrolyte balance, remove waste, and help
maintain normal blood pressure. Only trained dialysis technicians and physicians
are allowed to access the AV fistula. Phlebotomists must not access the AV
fistula or any veins located on the same arm as the AV fistula. Instead, use the
opposite arm for venipuncture.
26. Remove the needle and tourniquet.
a. Rationale: The procedure should be discontinued immediately, with the initial
step of releasing the tourniquet. The needle would also need to be removed, but
the tourniquet should be removed first because it is causing pressure to the vein.
Since the needle is being removed, activating the needle safety mechanism
before removing the tourniquet would not be appropriate. The phlebotomist
should not continue obtaining the specimen, because the patient is clearly not
tolerating the procedure.
27. Implied consent.
a. Rationale: Venipuncture on a non-responsive patient in an emergency
department constitutes implied consent. Implied consent is not a verbal consent
and is not explicitly given by the patient; instead it is implicitly given by the
patient’s body language, actions or situation. Non-responsive patient in an
emergency department constitutes a situation where all measures are taken with
the patient’s best interests in mind and permission is assumed. Expressed
consent is a consent that requires verbal and often written agreement to receive
treatment involving high-risk surgeries and experimental medication after all the
risks and benefits have been discussed with and understood by the patient.
Informed consent is a consent that requires verbal agreement to receive
treatment for a medical procedure or a treatment. Refusal of consent is an
explicit denial to receive medical care and is supported by the Patient’s Bill of
Rights.
28. Hemolysis
a. 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.
29. 1.00 mm lancet
a. 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 a 1.00 mm lancet to prevent bone
injury and excessive discomfort. a 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 the patient to
stay perfectly still, which is not possible with infants.
30. N95 Respirator
a. Rationale: Airborne infections are carried by droplet nuclei particles smaller than
5 um and include tuberculosis, measles, chickenpox and mumps. Protection from
these microbes requires an N95 respirator. Gloves are worn as part of PPE under
standard precautions. A face shield is typically used to protect the wearer from
splashes of blood or other body fluids that might enter the eyes or mucous
membranes of the face.
31. Lavender, green, red
a. 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 gasses, EDTA tubes, Other
additive tubes, then Serum tubes.
32. Light blue, sodium citrate
a. Rationale: An INR test refers to an International Normalized Ratio, which
provides a standardized method of reporting prothrombin time results by
comparing the ratio of the patient prothrombin time to the control prothrombin
time. This, in turn, helps to standardize the method of reporting the effects of oral
anticoagulant therapy on blood clotting. It uses the light blue tube with sodium
citrate as it would for a regular prothrombin time (Pro Time) test.
33. Capillary using heel puncture lancet
a. 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).
34. Perform regular hand hygiene
a. Rationale: Performing regular hand hygiene is the first of preventative measures
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.
35. Sodium fluoride
a. Rationale: Blood cells will continue to metabolize glucose in the collection tube
which will decrease the result. Sodium fluoride is added to a gray top tube to
prevent glycolysis and stabilize the glucose result. It acts on the enzyme enolase
and interrupts the glycolytic pathway. Glucose in a gray top tube can remain
stable for up to three days. Sodium citrate (light blue top), potassium oxalate
(gray top) and EDTA (lavender top) are all anticoagulants that prevent blood
samples from clotting in the tubes.
36. Horizontal or vertical back-and-forth friction
a. Rationale: 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 inserting the needle into the
patient. 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.
37. Apply a warm compress to the area for 5 minutes.
a. Rationale: The phlebotomist should apply a warm compress to the area for 5
minutes. Warm moist heat promotes circulation and vasodilation and will help
make the vein more visible. Tapping the arm or dangling the arm will not cause
the vein to be as prominent as applying a warm compress. Applying firm
pressure to the arm will occlude the blood flow and will not make the vein more
prominent.
38. Elevate the arm while applying pressure.
a. 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.
39. Standard and Airborne Precautions
a. Rationale: Universal precautions (1980s) were introduced to protect health care
workers from bloodborne pathogens. These rules were updated to Standard
precautions (1996) to combine the use of PPE with hand hygiene and apply to
blood, all body fluids, non-intact skin or mucous membranes. Transmission
based isolation precautions are a subset of Standard Precautions designed by
how infectious agents are spread. There are three categories. Contact requires
gloves and gown, droplet requires a mask and eye protection (goggles), and
airborne requires an N95 respirator with the patient placed in a negative airflow
environment.
40. Medical asepsis
a. 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.
41. Decreased red blood cell count
a. 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.
42. CLIA
a. Rationale: Clinical Laboratory Improvement Amendments (CLIA) are laws put in
place to ensure quality assurance standards for medical laboratories, and
enforced by the Department of Health and Human Services. HIPAA (Health
Insurance Portability and Accountability Act) is a set of regulations put in place to
ensure confidentiality of health insurance; also making it easier for a person to
keep their health insurance if they change or lose jobs. The DEA is a United
States federal law enforcement agency under the U.S. Department of Justice.
OSHA standards are established minimum health and safety standards for
workers and provide for the inspection of places of employment and the
penalizing of employers who do not provide conditions that meet the established
standards.
43. Explain the procedure and reassure the child that the parent can stay with her.
a. Rationale: Performing a venipuncture on a school age child requires age related
competencies and understanding of the needs of various age groups. It is best to
explain the procedure in simple terms and reassure the child that the parent can
stay with her. It is important to always speak directly with the patient regardless of
the patient's age and status in order to demonstrate professionalism, respect and
establish trust. Telling the child that she has to do this may make the child more
apprehensive and more frightened. Never tell the child or any patient that the
procedure will not hurt. Every patient experiences pain differently and has
different pain tolerance. It is best to tell the child that they may feel a little pinch or
relate the procedure to something a child might have experienced. Telling the
child the procedure will not hurt will only lead the child to no longer trust the
phlebotomist when it does hurt. It is acceptable to allow the child to handle or
look at the tubes and packaged alcohol swabs before the procedure to become
more comfortable, but it is imperative that any sharps are kept out of reach and
that the phlebotomist performs the entire procedure.
44. Green
a. Rationale: Green tube contains anticoagulant heparin in the form of lithium
heparin or sodium heparin. Heparin inhibits thrombin to prevent fibrin formation
from fibrinogen. Red tube contains clot activator silica. Silica enhances clotting by
providing increased surface area for platelets. Lavender tubes contain EDTA
which works by inactivating calcium. Yellow tube contains anticoagulant sodium
polyanethol sulfonate (SPS). SPS chelates calcium to prevent fibrin formation
from fibrinogen.
45. Left ring finger
a. 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.
46. Petechiae.
a. Rationale: Small red spots near the tourniquet on a patient’s arm are most likely
indicative of petechiae. Petechiae are small, red, non-raised spots that appear in
response to pressure from the tourniquet. They do not pose a health risk to the
patient. Petechiae may indicate poor capillary integrity and poor platelet function.
A collapsed vein normally occurs in response to excessive vacuum in the
evacuated tube or excessive pressure created with the plunger of a syringe
during a venipuncture. A hematoma is a bruise under the skin resulting from
blood pooling into the surrounding tissues during or after a venipuncture. Edema
is swelling of tissues due to accumulation of interstitial (tissue) fluid.
47. Bilirubin
a. Rationale: Analyte is any substance being tested in the liquid portion of the blood,
except for formed elements (red blood cells, white blood cells, platelets). The
most common light sensitive analyte is bilirubin. Bilirubin and vitamins are the
most common light sensitive specimens protected from being broken down by
ultraviolet light using the amber tube or wrapping the specimen in aluminum foil.
Folic acid must be immersed in a slurry of ice and water. Chilling helps slow
down metabolism and prevent evaporation by keeping volatile substances
dissolved in the liquid portion of the blood. Potassium and calcium do not require
special handling.
48. The small amount of tissue between the skin and bone in the finger makes an injury to
the bone likely.
a. 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.
49. Hemoconcentration
a. Rationale: A tourniquet left in place for longer than 60 seconds predisposes the
formation of blood clots due to slow blood flow (a.k.a. venous stasis). Venous
insufficiency (VI) is a state in which the veins do not adequately send the blood
from the extremities back to the heart. Fibrinolysis refers to the breaking down of
a clot. Hemangioma is a term used to describe a condition in which blood vessels
abnormally congregate in a place on the body, causing a non-cancerous tumor.
50. Increased risk of nerve damage, Increased risk of arterial involvement
a. 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.
51. Annual employee safety training
a. 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.
52. Report the incident to a supervisor.
a. 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.
53. Middle finger of non-dominant hand
a. Rationale: Capillary blood samples may be taken from the lateral side heel of
children until they begin to walk at which time the heel becomes tougher and
more difficult to penetrate. In this case the middle finger of the non-dominant
hand may be used. The great toe is not used and the index finger would be more
sensitive and painful.
54. Cephalic
a. Rationale: The most suitable veins for venipuncture are located in the antecubital
fossa (region) of the 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.
55. They can easily be contaminated.
a. Rationale: When sepsis is suspected, the physician orders blood cultures.
Specimen collection for blood cultures is more detailed than for routine
venipuncture, thus adding collection time. Blood cultures are always drawn first to
avoid contamination from drawing additional tubes. It is necessary to disinfect the
draw site before collecting blood cultures so they are not contaminated with
normal skin flora. Contamination can result in unreliable test results, which in turn
can lead to incorrect diagnosis and treatment of the patient. Blood culture bottles
are sterile and the different colored tops indicate different additives.
56. Butterfly needle
a. 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).
57. Lavender, Light blue, Green
a. 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)
58. Light blue, green, lavender.
a. Rationale: The correct order of draw would be: two light blue top tubes (one
waste and one for PT which is a coagulation test), green top tube (for the Chem
7), and the lavender top tube (for the CBC).
59. Hold pressure and elevate the patient's arm., Wait for bleeding to stop., Apply a pressure
dressing over the site.
a. Rationale: Complications can arise with any medical procedure. A phlebotomist
should confirm hemostasis before leaving a venipuncture patient or allowing the
patient to leave. If a patient continues to bleed after a reasonable amount of time,
further intervention is required. Another medical professional (like a nurse) may
be needed to help stop the bleeding. This is common in patients on
anticoagulants.
60. The Patient’s Bill of Rights.
a. Rationale: It is within a patient's bill of rights to be provided a translator if one is
available. If a patient requests a translator, that translator becomes a part of the
health care team. By requesting a translator, the patient essentially agrees to the
translator knowing private, confidential, protected medical information and
therefore it would not violate HIPAA.
61. Release the tourniquet, withdraw the needle, and apply pressure.
a. Rationale: The correct response is to release the tourniquet, withdraw the needle,
and apply pressure to avoid any further damage or pain at the venipuncture site.
The tourniquet MUST be released before the needle is withdrawn. The
application of pressure by the phlebotomist is meant to stop any bleeding. The
use of ice and bending of the arm are not typically recommended after any
phlebotomy procedures.
62. Lavender
a. Rationale: The lavender top (EDTA) tube is used in the Hematology department
for blood cell counts. It has been found to best preserve the size and morphology
of red cells, white cells and platelets. Adequate filling of the tube is required as
too much EDTA will shrink the red cells, causing inaccurate results. Green tops
(heparin) and red or red/gray speckled (tiger tops). Serum tubes contain no
anticoagulant and are typically used by the Chemistry and Serology departments.
63. SDS
a. Rationale: A Safety Data Sheet (SDS) is a hazardous chemical reference. It
provides healthcare workers with procedures for working with substance safety to
ensure regulatory compliance. Clinical Laboratory Improvement Amendments
(CLIA) of 1988 are United States federal regulatory standards that apply to all
clinical laboratory testing performed on humans in the United States, except
clinical trials and basic research. HIPAA (Health Insurance Portability and
Accountability Act) requires medical professionals to protect the confidentiality of
patients’ health information. The National Institute for Occupational Safety and
Health (NIOSH) makes recommendations for preventing illness and injury
acquired on the job.
64. While in the patient’s room, after drawing the blood
a. 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.
65. Blood borne pathogens.
a. Rationale: The Needlestick Safety and Prevention Act requires reporting and
documentation of all sharps injuries. In compliance with OSHA standards, a log
or report must be kept in the medical facility describing the incident, type of
device, time, date, location, and follow up. This also includes minor incidents that
do not result in injury or illness.
66. Discontinue the venipuncture and call for help.
a. Rationale: If the needle is still in the arm as the patient falls it could cause serious
injury.
67. Sodium citrate, non-additive, lithium heparin, potassium EDTA
patient results. The order is sterile (blood cultures), sodium citrate (blue), serum
(red or gold with or without clot activator or gel separator), heparin (green), EDTA
(purple), sodium fluoride & potassium oxalate (gray). In this case, the light blue
would be drawn first for the D-dimer, the non-additive (serum) tube second
(estrogen), lithium heparin (STAT electrolytes) third and potassium EDTA (type &
screen) last.
68. Collapsing vein
a. 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.
69. Pulling the skin taut using gentle and sufficient pressure to anchor the vein
a. Rationale: Blood collection from a geriatric patient can be more difficult due to
fragile skin and poorly anchored veins. The best technique for a successful
venipuncture on a geriatric patient is to pull the skin taut and firmly anchor the
vein. Pulling the skin taut helps stretch the skin and tissues underneath, which in
turn stabilizes the vein and allows the needle to enter the skin more easily. A
tighter tourniquet will only cause more discomfort, potential bruising and skin
tearing, as well as hemoconcentration of the blood specimen. Vigorous
massaging of the arm can cause bruising and hemoconcentration of the blood
specimen. The needle angle used during venipuncture is directly related to the
depth of the vein. Deep veins require a steeper angle, while superficial veins
require a shallower angle.
70. Release the tourniquet, remove the needle, and immediately apply pressure at the site.
a. 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.
71. Personal Hygiene
a. Rationale: An overall clean and put together looking individual can say a lot about
a person's outlook on their health.
72. Benzalkonium chloride
a. 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.
73. Finger.
a. 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.
74. Light blue, lavender
a. 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.
75. Dorsal side of the hand
a. Rationale: Patients with central lines would be candidates for specimen collection
from the 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.
76. Keep the test tube away from direct light by wrapping it in foil.
a. Rationale: Levels of both bilirubin and carotene are susceptible to deterioration if
exposed to light. Bilirubin is the most sensitive – it may drop in concentration as
much as 50% in one hour. Therefore these tests are protected from light by either
wrapping the specimen in aluminum foil or transferring the spun serum or plasma
to a brown aliquot tube. Other light sensitive analytes include RBC folate and
vitamin B12. The number of inversions has no effect on light sensitivity and as
long as the specimens are light protected, it doesn’t have to be taken
immediately to the lab. Analytes that need to be placed on an ice slurry include
lactic acid, ammonia and some coagulation factors.
77. Strep test and urine reagent strip
a. Rationale: CLIA (Clinical Laboratory Improvement Amendments of 1988) is a
federal law that regulates all laboratory testing in the United States and sets the
minimum requirements for laboratory practices to ensure the minimum standards
of quality. The three categories of test complexity include waived, moderate
complexity (which also includes provider performed microscopy procedures or
PPMP), and high complexity testing. The FDA (Food and Drug Administration)
determines test complexity based on the level of difficulty required to perform the
test, level of skill required to perform the test, and the level of potential harm to
the patient should the test be performed incorrectly. Waived tests are considered
to be simple tests with minimal risk of error requiring no or minimal education
about the instrument. Therefore, waived tests are within the CLIA defined scope
of practice for a phlebotomist. Strep test and urine dip are very simple tests that
require minimal training and have low risk of harm to the patient. Both tests are
non-invasive and simple enough for a phlebotomist to perform. Strep test
requires a throat swab and a urine dip test requires a urine reagent strip dipped
into a urine cup. Cell differential and urine sediment are more complex and
require microscopic analysis of the specimen, thus requiring a higher skill level
and can present greater risk to the patient if performed incorrectly.
78. Microcollection container
a. 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 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.
79. Should have kept the specimen at 37˚C.
a. Rationale: Many types of specimens are required to be kept at certain
temperatures for accurate test results to be obtained by the laboratory.
Cryofibrinogen, cryoglobulin and cold agglutinins must be kept at 37o C (body
temperature). Tests requiring protection from light include: bilirubin, carotene,
porphyrins and vitamins A, B2, and C. Specimens that require chilling on an ice
slurry are ammonia, lactic acid, pH & blood gasses among others. Consult your
facility’s policies for the correct procedures to follow. Aliquoting of the specimen
(dividing it into parts) is done during or after processing in the laboratory.
80. Call for help., Protect the patient’s head and lower her to the floor.
a. 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 choke 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.
Patients experiencing a seizure must be kept safe by removing potentially
hazardous objects from the immediate area and protecting the patient’s head
without any forceful restraint. Patients after a seizure must be evaluated and
observed by qualified healthcare professionals such as a physician.
a. Rationale: Hemoconcentration is a 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.
82. Brachial artery
a. 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.
83. Contact Droplet
a. 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 a 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 the N95 mask will protect healthcare professionals
against Airborne and Droplet transmission while the regular or surgical mask will
only protect against Droplet transmission.
84. A yellow tube with SPS
a. 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 ChloraPrep and benzalkonium chloride are used, the venipuncture
site must be cleansed using a 30-60 second friction scrub. Higher degree of skin
antisepsis ensures that normal flora from the skin will not contaminate blood
culture bottles and thus prevents false positive blood culture results. 70%
isopropyl alcohol can be used to clean the venipuncture site prior to collecting a
lavender tube, light blue tube, and yellow tube with ACD.
85. Lancet (depth 2.0mm), filter paper collection card
a. Rationale: Neonatal screening for metabolic disorders is done with a dermal
puncture to the medial or lateral plantar surface of the heel using a special lancet
that penetrates no more than 2.0 mm. The blood collected is transferred directly
to a special filter paper card. A green top microtainer is not used as the heparin
anticoagulant would interfere with testing. A 23g needle, syringe, butterfly and
adapter are all venipuncture equipment and not used for this dermal procedure.
86. CLIA
a. 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).
87. Green surgical soap, hydrogen peroxide
a. 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, Purell wipes and solutions of
chlorhexidine and alcohol (Chloraprep) should not be used. Green surgical soap
or hydrogen peroxide would be acceptable.
88. Distal to the IV site
a. Rationale: It is not uncommon for the patient’s physician to restrict blood draws
from certain areas of the body on which mastectomy, AV fistulas, surgeries or
other treatments may have been performed. In this case, a site for venipuncture
should be selected distal to (away from) the IV in the left arm. A site proximal
(close to) the IV might contaminate the blood sample with the contents of the fluid
being administered. The exclusion of the right arm includes the hand. Blood
drawn from a foot requires a doctor’s written permission. If a small amount of
blood is needed for the tests requested, the phlebotomist might consider a
dermal puncture of a finger.
89. Remove the hypodermic needle from the syringe after activating the safety device and
transfer the blood into capped evacuated tubes using a syringe transfer device.
a. Rationale: To safely move blood from a syringe to evacuated tubes, a syringe
transfer device is used. Upon completing the venipuncture, the needle safety
device is activated then the needle may be removed from the syringe and
discarded into a sharps container. A transfer device is attached to the syringe
and the tubes may be placed into it as if it were an ETS holder in the correct
order of draw. After the tubes are filled, the syringe and transfer device are
discarded into the sharps container as one unit. Tubes are never uncapped and
blood is not pushed out of the syringe through the needle. Doing such would risk
hemolyzing the blood.
90. Initials of the person collecting the sample
a. Rationale: When labeling a tube after collection, the phlebotomist should add her
initials, the time of draw and any special comments such as “line draw”. The
patient’s first and last name, date of birth and identification number should be
preprinted of the label
91. Hemolysis, specimen contamination
a. Rationale: If the phlebotomist uses a 25 g needle with evacuated tubes,
hemolysis of the blood sample is likely to occur as the needle is too small for the
vacuum in the tubes. Cleaning the site with 70% isopropyl alcohol is
contraindicated when drawing an alcohol level as the specimen might become
contaminated with the antiseptic and affect the results. Infection could occur from
improper cleaning, but has nothing to do with the needle gauge or use of the
wipe. Microclots result from inadequate mixing of evacuated tubes with their
additive contents. Hemoconcentration is caused by leaving a tourniquet on too
long which alters the ratio of cells and other constituents to the plasma in the
blood.
92. Povidone-iodine
collection. If iodine is used, venipuncture sites 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 a 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 sites 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.
93. A patient who contracts a MRSA infection from a venipuncture.
a. Rationale: A nosocomial infection is a “hospital-acquired” infection acquired by a
patient who enters the hospital without any symptoms and appears to have
acquired the infection during the hospital stay. A female patient who develops a
urinary tract infection after having a urinary catheter inserted is a perfect
example. The other patients were exposed prior to admission or were never
admitted, in the case of the healthcare worker.
94. Malpractice
a. 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.
95. Normal glucose is at 3 SD on the high side and abnormal glucose is 2 SD on the low
side.
a. Rationale: Results should fall within the range of two standard deviations (± 2
SD) 95 % of the time, and the values should be evenly distributed on either side
of the mean, confirming precision and accuracy. Two consecutive values cannot
fall outside of the two standard deviations, and no value should exceed three
standard deviations.
96. Thumb 1-2 inches below the site.
a. Rationale: Anchoring a vein prior to venipuncture serves two purposes – to keep
the vein from rolling away when the needle is inserted and to pull the skin taut
which makes the procedure less painful for the patient. The proper way to do this
is to place the thumb of the non-drawing hand 1 – 2 inches below the intended
site while grasping the patient’s arm. Placing the thumb below and the index
finger above the site (“C” or window hold) leaves the index finger exposed to a
possible needlestick injury. Using only the index finger would not allow the hand
to steady the arm. Placing the thumb 1-2 inches above the site would not help to
anchor the vein.
97. Replace the initial tube with another tube to check vacuum.
a. Rationale: Evacuated tubes are manufactured items and have expiration dates to
assure the viability of their contents, their sterility and the strength of the vacuum.
However, even with good quality control procedures, the tubes may become
defective during transport, handling or storage. As decreased vacuum may not
allow the tube to fill properly, it is wise to keep an extra set of tubes at hand so an
exchange can verify that the tube, not the draw, is causing the problem. If the
second tube does not fill, the needle may be repositioned slightly to recover the
draw. The venipuncture may have to be discontinued and another collection
system, such as a syringe, used on the next attempt.
98. Collect distal to the IV in the antecubital area of the left arm after the nurse has turned off
the IV for 2 minutes.
a. Rationale: A blood test can be considered a “snapshot” of the patient’s condition
at the time it was drawn. Contaminating this specimen with IV fluid will give false
results and cause the patient to be incorrectly treated. If a collection must be
made in an arm with an IV, the nurse must turn off the infusion for 2 minutes and
the tourniquet is placed distal to the IV site. The phlebotomist does not tamper
with any medical equipment attached to a patient. It is not necessary to
disconnect or remove the IV for a blood draw.
99. Wash the exposed area with soap and water.
a. Rationale: All healthcare facilities are required by OSHA to have a Bloodborne
Pathogen exposure control plan. Part of this plan includes the steps to follow if a
sharp injury occurs. The first step is to remove the sharp from the wound and
wash the site with soap and water for at least 30 seconds. Antiseptics such as
Betadine are not necessary. Then inform the immediate supervisor and report to
a licensed healthcare provider for evaluation and treatment. It is very important to
also document the event on an incident report form. The practice of “milking the
site” or making the site bleed is not encouraged.
100. Locate the patient
a. Rationale: Stat, or urgent testing is a conventional circumlocution, which is used
to designate timely or “rush” performance of laboratory tests. The term “stat” is
literally derived from the Latin word “statim”, which actually means “immediately”.
If the patient is not in their room, make every effort to locate the patient by
checking with the nursing station. If the patient is in another department and the
test is a short turnaround time (stat) or timed request, proceed to that area and
draw the blood there.
101. "I will wear a gown, gloves, and a mask for inpatient collections.“
a. Rationale: In a healthcare setting, the staff wears Personal Protective Equipment
(PPE), not the patients. The purpose of following contact-droplet isolation
precautions are to contain the patient’s environment and prevent the spread of
infection. Since they have contact with multiple patients, medical professionals
must wear proper PPE and perform proper hand hygiene when caring for every
patient. Antimicrobial wipes can be utilized to clean exam rooms between
patients. In order to limit potential for accidental exposure/puncture, Sharps
containers should be replaced when 2/3 full.
102. Review the requirements for collecting and handling the blood specimen.
a. 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 the 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.
103. Hold direct pressure for up to 5 minutes.
a. Rationale: Patients on anticoagulant therapy tend to bleed longer from the site of
a venipuncture. The patient can assist but it is the responsibility of the
phlebotomist to assure that bleeding has completely stopped before bandaging
and releasing the patient. This may take direct pressure for 5 minutes or longer.
The patient is never left alone and the doctor relies on the phlebotomist to
resolve this situation.
104. 3-4 inches
a. Rationale: The tourniquet should be applied 3-4 inches above the intended
venipuncture site. Too close to the site may cause the vein to collapse and too far
away might not be effective in distension of the veins. 1-2 or 3-4 cm would be too
close. Tourniquets are used to make it easier to locate veins by causing them to
become distended and easier to palpate. This occurs because the tourniquet
impedes venous blood flow right (i.e., below the application site) but does not
impede arterial blood flow. Most phlebotomy experts recommend a tourniquet be
applied approximately 3 to 4 inches above the site of blood collection for optimum
palpation in venipuncture. Placing a tourniquet too far away will not impede blood
flow sufficiently to help with palpation, but too close may cause
hemoconcentration, possibly affecting the ratio of cellular components to plasma
and laboratory test results.
105. Per manufacturer's instructions
a. Rationale: Quality control (QC) on a glucometer should be performed and
documented per manufacturer's instructions (which is likely every day) and after
any maintenance, such as a battery change. In addition, QC solutions should be
at room temperature and used before the expiration date. If the QC results are
not within the acceptable range, the meter can not be used for patient testing.
Always follow the manufacturer's instructions and your facility’s procedures and
policies. Running QC every 5, 10 or 15 days is not recommended and will not
validate the patient results.
106. Refer the patient to the physician for interpretation of all results.
a. Rationale: The phlebotomist is able to collect blood specimens via capillary
puncture and venipuncture, process specimens and perform CLIA waived point
of care tests. Phlebotomists are not able to interpret or analyze results whether
the tests are categorized as waived, moderate or high complexity. It is always
best to instruct the patient to consult with the physician for interpretation of the
results.
107. Hematoma
a. 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.
108. STAT and on ice slurry.
a. Rationale: Some blood specimens require special treatment and handling to
preserve the analyte while being transported to the lab for testing. Lactic acid and
ammonia are chilled in ice slurry and delivered STAT as they deteriorate very
quickly at room temperature. It is not necessary to protect them from light.
a. 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.
110. Performing CLIA high complexity tests.
a. Rationale: CLIA refers to the Clinical Laboratory Improvement Amendment,
which specifies personnel requirements for performing laboratory testing based
upon their complexity. Moderate and high complexity testing are outside the
scope of practice for a phlebotomist. Medical assistants may perform
CLIA-waived testing, such as Point of Care Testing, with proper training.
111. Draw blood from the hand using a winged infusion set.
a. 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.
112. Additive to blood.
a. Rationale: The manufacturers of evacuated tubes adjust the amount of additive
contained in each tube in order to preserve the analytes to be tested. It is
imperative to fill these tubes to the correct level for accurate patient results. This
is especially true of the sodium citrate (blue) tube which must have a ratio of 1
part sodium citrate to 9 parts of blood in order to correctly measure coagulation
factors. Other than blood and additives, there are no other liquids in these tubes.
The amount of air within the tube does not affect patient results other than having
them insufficiently filled.
113. "May I have your name please?"
a. 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.
114. Clinical Laboratory Improvement Amendments (CLIA)
a. Rationale: The Clinical Laboratory Improvement Amendments (CLIA) became
law in 1988 and was implemented for all labs testing human specimens in 1992.
It is an effort to standardize policies, procedures and personnel criteria to provide
better patient outcomes. The law is administered by CMS and the FDA and
defines four categories of testing: waived, provider performed, moderate and high
complexity according to the training and degree of judgment required to perform
the test. Each laboratory must have a license to operate under the appropriate
category and be periodically inspected. COLA, CAP, and JCAHO are accrediting
agencies that inspect laboratories to assure the CLIA law, good laboratory
practices and the highest standards of patient care are being employed.
115. Make the puncture perpendicular to the fingerprint whorls.
a. Rationale: Capillary puncture can be performed on the palmar surface of the
distal segment of the 3rd digit (middle finger) or 4th digit (ring finger). Lancet
must be placed across (perpendicular) to the fingerprint whorls in order to allow
blood to form round drops as it is collected. Placing the lancet along (parallel to)
the fingerprint whorls will allow the blood to channel away from the puncture site
into the grooves and make collection very difficult. Never wipe, fan or blow at a
site that has been cleansed. Alcohol must air dry to allow time for it to work and
inhibit bacteria. Wiping can prevent alcohol from working properly and can
introduce more microbes. Fanning creates air turbulence and can introduce more
microbes. Blowing introduces microbes from the mouth into the cleansed site.
Capillary puncture does not require a higher degree of antisepsis such as iodine.
Iodine should not be used for capillary puncture as it can affect
BURRP—bilirubin, uric acid, phosphorus and potassium tests. Milking is
contraindicated during capillary puncture as it will increase specimen hemolysis
and tissue fluid contamination.
116. Are extremely obese.
a. 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.
117. Light blue, SST
a. Rationale: The order of draw is designed to prevent carryover of additives from
one tube to the next thereby affecting patient results. CLSI states the order of
draw for ETS tubes to be: SPS (sterile), sodium citrate (blue, serum, red or gold),
heparin (green), purple (EDTA), oxalate / fluoride (gray). In this case the order
would be light blue then SST (serum separator tube). Royal blue tubes are used
for heavy metal screens and the red (serum tube) is never drawn before a light
blue.
118. First dispose of the sharps in puncture-proof biohazard sharps container, second
dispose of the contaminated gloves in a biohazard bag.
a. Rationale: It is always important to immediately activate the needle safety device
after removing the needle from the venipuncture site. The needle and holder are
then disposed of as a unit in a puncture proof sharps container. Gloves visibly
contaminated with blood must be placed in a biohazard bag.
119. Informed
a. Rationale: Informed consent means the patient agrees to and signs a document
in regards to a procedure after the provider explains the risks and consequences.
Expressed consent is when the patient clearly gives permission to the procedure
either verbally or nonverbally. Implied consent means consent is understood by
the patient’s actions even though the patient did not directly express consent.
Verbal consent means the patient has said he/she agrees to the procedure even
though it is not written down in contract.
120. Heel stick lancet
a. 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.
121. Release the tourniquet.
a. 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.
122. Right antecubital fossa
a. Rationale: Due to the mastectomy, avoid any left side sites. The right antecubital
fossa is the best collection site. Blood samples should not be collected from the
arm on any side a patient has had breast cancer surgery (a mastectomy or a
lumpectomy with lymph node removal). The presence of lymph fluid dilutes the
blood in this area, causing erroneous patient test results. The lymph fluid may
also make the patient’s arm swell, thus making tourniquet application painful.
Additionally, all skin punctures should be avoided on the side of breast cancer
surgery. Not only could test results be altered, but the performance of
venipuncture, skin puncture, injections, etc. on breast cancer surgery patients
may lead to the development of a bacterial infection. The right saphenous vein in
the leg would not be a good choice (use the antecubital in the arm instead).
123. OSHA.
a. 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.
124. Potassium EDTA
a. Rationale: The potassium EDTA microcollection tube should be collected first
because it is used for whole blood tests and microclots easily in these containers
from inadequate mixing. Next should be the other additive tubes, sodium heparin
and potassium oxalate. Last would be the non additive tube. There is no concern
about carryover of additives with dermal collection as there would be with
venipuncture.
125. Maintain records
a. Rationale: The documented maintenance of an instrument, such as a glucometer,
is necessary to prove that it is performing correctly before being used to provide
patient results. If records are not kept it will be assumed maintenance and quality
control (QC) have not been performed and patient results will be invalid. Patients
are not trained to do this – it is the responsibility of the laboratory, as is
comparing policies and procedures to assure they are in accord. Patient results
are run and recorded after the instrument has been validated with the
performance of quality control.
126. Explain to the patient that a bruise may be likely, but it should be gone within a few
days.
a. Rationale: Phlebotomists 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 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, the 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.
127. The specimen was hemolyzed.
a. Rationale: Hemolysis causes falsely increased results for many analytes,
including potassium, magnesium, iron, lactate dehydrogenase, phosphorus,
ammonia, and total protein. Hemolysis also shows decreased RBC count,
hemoglobin, and hematocrit.
128. With a 37 degree Celsius heat block.
temperatures in order for accurate test results to be obtained by the laboratory.
slurry are ammonia, lactic acid, pH & blood gasses among others. Consult your
a. Rationale: To remove PPE (personal protective equipment), the gloves are
removed first as these are considered likely to be most contaminated. Using a
gloved hand, grasp the palm area of the other gloved hand and peel off the first
glove. Hold the removed glove in a gloved hand. Slide fingers of ungloved hand
under remaining glove at wrist and peel off second glove over first glove. Discard
gloves in a waste container. The gown is then removed by pulling it from the
shoulders, turning it inside out and then rolling it into a bundle before disposal.
The mask is removed last by touching only the ties.
130. Right arm distal to the IV site.
a. 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.
131. Immerse the specimen in an ice and water slurry.
a. 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 warmers 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.
132. Use disinfectant to moisten the droplet, absorb with a paper towel, then clean with
disinfectant.
a. 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 antimicrobial soap are not as
effective against microorganisms as 10% bleach or commercial disinfectants.
133. Apply a warm compress.
a. Rationale: The heat from a warm compress will encourage capillary vasodilation
resulting in increased blood flow. Warming helps make blood collection easier
and faster. Warm the heel for 3-5 minutes, which allows sufficient time for the
capillaries to dilate. Squeezing can create discomfort and will not necessarily get
more blood (it may also extract serous fluid that would dilute an already small
amount of blood sample). The only content to be added to a microtainer
collection tube is blood (adding a diluent would skew the results). The fingers of
infants should not be used for collection since lancets are too long (and would
puncture bones and nerves).
134. Lateral surface of heel
a. Rationale: For infants less than one year of age, the heel is typically used for a
dermal puncture. Capillary blood samples may be taken from the heel of children
until they begin to walk at which time the heel becomes tougher and more difficult
to penetrate. The site chosen should be the lateral or medial side and not the
plantar surface as it is too close to the bone. Fingers are too small and there is
not enough tissue surrounding the bone.
135. Material Safety Data Sheet
a. Rationale: All chemicals must have a Material Safety Data Sheet (MSDS) or
since the implementation of GHS, now called Safety Data Sheets. Information
provided must include: product identification, hazard(s) identification, composition
(ingredients), first aid measures, firefighting measures, accidental release (spill)
measures and handling and storage. Recently MSDS have been changed to
Safety Data Sheets (SDS) in an effort to align with the Globally Harmonized
System (GHS) that is now being used worldwide. These documents contain all
the information on how to safely handle each chemical including how to contain
and clean up a spill. Product inserts detail how the chemical is to be used in a
test system. A site supervisor may be responsible for assuring the training and
competence of employees in handling chemicals. OSHA guidelines provide an
outline for workplace safety – which includes proper handling of chemicals.
136. Call for a professional interpreter.
a. Rationale: It is imperative that the patient understand the procedure being
performed and that a professional medical interpreter be present. Recent
changes in medical law require a professional medical interpreter. The use of
non-verbal cues or allowing a family member who might not understand medical
terms to interpret may cause miscommunication and incorrect medical treatment.
Informing a supervisor would just waste time in getting the patient the correct
care.
137. Gloves only
a. 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.
138. Re-position the needle and recollect the lavender tube.
a. Rationale: It is possible for needle position to change during successive tube
exchanges. In a patient with 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 the
vein. Repositioning 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 redraw all three tubes from the patient using a different site since
the first two tubes filled successfully. If redraw 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. Phlebotomists must
not submit a known QNS specimen to the laboratory. Phlebotomists must notify
the laboratory and ask for another phlebotomist if he/she is not able to collect
sufficient quantities for testing. Knowingly submitting QNS specimens will delay
patient treatment. After two unsuccessful attempts, a phlebotomist can notify the
laboratory (it should not be automatically assumed that the draw may be
postponed for the next round of draws; if it is a STAT situation, the blood draw
cannot wait).
a. 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.
140. Blood culture bottles, Light blue, Red, Lavender
a. 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.
141. OSHA
a. 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.
142. Have edema of the hands and feet.
a. Rationale: Patients with peripheral edema have a great deal of fluid in their
tissue. Collection of capillary blood would provide a sample that is likely to be
highly diluted with tissue fluid, affecting laboratory test results. Capillary testing
would be a choice for the other patient conditions.
143. An expired tube was collected.
a. 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.
144. Radial artery
a. Rationale: Several different arteries can be used for blood collection. The first
choice is the radial artery, which is located on the thumb side of the wrist;
because of its small size, use of this artery requires extensive skill in arterial
blood sampling. Alternative sites for access are brachial or femoral arteries, but
these have several disadvantages in that they may be harder to locate because
they are less superficial than the radial artery, have poor collateral circulation,
and are surrounded by structures that could be damaged by faulty technique.
145. Gown, mask, face shield, gloves
a. Rationale: When donning (putting on) PPE, the gown is put on first and fastened
in the back. Next, the mask (covering nose & mouth) or face shield, if using.
Gloves are put on last and pulled over the cuffs of the gown. To remove PPE, the
gloves are taken off first, then the gown and finally the mask.
146. Biohazard material present.
a. 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.
147. Do not bandage.
a. 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.
148. “Are you taking any medications?”
a. Rationale: It is important to know what medications the patient is taking prior to
performing a drug screen as those prescriptions and supplements might cause
false positive or negative results. The typical urine drug screen tests for drug
abuse involving amphetamines, barbiturates, benzodiazepines, cocaine, ethanol,
marijuana, opiates, and phencyclidine. Diet restrictions, timing of meals or
positions issues such as standing, sitting or lying down will not affect the results
of a drug screen.
149. 8-12 hours
a. Rationale: To ensure accuracy of the blood test results. Gum chewing, eating
mints, and/or smoking are not allowed. Sips of water may be permitted
depending on provider NPO policy.
150. Up
a. 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.
Study Guide - Collections - 92 Q’s Answers

1. Lactic Acid
a. A lactic acid level is likely to be a STAT order as this analyte deteriorates very
quickly after being drawn and is usually associated with emergency situations.
Therapeutic drug levels, electrolytes and blood smears are much more stable
analytes.
2. STAT troponin level on a patient sent over from a doctor’s office, type and screen on a
preoperative patient due for surgery that day, 2-hour post-prandial glucose level due in
40 minutes, weekly PT/INR
a. It is important that a phlebotomist be able to prioritize blood draw orders. This
assures that patients get correct and timely medical treatment. A STAT troponin
level is used to triage the possibility of heart attack. The type and screen for
surgery the same day is needed so the Blood Bank staff can assure blood
components can be ready if necessary. For accurate results, timed tests need to
be drawn within a certain window. The weekly PT/INR can be done anytime.
3. To protect specimens from light.
a. Levels of bilirubin are susceptible to deterioration if exposed to light. Bilirubin is
the most sensitive – it may drop in concentration as much as 50% in one hour.
Therefore these tests are protected from light by either wrapping the specimen in
aluminum foil or transferring the spun serum or plasma to a brown aliquot tube.
The specimen does not have to be cooled down or maintained at body
temperature (37oC). Also, the foil wrapping does not prevent contamination of
the specimen.
4. Lactic Acid chilled in slurry of ice and water
a. Some blood specimens require special treatment and handling to preserve the
analyte while being transported to the lab for testing. Lactic acid and ammonia
are chilled in ice slurries as they deteriorate very quickly at room temperature.
Cryoglobulin must be kept at body temperature (in a 37 degree C heat block)
until analysis can begin. Vitamin A samples need to be protected from light and
may be wrapped with aluminum foil.
5. Biohazard Transport Bag
a. Biohazard transport bags are used to transfer specimens to the lab in an effort to
prevent the spread of infection. There are two pockets. The inside one holds the
specimen and the outside pocket is for any labels or paperwork. Red biohazard
bags are used for disposal of medical waste such as used gloves or objects
contaminated with blood or body fluids. Yellow bags are used for containing
contaminated linens or PPE. Brown paper bags are not used for specimen
transport.
6. A glucose test in a gray top tube
a. Glucose levels are stable in a gray top tube at room temperature for up to three
days because they contain the glycolytic inhibitor sodium fluoride. A urine or stool
sample would need to be refrigerated to prevent overgrowth of bacteria or
deterioration of analytes. Red top tubes for B12 levels should be centrifuged and
the serum removed from the cells within 2 hours of collection.
7. Ammonia, cold agglutinin, bilirubin
a. Many types of specimens require special handling for accurate test results to be
obtained by the laboratory. Ammonia must be transported in an ice slurry as this
analyte deteriorates rapidly. Cold agglutinins must be kept at 37o C (body
temperature). Bilirubin requires protection from light. Consult your facility’s
policies for the correct procedures to follow. CBCs and blood cultures are kept at
room temperature.
8. The specimen was transported in a pneumatic tube system and cells were not separated
from serum or plasma within the time limit.
a. When a physician orders laboratory testing, he is looking for a “snapshot” of the
patient’s condition at the time the specimen was collected. If the cells are not
separated from the serum/plasma in a timely manner (2 hours), metabolism will
continue and the levels of analytes will change. Since this glucose was drawn in
a gel barrier tube and left unspun for 4 hours, the results could be lowered by as
much as 7% per hour. This could cause inaccurate treatment of the patient. It is
not necessary to place this specimen on ice or protect it from light. Timely
transport and processing are crucial.
9. Samples are balanced in the centrifuge.
a. It is very important to ensure that sample tubes are balanced to each other when
spinning them in a centrifuge. The speed and timing of the instrument are
determined by each laboratory to yield the volume of plasma or serum needed for
testing. Serum tubes need to be allowed to completely clot for 20 to 30 minutes
to prevent fibrin strands from forming.
10. Red
a. Evacuated blood collection tubes are color coded to indicate their contents. The
red top is a serum tube that requires 20-30 minutes in an upright position to
completely clot before centrifugation. The gray (potassium oxalate), green
(heparin) and light blue (sodium citrate) tubes all contain anticoagulants that keep
the blood liquid. These specimens may be centrifuged immediately after
collection to yield plasma.
11. Tiger top SST
a. The tiger top SST (serum separator tube) would be allowed to clot for at least 20
minutes, then centrifuged and the serum be removed from the cells for testing.
The yellow ACD is used for HLA phenotyping, DNA and paternity testing, royal
blue (EDTA) is used for heavy metal screening and the yellow SPS is used for
blood cultures. All of these tests use whole blood and do not require
centrifugation.
12. Place the urine specimen in the refrigerator.
a. For accurate test results, a urine specimen should be refrigerated if testing is
delayed more than one hour. Chemical and cellular contents will deteriorate at
room temperature. Bacteria will multiply and change test results. However, the
specimen should be brought to room temperature before testing. Unless the test
requested is susceptible to light, there is no need for light protection. It is not
necessary to use ice, refrigeration at 2 – 8 oC is sufficient.
13. At least 20 minutes after collection and aliquot into an amber tube.
a. The specimen should be allowed to completely clot for at least 20 minutes and
the serum aliquoted into an amber tube. Levels of bilirubin are susceptible to
deterioration if exposed to light. Bilirubin may drop in concentration as much as
50% in one hour if not protected from light.
14. Not transported at the correct temperature.
a. A blood specimen for ammonia testing should be placed in an ice slurry as this
analyte deteriorates rapidly. However, electrolytes should be kept at room
temperature. Lithium heparin is the correct anticoagulant for both tests. Neither
analyte needs protection from light. Fifteen minutes for drawing to lab transport
time is acceptable.
15. 24 hour
a. Cortisol is a hormone produced in the adrenal glands that helps to regulate
glucose, blood pressure and other metabolic processes. It exhibits diurnal
variation – meaning the results are affected by the time of day the specimen is
collected. By collecting all urine for 24 hours, a more comprehensive result is
obtained. A timed or random specimen would only give a snapshot of cortisol
level at the time it was collected. Clean catch specimens are used for urine
cultures to help diagnose the cause of a UTI (urinary tract infection).
16. Lipemia
a. A milky appearance of serum or plasma indicates lipemia. This condition may
result after ingestion of a fatty diet. Lipids are not water soluble and can remain in
the bloodstream for 12 hours. This is why patients are asked to fast for a period
of time before having a lipid panel drawn. In addition, many other laboratory tests
cannot be accurately measured until the lipid is cleared for the plasma. Although
diabetic patients may experience lipemia, the condition is not usually associated
with the disease. Icteric samples have an excess of bilirubin, an indication of liver
disease. Anemia is the abnormal reduction of red blood cells in the circulating
blood.
17. Draw a new chemistry tube on the patient.
a. It is not uncommon for additional testing to be requested on blood specimens that
have already been drawn. However, if alcohol had been used to clean the
venipuncture site, an alcohol level should not be run on this specimen. Since the
tube’s cap had already been removed, the alcohol level would not be accurate
because this analyte is a volatile substance and subject to evaporation. The
proper step to take is redraw the patient for the alcohol level.
18. Transfer the specimen to the centrifuge to be spun down
a. Glucose specimens drawn in gray top tubes (sodium fluoride / potassium oxalate)
are stable at room temperature for 24 hours. Therefore, the phlebotomist was
correct in centrifuging the specimen for testing. If the chemistry department is
responsible for processing the blood, it would be accepted and not rejected.
19. Glucose and electrolytes
a. Specimens are rejected when they are deemed unsuitable for accurate analysis
by laboratory personnel. In this case, a lipemic sample for glucose measurement
cannot be used because the cloudiness of the serum or plasma interferes with
the instrument’s test method. Electrolytes consist of sodium, potassium, chloride
and bicarbonate. Hemolysis in these samples will cause a false elevation of
potassium and possible mistreatment of the patient. Serum from a clotted blood
sample is used for the HCG and the level of bilirubin in an icteric sample is an
indication of liver disease.
20. Cytology
a. Pap smears sent to the lab for cancer screening are delivered to the Cytology
department. Hematology counts levels of blood cells, Immunology checks for
levels of antibodies and Microbiology assesses specimens for pathogenic
bacteria.
21. Serology/Immunology
a. There are many departments within a clinical laboratory and each is responsible
for a certain discipline of testing. The serology / immunology area tests for
antibodies to viruses such as HIV (Human Immunodeficiency Virus), levels of
hormones like HCG (Human chorionic gonadotropin) and autoimmune antibodies
such as ANA (Antinuclear Antibodies). Microbiology tests blood, other body fluids
and tissues for the presence of bacteria, viruses, and parasites. The biochemistry
department measures levels of glucose and other nutrients, enzymes, hormones,
lipids and proteins, vitamins, therapeutic drugs, drugs of abuse, minerals and
trace elements. Hematology describes and measures levels of red blood cells,
white blood cells and platelets.
22. Chemistry Department
a. A BMP is a panel of tests (glucose, calcium, BUN, creatinine, sodium, chloride,
potassium, CO2) performed in the Chemistry department. The Serology
department tests for antibody levels, the Blood Bank does blood types and
transfusions and the Coagulation department tests for clotting factors.
23. Immunology
a. The specimen collected for an RPR should be delivered to the immunology
department. This area of the lab performs testing for antibodies to antigens
(bacteria, viruses and other organisms) found in the blood. The RPR is a
screening test for syphilis. Hematology counts blood cells, microbiology performs
cultures and histology prepares thin sections of tissues for diagnosis of disease.
24. Citrate to coagulation, EDTA to hematology, and oxalate to chemistry.
a. Clinical laboratories are divided into several departments by the type of testing
that each performs. Citrate tubes (light blue) go to the Coagulation area. EDTA
tubes (lavender) are processed in Hematology. An oxalate tube (gray) would go
to the Chemistry department.
25. Chlorhexidine gluconate
a. CLSI recommends chlorhexidine gluconate to prepare a venipuncture site for
blood culture collection on infants older than 2 months. Iodine preparations or
benzalkonium chloride are not typically used as they may be too harsh for
sensitive skin
26. Aerobic
a. Blood cultures are typically drawn when the patient’s physician suspects a
bacterial infection in the bloodstream (septicemia). To maximize the chance of
harvesting the infectious agent, the cultures are drawn in sets of two bottles, one
aerobic (with air) and one anaerobic (without air). A volume of 20 ml is collected
aseptically with 10 ml distributed into each bottle. If the collection is performed
with a butterfly system, the aerobic bottle is filled first as the tubing of the butterfly
set will introduce air into the container. Once the tubing is filled with blood, the
anaerobic bottle is attached and filled. The same order is used regardless of the
size or draw volume of the bottles. Mycobacterium is the causative agent of
tuberculosis and not a collection device.
27. The specimen may be contaminated with interstitial fluid.
a. Milking a capillary puncture, in an effort to obtain more blood, involves excessive
squeezing and the possible introduction of tissue fluid into the specimen, thereby
diluting or contaminating the result. The phlebotomist needs to assure the area is
warm to encourage good blood flow, perform an adequate puncture with the
correct device, wipe the first drop of blood away and continue with a “squeeze,
collect and release” rhythm to allow blood flow to recover after the squeezing and
collection. Contamination with staphylococcus aureus can occur if the puncture
area is not adequately cleaned or is retouched after cleaning. Contamination with
isopropyl alcohol can occur when the area is not allowed to be completely dry
resulting in the possibility of hemolysis of the specimen.
28. Dermal puncture, heel stick
a. Capillary blood samples may be taken from the lateral side heel of children until
they begin to walk at which time the heel becomes tougher and more difficult to
penetrate. In this case, as the patient is 3 months old, a heel stick would be the
best choice. The middle finger or great toe are not used. Since a very small
amount of blood is needed, a venipuncture in the antecubital area is not
necessary.
29. Blood gas, bilirubin
a. Collecting blood samples by capillary (dermal) puncture is an alternative to
venipuncture when a small amount of blood is needed and the procedure is
appropriate for the test requested. Blood gasses and bilirubin determinations may
be done with this method. Blood cultures and erythrocyte sedimentation rates
(ESR) require a larger amount of blood. Coagulation tests that require plasma
specimens such as the PTT are not done by dermal puncture.
30. Allow the site to air dry before the puncture.
a. When performing a capillary (dermal) blood collection, it is necessary to allow the
alcohol used for cleansing the site to completely dry before making the puncture.
If the area is wet, it will be more painful to the patient, contaminate the blood
sample, and cause hemolysis of the red blood cells. A wet site also prevents the
formation of a rounded drop because blood will mix with the alcohol, running
down the finger and making it harder to collect. The first drop of blood is wiped
away as it would be contaminated with tissue fluid. Diluting the strength of the
alcohol will make it less effective. Two alcohol pads are not required.
31. EDTA, other additive tubes, non-additive tubes
a. The order of draw for dermal punctures is different than for venipuncture. Since
there is no risk of “carryover” of additives with which to be concerned , the CBC
(EDTA) tube should be collected first as it presents the most likely to form clots.
Then other additive tubes such as heparin and sodium fluoride. It is important to
continually mix the additive tubes while performing the procedure. Serum tubes
(red or gold with no anticoagulant) are collected last as clots forming in these will
not matter.
32. 1 EDTA and 1 heparin.
a. If there are no veins available for venipuncture and a smaller amount of blood
can be used for the tests requested, a capillary collection may be appropriate. A
lavender (EDTA) microtainer would be used for the CBC and drawn first. Since
the request is STAT, the CMP would be drawn in heparin as this tube could be
immediately centrifuged and resulted quickly. The polymer gel or non additive
tube would have to be allowed to clot, adding to the result turn around time.
33. Avoid taking vitamin C prior to collection.
a. Many laboratory tests have special instructions to be followed by the patient in
order to help produce accurate results. For fecal occult blood (FOB) tests it is
necessary to avoid ingesting vitamin C for 72 hours as this may cause a false
positive test. Fasting, consuming 8 oz of fiber or stopping prescription
medications do not affect the test and may be contraindicated.
34. To keep the specimen refrigerated at all times.
a. For accurate results, a urine specimen for 24 hr analysis should be kept
refrigerated during the collection. Refrigeration prevents the analytes in the
specimen from deteriorating at room temperature. Maintenance of dietary
restrictions and the clearance of contrast dye are important for certain tests. The
avoidance of laxatives helps ensure the specimen will not be contaminated with
stool.
35. Sterile cup, immediate delivery to lab
a. Sputum specimens are collected into sterile cups and quickly delivered to the lab
when a bacterial infection such as bronchitis or pneumonia are suspected. If the
container is not sterile, other contaminating organisms may cause a false positive
result. Failure to transport to the lab in a timely fashion may cause the loss of
bacteria and a false negative culture result. A random sample is usually used, not
a 24-hour collection.
36. Collect the initial blood specimens for glucose and insulin levels., Instruct the patient to
drink the predetermined dose of the glucose beverage., Start the timing for the glucose
tolerance test., Collect blood specimens at physician prescribed intervals.
a. When a patient reports to the outpatient draw station for a glucose tolerance test
and patient identification and compliance with the fasting period has been
established, the first step is to draw blood for a fasting blood glucose to establish
a baseline. It is crucial to make sure the patient’s glucose is not too high before
administering the glucose dose. Should the initial glucose be above the lab’s
established limit for this procedure, the ordering physician should be consulted as
to how to proceed. When the fasting sample is within limits, the patient is given a
known dose of glucose beverage and instructed to drink it within 5 minutes. The
timing for the test begins when the drink is finished. Typically, samples are drawn
at ½ hour, 1 hour and continued as ordered by the physician.
37. Castile soap wipes
a. It is important not to contaminate the urine sample with normal skin flora,
therefore the genital area is cleansed with castile soap wipes just prior to
collecting the sample. Alcohol, iodine and betadine are not used for this purpose
as they would be too harsh for the skin.
38. At body temperature and return it to the lab within 30 minutes.
a. Semen is analyzed for fertility testing and effectiveness of post vasectomy
procedures. It is vital that after the sample is collected in a sterile container, it be
kept at body temperature and returned to the lab within 30 minutes. Fertility
testing includes measurements of macroscopic, microscopic and physiologic
elements. Sperm motility can decrease significantly within 2 hours. Placing the
container in ice is contraindicated.
39. Collect a first morning specimen., Collect the specimen 1 hour after eating a meal.
a. First morning specimens are preferred for sputum collections as secretions tend
to collect in the lungs overnight and a larger volume of specimens can be
produced. It is advisable to wait at least an hour after the patient has eaten to
minimize the risk the patient will gag or vomit. Rinsing the mouth with water
before the collection will reduce the risk of contaminating the sample with normal
mouth flora. Mouthwash may contain antiseptics which could contaminate the
sample. Sterile water is not necessary. A normal diet may be followed before the
procedure.
40. Read the temperature strip.
a. Urine specimens for drug screening are most vulnerable to adulteration during
the collection process. The temperature of the sample must be taken within 4
minutes of collection and be within a range of 32.5 oC to 37.7 oC. Also checked
are the pH, color and specific gravity for signs that the specimen has been
tampered with. The phlebotomist should always wash her hands and put on
gloves before beginning the process and document medications being taken by
the donor if applicable. Specimens are packaged and prepared for transport
under the chain of command protocol.
41. “Rinse the mouth with warm water.
a. Before collection of a sputum specimen, the patient is asked to rinse the mouth
with warm water. This helps minimize contamination with saliva. Brushing the
teeth and using mouthwash might contaminate the sample with those chemicals.
Deep breathing has no effect on the collection and coughing is the way in which
the sample is collected.
42. Keep at room temperature., Develop with hydrogen peroxide.
a. Guaiac smears are a waived point of care method of screening for fecal occult
blood. After the patient collects these, they are returned to the lab or physician’s
office for testing. The test consists of developing the area with hydrogen
peroxide. A blue color around the specimen on the card indicates the presence of
blood. Each card has a quality control (QC) area which is developed first. Should
the QC not perform correctly, the patient results are invalid. These specimens are
kept at room temperature. Normal saline or 70% alcohol is not used in this test.
43. Foot/ankle
a. The most often used site for venipuncture is the antecubital fossa. The veins in
this area of the arm are easily felt and accessed. The hand or the top of the wrist
may also be selected. The underside of the wrist is never used as the nerves and
tendons present would make the draw too dangerous. A draw in the foot or ankle
requires a physician’s written permission and is contraindicated in diabetic
patients because of their predilection to tissue necrosis and thrombosis
formation.
44. Anticoagulants
a. Medications such as coumadin and heparin are given to patients whose disease
process leads to intravascular clotting such as heart attacks (myocardial
infarction) and DVTs (deep vein thrombosis). Also called blood thinners, these
drugs work by lengthening the time that blood takes to clot. Antihypertensives are
used to lower blood pressure. Anti Glycolytic lower blood glucose and
antihistamines offer allergy relief.
45. Left arm
a. When a patient has a mastectomy, often lymph nodes are removed with the
breast tissue. This leaves the patient predisposed to lymphostasis and possible
infection on that side of the body. Therefore, another site must be chosen for
venipuncture unless the doctor has given written permission for a draw in that
area.
46. Hold pressure on the site for a minimum of five full minutes until the bleeding stops.
a. The phlebotomist is responsible for post venipuncture wound care which includes
confirming that the site has stopped bleeding. If the patient is on coumadin or
other anticoagulant therapy, this may require applying pressure for five minutes
or longer and the application of a pressure bandage before releasing the patient.
Immediately applying a pressure bandage does not assure the wound will close
and bleeding will stop. Leaving the patient to apply pressure while going to find a
physician may result in patient injury. A patient should never be left alone.
47. Perform the blood draw in the presence of the physician.
a. If the patient is not mentally competent enough to understand and consent to a
medical procedure, the caregiver or physician must be present. Performing a
draw without positive identification from the patient can be seen as malpractice
and without consent is considered assault and battery. Patients can only be
restrained on orders from a physician and after all other measures have been
exhausted. Phlebotomists do not place patients in restraints.
48. Wrap the arm in gauze and apply the tourniquet
a. If the skin is irritated or very thin, the tourniquet may be applied over clothing, a
clean dry washcloth or length of gauze. A tourniquet is used during the
venipuncture procedure to distend the vein, making it easier to see and providing
adequate pressure to assist in collecting the specimen. The tourniquet should be
applied 3 to 4 inches above the intended venipuncture site. If applied too closely,
the vein may collapse during the procedure and if too far away, not enough
pressure will be generated to distend the vein adequately. Typically, tourniquets
are a flat strap made of a latex free elasticized material. The current trend is to
use them once and discard them. This practice aids in preventing transmission of
infection. If the tourniquet is reused, it must be disinfected regularly. A cloth
tourniquet would be an infection control risk if used repeatedly.
49. Hand vein
a. Edematous areas should be avoided because the blood sample will be
contaminated with tissue fluid and give false test results. A tourniquet cannot be
placed on the right arm due to burns. A hand vein on the right arm may be the
best choice. The femoral veins and arteries are only accessed by a physician.
Written permission from the patient’s doctor must be obtained before drawing
from a foot.
50. Position the patient supine.
a. If a patient is known to have a history of syncope (fainting) during blood draws, it
is best to perform the procedure in a supine position. This minimizes the chance
of patient injury. Asking a co-worker to assist might help distract the patient and
provide help if it is needed. It is not necessary to inform the ordering physician
unless there is an untoward event. Giving the patient orange juice might induce
vomiting or affect the test results.
51. Match the labels on the tubes., Prepare under a bench top splash shield., Use a
disposable transfer pipette.
a. An aliquot is a portion of a specimen taken from the original sample to have
further testing done in a different area of the lab. It is crucial to have the exact
same information on the aliquot container as the original tube. When separating
specimens, a bench top splash shield should be used to prevent splashes of
blood or body fluids from coming into contact with the processor. Specimens are
not poured directly into aliquot containers. Disposable transfer pipettes are used
in moving portions of the sample to the aliquot tube.
52. “I must pre-label aliquot tubes one patient at a time.”, “I must remove stoppers from
tubes using a face shield.”
a. Aliquoting is the process of transferring a portion of the original specimen to
another container for testing. The secondary tubes must have the exact same
information as the primary container. Tubes are prelabeled one at a time before
the transfer to prevent picking up the wrong tube. Stoppers should be removed
using a face shield to protect the processor from aerosols or splashes of fluid. If a
tube is centrifuged, it would no longer be useful for whole blood testing.
Potassium (K) levels do not need protection from light.
53. The first drop of blood may contain fluid from the tissues.
a. The first drop of blood obtained after a dermal puncture will contain tissue fluid
and should be wiped away for accurate test results. The 70% alcohol used to
clean the site should be allowed to dry completely so as not to contaminate the
sample or cause pain to the patient. Bacteria on the finger should have been
cleaned away during site preparation. The amount of oxygen in the capillary
specimen will not affect test results unless arterial blood gasses are being
measured.
54. INR
a. Currently, the only coagulation test available as a POC (point of care) is the INR
which monitors coumadin levels. The D-dimer must be performed in the lab. Hct (
a hematology test) and Bun (a chemistry analysis) can be done as POC but are
not coagulation tests.
55. Follow dietary guidelines specifically for the test.
a. Many laboratory tests have special instructions to be followed by the patient in
order to help produce accurate results. Fecal occult blood (FOB) tests are done
on special collection cards supplied to the patient by the ordering doctor’s office
or lab to assess the presence of intestinal bleeding. It is necessary to avoid
ingesting vitamin C or red meat for 72 hours as this may produce false test
results. Gastric ulcers would cause a positive result. Thoroughly cleaning the
anal area or discontinuing medications (other than aspirin or NSAIDS) is not
necessary.
56. FOB
a. Although more and more laboratory tests are available as POCT (point of care
testing), cortisol, iron and T4 are still performed in the main lab. Fecal occult
blood (FOB) is a waived test used to screen for gastrointestinal bleeding. This
may be done as POCT.
57. The doctor who ordered the test.
a. A critical result should be reported to the ordering physician so that immediate
follow up action can be taken to prevent harm to the patient. It may be acceptable
to report these results to the doctor’s nurse or medical assistant but the
phlebotomist should document the date, time and to whom the information was
given. The lab manager is not usually involved in result reporting except to create
and enforce the policies that govern the task.
58. Green and AST
a. Blood is drawn into tubes containing additives that preserve the analyte being
tested for. The colors of the tube caps indicate the contents. The liver enzyme
AST can be collected into a green (heparin) tube. A gold serum tube with gel
cannot be used for blood types as the gel creates a barrier over the red cells.
Lactic acid must be drawn into a gray top (sodium fluoride, potassium oxalate)
and delivered STAT on ice. A blue top (sodium citrate) is used for D-dimer which
is a coagulation factor test.
59. Light blue, lavender, gold gel barrier
a. A Prothrombin Time (PT) is drawn in a light blue top tube which contains sodium
citrate. A gold gel barrier tube can be used for the Prostate-specific antigen
(PSA) as this test requires serum. The lavender tube (K EDTA) would be used for
the complete blood count (CBC) because this test must be done on whole blood.
The gray top ( sodium fluoride and potassium oxalate) is reserved for glucoses,
lactic acids and alcohol levels. Yellow ACD (acid, citrate, dextrose) tubes are
used for special tests such as cellular studies, HLA typing and paternity testing
60. Gray top
a. It is not uncommon for test requests to be added onto a patient’s orders. In this
case, a gray top would suffice for the glucose level. Blue tops (sodium citrate) are
used for coagulation testing. Lavender tops (EDTA) are used for Hematology
tests. A tan top also contains EDTA but is used for lead tests.
61. Lavender
a. Many evacuated blood collection tubes contain additives that stop blood samples
from clotting to preserve the analytes to be measured. Lavender tubes contain
EDTA which prevents platelets from clumping and preserves the appearance of
red and white cells for microscopic examination. Light and dark green tubes
contain heparin and are used for many chemistry tests. Light blue tubes use
sodium citrate and are used to assess coagulation factors.
62. Continue to draw using a gray top.
a. A blood sample for glucose testing may be drawn in a gray top tube (sodium
fluoride and potassium oxalate) so the phlebotomist should change from a pink
top (EDTA) to a gray. If not needed for other tests, the pink top may be discarded.
If the draw is proceeding well there is no need to discontinue or reschedule it. A
black top (EDTA) is used for ESR (erythrocyte sedimentation rate) tests and not
for glucose.
63. Light blue, lavender, gray
a. Blood collection tubes are color coded to indicate their chemical contents. The
Clinical Laboratory Standards Institute (CLSI) defines the order of drawing these
tubes to prevent carryover of the contents from one tube to the next. A small
amount of the chemical may be retained on the inner needle or rubber sleeve of
the ETS system and contaminate the next tube thereby affecting patient results.
The order is sterile (blood cultures), sodium citrate (blue), serum (red or gold with
or without clot activator or gel separator), heparin (green), EDTA (purple or pink),
sodium fluoride & potassium oxalate (gray). In this case, the light blue would be
drawn first for the INR, lavender second for the CBC and gray last for the FBS.
64. 60 min
a. The prenatal oral glucose challenge is performed to identify the likelihood for
gestational diabetes - a condition that can present health risks for the mother and
baby. The fasting patient is given 50 to 75 mg of an oral glucose drink and a
blood specimen is collected 60 minutes after the drink is finished. A value of 140
mg/dl is considered normal. If the test is positive, then a full oral glucose
tolerance test may be ordered.
65. Use a capillary collection procedure.
a. Blood for neonatal screening is typically collected from a dermal puncture to the
medial or lateral plantar surface of the heel. The baby must have an identification
band attached – usually to a leg. Warming the site will yield a better blood flow as
babies have higher red blood cell counts. A syringe would be used on an arm,
hand or wrist and are not used for these collections.
66. Collect the blood sample before the drug is administered.
a. It is crucial to accurately monitor the levels of therapeutic medications as many of
these drugs have harmful side effects. The physician needs to know that the
dose of a particular medication is at the appropriate level to assure its
effectiveness. If the level is too low, no medical benefit will be produced. If too
high, there may be toxic consequences. This is called a therapeutic window. A
trough (lowest) level is drawn immediately prior to administration and serves as a
baseline. A peak (highest) level is drawn at a prescribed time after the drug has
been administered. It is not the responsibility of the phlebotomist to stay with or
monitor the patient. Collecting two trough samples or pre labeling tubes is not
good laboratory practice.
67. 30 minutes prior to medication administration
been administered. Drawing a trough at any time after the medication has been
started is contraindicated as it would not provide the lowest level of the drug.
68. Verify the time of collection with the patient’s nurse or physician.
been administered. In this case, the phlebotomist needs to verify the time the
dilantin infusion was begun as it appears the opportunity to draw an accurate
trough level has been missed. Consulting with the patient’s caregiver - not the
chart - will determine the course of action. If a sample needs to be collected, a
site distal to the saline infusion would be appropriate. The laboratory supervisor
would have no accurate information pertaining to this particular case.
69. Place the thumb 1 to 2 inches below the site.
a. Using the thumb of the non-dominant hand to anchor the vein 1 to 2 inches below
the site 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 index finger (C or window hold) leaves the index finger in line for a
possible needlestick injury. Just enough pressure should be applied to keep the
vein still.
70. Place the thumb 1-2 inches below the venipuncture site., draw the skin away from the
site.
a. Using the thumb of the non-dominant hand to anchor the vein 1 to 2 inches below
the site 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.
71. 23g needle at a 10 to 15 degree angle
a. Hand veins are close to the surface and tend to “roll”. A smaller (23g) needle and
lower angle (10-15 degrees) may help the phlebotomist be successful. Any size
needle inserted at a steep angle of 40-45 degrees would likely go through the
vein and may cause the patient injury. A 21g needle is too large for a hand vein
and might cause a hematoma.
72. Blood culture
a. If the intended site of venipuncture for blood culture collection is not cleaned
properly or is recontaminated by touching, skin bacteria can be introduced into
the specimen and produce false positive results. This is why these tests are
drawn first while the skin is as clean and free of bacteria as possible. The special
skin cleansing is not required for hematocrit, cholesterol and complete blood
count (CBC).
73. SPS, SST, heparin, EDTA
a. The order of draw is designed to prevent carryover of additives from one tube to
the next thereby affecting patient results. CLSI states the order of draw for ETS
tubes to be: SPS (sterile), sodium citrate (blue), serum (red or gold), heparin
(green), purple (EDTA), oxalate / fluoride (gray). In this case the order would be
SPS blood cultures, SST (serum separator), Heparin (green), EDTA (purple)
74. D-dimer, RPR, ESR, lactic acid
or without clot activator or gel separator), heparin (green), EDTA (purple), sodium
fluoride & potassium oxalate (gray). In this case, the light blue would be drawn
first for the D-dimer, the non-additive (serum) tube second (RPR), lavender
(ESR) third and gray (lactic acid) last. The gray top should be transported in an
ice slurry.
75. PTT, BMP, CBC, lactic acid
The order is sterile (blood cultures), sodium citrate (blue), serum ( red or gold
with or without clot activator or gel separator), heparin (green), EDTA (purple or
pink), sodium fluoride & potassium oxalate (gray). In this case, the light blue
(sodium citrate for PTT) is drawn first, then a red, gold or green for the BMP, then
a lavender (EDTA) for the CBC and a gray (fluoride / oxalate) for the lactic acid
last.
76. Light blue, red, green
or without clot activator or gel separator), heparin (green), EDTA (purple), sodium
fluoride & potassium oxalate (gray). In this case, the order would be: light blue
drawn first, the non-additive (serum) tube second and the green last
77. EDTA, heparin, sodium fluoride, no additive
a. The order of draw for dermal punctures is different than for venipuncture. Since
there is no risk of “carryover” of additives to be concerned with, the CBC (EDTA)
tube should be collected first as it presents the most likely to form clots. Then
other additive tubes such as heparin and sodium fluoride. It is important to
continually mix the additive tubes while performing the procedure. Serum tubes
(red or gold with no anticoagulant) are collected last as clots forming in these will
not matter.
78. Light blue, red, green, lavender
Clinical Laboratory Standards Institute (CLSI) defines the order in which these
tubes should be drawn to prevent carryover of the contents from one tube to the
patient results. The recommended order is sterile (blood cultures), sodium citrate
(blue), serum (red or gold with or without clot activator or gel separator), heparin
(green), EDTA (purple or pink), sodium fluoride & potassium oxalate (gray). In
this case, the order would be light blue (D-Dimer), red (estrogen), green (STAT
electrolytes), lavender (ESR).
79. Prothrombin, cholesterol, CBC, glucose
tubes to be: SPS (sterile), sodium citrate (blue, serum ( red or gold), heparin
prothrombin (blue), cholesterol (gold), CBC (purple), glucose (gray).
80. Light blue, gold, lavender, gray
The order is (for the most commonly used tubes): sterile (blood cultures), sodium
citrate (blue), serum ( red or gold with or without clot activator or gel separator),
heparin (green), EDTA (purple), sodium fluoride & potassium oxalate (gray). In
this case, the order would be light blue (PT/INR), gold (CMP), lavender (ESR),
and gray (lactic acid). Pink tubes also contain EDTA but are typically used for
Blood Bank tests.
81. Sodium citrate, heparin, EDTA
tubes to be: SPS (sterile), sodium citrate (blue, serum ( red or gold), heparin
sodium citrate (PTT), heparin (BMP) EDTA (CBC).
82. Light blue, red, lavender
sodium fluoride & potassium oxalate (gray). In this case, the light blue (sodium
citrate for coagulation studies) is drawn first, then the red (no additive for serum
chemistry) and the lavender (EDTA) for hematology last.
83. Light blue, gold, lavender, pink, gray.
sodium fluoride & potassium oxalate (gray). In this case, the order would be light
blue (APTT), gold (calcium), lavender (CBC), pink (ABO group and Rh type), and
gray (glucose).
84. Light blue, green, lavender.
a. The correct order of draw would be light blue for the PT, green for the BUN and
electrolytes and lavender for the CBC.
85. They run a risk of choking.
a. Applying a bandage to the site of blood collection for small children leads to the
risk of choking if they place it in their mouth. Simply applying pressure and
checking the site until assured that bleeding has stopped will usually suffice.
There is no risk of contamination and clotting should be complete in the usual
time. Petechiae might appear after a tourniquet application, but usually resolve
after the procedure is ended.
86. Coban
a. Geriatric patients tend to have thin skin that can tear when an adhesive bandage
is removed. Coban is used in these cases as it sticks to itself and not to the skin.
Paper tape, Band-Aids, and micropore tape are all adhesive bandages.
87. Paper tape.
a. Paper tape is the best choice to prevent tearing of fragile skin during the removal
of a bandage after performing a venipuncture. Bandaids, silk or surgical tape are
harder to remove and could damage the skin leaving it open to infection.
88. Hold pressure for 5-10 minutes.
a. It is the responsibility of the phlebotomist to assure bleeding from the
venipuncture site has completely stopped before applying a bandage and
releasing the patient. As those with hemophilia tend to bleed longer, direct
pressure to the wound site for 5-10 minutes may be required. The patient may be
enlisted to assist if able. Bandaging the patient as normal or applying an extra
layer of gauze will not aid in cessation of bleeding in this case. Lowering the
patient’s head will only help to prevent syncope (fainting).
89. Gauze and instruct the patient not to bend the arm.
a. It is the responsibility of the phlebotomist to assure that bleeding has stopped
after completing a venipuncture procedure. This is accomplished by applying
direct pressure to the wound site with a gauze pad. If the patient is capable, they
may be enlisted to apply the pressure and allow the phlebotomist to complete
other tasks. Cotton balls are not used because the fibers may stick to and
dislodge the platelet plug when the bandage is removed and bleeding may
resume. Bending the arm up will encourage bleeding under the skin at the site
and a hematoma may form.
90. Upon completion of the blood draw.
a. Specimens should be labeled immediately after drawing at the patient’s side.
Some facilities require the patient to review the labels on the tubes to assure that
they are correct. Labeling tubes after the patient is released omits this step.
Applying labels during equipment assembly or before approaching the patient is
contraindicated as the phlebotomist may encounter a faulty tube and have to
obtain a new set of labels. Also, it is too easy to pick up a pre labeled tube for
another patient.
91. Source of specimen
a. If using a micro collection tube for something other than capillary collection, the
phlebotomist needs to add the source of the specimen to the label – such as
“venous blood”. Reference ranges for many tests are different for capillary,
venous and arterial samples. The patient’s initials are not used. The date and
time of collection and the phlebotomist’s initials are always added to the label.
92. Patient’s date of birth, patient’s first and last name, date and time of collection
a. It is especially crucial that patients having any Blood Bank testing, particularly
transfusions, be properly identified. Failing to correctly perform this step can be
fatal. At a minimum, the patient’s full name, date of birth and date and time of
collection must appear on the tube label. In addition, the blood bank specimens
must include the initials (or unique id ) of the phlebotomist and the medical record
number. Also, if the patient is to be transfused, they are given a special armband
with a unique number from a specially labeled identification card that has multiple
stickers with this number. When blood products are selected and crossmatched
for this patient, one of the numbered stickers is placed on each of the product
labels. The numbers from this band and card must match with those on the blood
product before the transfusion can take place. Room numbers and physician’s
names may appear on pre-printed labels, but are not necessary for proper
identification
Study Guide - Infection Control and Safety -
53Q’s Answers
1. Material Safety Data Sheet
a. OSHA mandates that all chemicals have a Material Safety Data Sheet (MSDS).
With implementation of GHS, now called Safety Data Sheet. Details provided
must include: product identification, hazard(s) identification, composition
measures and handling and storage. Recently MSDS have been changed to
Safety Data Sheets (SDS) in an effort to align with the new Globally Harmonized
System (GHS) that is now being used worldwide. These documents contain all
the information on how to safely handle each chemical including how to contain
and clean up a spill. The Clinical Laboratory Improvement Amendments (CLIA)
govern laboratory operations, the Poison Control Center assists with treatment of
poisoning incidents and the Physician’s Desk Reference (PDR) outlines
pharmaceutical products.
2. Provide a confidential medical evaluation.
a. Counseling, education, and follow-up should be provided by an employer for up
to one year after exposure.
3. MSDS
a. OSHA (Occupational Safety and Health Administration) is the federal agency
responsible for reducing and preventing exposure to worker injuries. This agency
requires that every chemical purchased or stored in a facility to have a MSDS
(material safety data sheet), now called SDS (safety data sheet) to align with the
international GHS (globally harmonized system). Information contained in these
documents include: chemical identification, hazard identification, composition
measures and handling and storage. The NFPA (National Fire Protection
Agency) has developed a labeling system to alert workers of exposure dangers
of chemicals. The CDC (Centers for Disease Control and Prevention) is the
federal agency responsible for identifying, monitoring and reporting diseases
capable of becoming epidemic.
4. OSHA, NFPA, CDC
a. OSHA (Occupational Safety and Health Administration) is the federal agency
responsible for reducing and preventing exposure to worker injuries. The NFPA
(National Fire Protection Agency) has developed a labeling system to alert
workers of exposure dangers of chemicals. The CDC (Centers for Disease
Control and Prevention) is the federal agency responsible for identifying,
monitoring and reporting diseases capable of becoming epidemic. CMS (Centers
for Medicare & Medicaid Services) oversees Medicare, Medicaid, CLIA 88 and
COLA. CLIA (CLIA 88) is the federal law that regulates medical laboratory
testing.
5. Rescue the patient, activate the alarm, confine the fire, extinguish the fire
a. The National Fire Protection Agency (NFPA) has developed a “code” word to
assist healthcare workers in remembering the steps to take in case of a fire
emergency. The word is RACE and stands for: R (remove individual in danger), A
(activate the fire alarm), C (contain the fire by closing doors and windows), E
(extinguish, if possible, with the nearest fire extinguisher).
6. Provide immediate medical evaluation and scheduled surveillance.
a. The Needlestick Safety and Prevention Act passed in 2001 outlines steps that
employers must take in case of employees’ sharp injuries. Among these is the
provision of immediate access to medical evaluation and treatment. This includes
having source individuals tested for bloodborne pathogens. Yearly educational
inservices are also part of this plan. Confidentiality and management of protected
health information (PHI) are mandated by the HIPAA law.
7. Butterfly winged infusion set
a. Of the equipment commonly used for venipuncture, the butterfly winged infusion
set is considered the most likely to cause a needlestick injury. Although required
to have safety devices, the small size can make these sets more awkward to
handle than the ETS or syringe system. Lancets have an automatic, spring
loaded withdrawal system that prevent the sharp from being exposed once
activated.
8. The type of device used to collect the specimen
a. In completing a phlebotomy related exposure incident report, it is imperative to
include the type of device used that malfunctioned during the collection of the
specimen and failed to protect the healthcare professional. The type of tube used
for the collection and the requisition test will not affect the exposure control
protocols and will play no role in assessing the injured employee. The physician
or the nurse must obtain consent from the source patient to test for bloodborne
pathogens. The patient, however, is under no obligation to consent and cannot
be compelled to divulge his or her medical condition under HIPAA. If the patient
does not consent, the exposed employee will be offered existing prophylactic
treatment options for known and/or suspected bloodborne pathogens.
9. Wash the site with soap and water.
a. After a bloodborne pathogen exposure event such as a needlestick injury, the
wound must be washed with soap and water. The phlebotomist should then
immediately report the event to the supervisor and to employee health. An
incident report should also be filled out. All healthcare facilities are required to
have an exposure control plan and the elements of this policy should be followed
and documented. The important thing is to be proactive in reporting and following
up on the exposure and to assess how to prevent future such accidents. Any
reports to the CDC are handled by administration.
10. Antimicrobial soap and water for a minimum of 30 seconds.
a. The first step to take after a sharp injury is to wash the area with soap and water
for a minimum of 30 seconds. Most soap solutions available in healthcare
facilities are antimicrobial. Sterile saline or 70% alcohol are not necessary.
Disinfectants are used for surfaces, not on skin.
11. Soap and tap water
area must be washed with soap and water. The phlebotomist should then
and documented. Alcohol, sterile saline or a sanitizing agent are not typically
used. The important thing is to be proactive in reporting and following up on the
exposure and to assess how to prevent future such accidents.
12. File an incident report.
area must be washed with soap and water. The phlebotomist should then
and documented. Unless informed consent is required to test the involved
patient’s blood for bloodborne pathogens, there is no reason to inform the
patient. Looking up the patient’s medical history would be a HIPAA infraction. A
glove change is required after each patient and would not contribute to the
phlebotomist’s safety after the needlestick. The important thing is to be proactive
in reporting and following up on the exposure and to assess how to prevent
future such accidents.
13. Wash the site with soap and water for a minimum of 30 seconds.
a. All healthcare facilities are required by OSHA to have a Bloodborne Pathogen
exposure control plan. Part of this plan includes the steps to follow if a sharp
injury occurs. The first step is to remove the sharp from the wound and wash the
site with soap and water for at least 30 seconds. Disinfectant is not necessary.
Then inform the immediate supervisor and report to a licensed healthcare
provider for evaluation and treatment. It is very important to also document the
event on an incident report form.
14. Flush the area with water and thoroughly wash it.
site with soap and water for at least 30 seconds. Then inform the immediate
supervisor and report to a licensed healthcare provider for evaluation and
treatment. It is very important to also document the event on an incident report
form. The hepatitis B vaccine is offered to all healthcare workers within 10 days
of beginning employment and the phlebotomist should not be working without it.
These wounds usually do not require much pressure to stop bleeding although a
bandage may be applied. Unless informed consent is needed to perform follow
up testing for hepatitis B and HIV, the patient is not informed.
15. Report the incident to the supervisor/manager.
a. All healthcare facilities are required by OSHA to have an exposure control plan in
place in case of sharp injuries or blood borne pathogen exposures. When an
incident occurs, the first step is to wash the injured area with soap and water.
Then report to the supervisor who will oversee and document the occurrence.
Both the phlebotomist and the source will be tested for HBV & HIV.
16. Absorb the spill using paper towels.
a. A spill of blood or other body fluid represents a possible bloodborne pathogen
exposure. Special chemical solutions and kits can be used. Gloves must be
worn. Cleanup should concentrate on the absorption of fluid without spreading it
around. Paper towels may be used but any glass or sharps involved must be
placed in a sharps container. Non sharp cleanup materials should be disposed of
in biohazard bags. The counter may be wiped down with a 10% bleach solution
which will not damage the surface.
17. wash with soap and water, alert supervisor, report to employee health, get consent from
the patient
site with soap and water for at least 30 seconds. Then inform the immediate
supervisor and report to a licensed healthcare provider for evaluation and
treatment. It is very important to also document the event on an incident report
form. In some states, informed consent is needed to perform follow up testing for
hepatitis B and HIV.
18. Bleach
a. Antiseptics such as benzalkonium chloride (BZK), chlorhexidine gluconate and
isopropanol are used on skin. Bleach (sodium hypochlorite) is used as a
disinfectant to decontaminate surfaces and has been shown to be a highly
effective germicide. Most commonly used is a 10% bleach solution (100 ml
bleach + 900 ml water).
19. 90 ml water to 10 ml bleach.
a. A 10% solution of bleach requires the addition of 10 ml of bleach to 90 ml of
water. This is the standard ratio used for surface disinfection purposes.
20. Disinfect the equipment.
a. The breakage of a tube of body fluid in a centrifuge creates a possible
bloodborne pathogen exposure. The equipment should be disinfected with an
approved disinfectant or 10% bleach. Gloves must be worn. There is no need to
discard or sterilize the equipment
21. Between patient use.
a. If blood glucose meters must be shared, the device should be cleaned and
disinfected after every use, per manufacturer’s instructions, to prevent carry-over
of blood and infectious agents.
22. Bleach
a. OSHA requires surfaces in specimen collection and processing areas to be
decontaminated with a 1:10 bleach solution or other EPA approved disinfectant.
This should be done at the end of each shift and gloves should be worn. An
antiseptic such as alcohol or iodine differs from a disinfectant in that it is used to
clean skin and not surfaces.
23. Methicillin-resistant Staphylococcus aureus
a. Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C.
diff) are two of the most commonly nosocomial or healthcare associated infection
pathogens. Staphylococcus epidermidis is one of the microorganisms that makes
up normal flora on the skin and is not considered to be pathogenic (able to cause
disease) under normal conditions. Group A Streptococcus is the pathogen that
can cause common strep and individuals may carry this microorganism without
having or showing or any symptoms. Neisseria gonorrhoeae is the pathogen that
causes the sexually transmitted diseases gonorrhea.
24. Contact with fecal contaminated food/water
a. Infectious disease of the liver caused by the Hepatitis A virus. All other hepatitis
viruses (B, C, D, E) are bloodborne pathogens.
25. Droplet
a. Severe Acute Respiratory Syndrome (SARS) is spread by droplets from coughing
or sneezing. A phlebotomist would use droplet transmission based precautions
for this disease. Transmission based precautions are used when a patient is
known to have or is suspected of having a specific disease. The three categories
are airborne, droplet and contact. Droplet precautions are used for SARS.
Standard precautions are based on the assumption that all patients may be
infectious and are used with all patients.
26. Standard Precautions
a. Standard precaution is an approach to infection control that treats all patients,
regardless of their disease and/or infection status, as potentially infectious. All
blood, body fluids, secretions, and excretions, except for sweat are considered to
be contaminated with bloodborne pathogens and capable of transmitting the
infection. Healthcare professionals must use Standard Precautions with all
patients at all times whenever contact with blood or body fluids is anticipated.
Standard Precautions include wearing gloves and using proper hand hygiene
before and after each patient contact. Contact, Droplet, and Airborne Precautions
are all part of Transmission-Based Precaution, which is always used in addition
to Standard Precaution and only when the patient is suspected of or has been
diagnosed with a highly transmissible and infectious agent. The need for
Transmission-Based Precaution will be determined by a physician
27. Droplet
a. In 1996 the CDC implemented two new levels of infectious control standards.
The first, Standard Precautions, replaced Universal Precautions, and stated that
all blood and body fluids are to be presumed infectious. The second,
Transmission Based Precautions, are established by how infectious agents are
spread and are used in addition to Standard Precautions when a specific disease
is suspected or known in a patient. Three categories are provided: Airborne,
Droplet and Contact. Airborne infections (requiring a mask or respirator) are
carried by droplet nuclei particles smaller than 5 um and include tuberculosis,
measles, chickenpox and mumps. Droplet infections (requiring a mask) are
dispersed by coughing and sneezing and include meningitis, whooping cough,
influenza and respiratory synctial virus. Examples of contagious agents spread
by Contact mode (requiring gown and gloves) are Clostridium difficile, rotavirus,
antibiotic resistant infections, and herpes simplex. See the following link:
http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan
-2011/transmission-based-precautions.html Complete isolation is a category of
former isolation procedures that have been replaced by Transmission Based
Precautions. (Basic Medical Laboratory Techniques, Estridge, 2002, 4th Ed., pg
471, Table 7-11)
28. HBV
a. Hepatitis B is the most transmissible infection, and the only one preventable by
immunization.
29. A disposable tourniquet
a. Contact precautions are used in combination with standard precautions for
patients known to have or suspected of having infections that are transmitted by
direct contact with the patient or indirect contact with surfaces of patient care
items. In this case, it is best to use a disposable tourniquet. Reusable
tourniquets, such as blood pressure cuffs or Velcro types would risk spreading
the infection. The size of the tourniquet is governed by the size of the patient.
30. Gown.
a. Standard precautions (1996) combine the use of PPE (personal protective
equipment) with hand hygiene and apply to blood, all body fluids, non-intact skin
or mucous membranes. Transmission based isolation precautions are a subset of
Standard Precautions designed by how infectious agents are spread. There are
three categories. Contact requires gloves and gown and are used in any case in
which the healthcare worker may be exposed to body fluids. Droplet requires a
mask and eye protection (goggles), and airborne requires an N95 respirator with
the patient placed in a negative airflow environment. Bonnets are used to keep
hair from falling into and contaminating surgical sites and are not typically used
by phlebotomists.
31. Gloves, gown
a. Transmission based isolation precautions are a subset of Standard Precautions
designed by how infectious agents are spread. There are three categories.
Contact requires gloves and gown, droplet requires a mask and eye protection
(goggles), and airborne requires an N95 respirator.
32. Bringing a phlebotomy tray into the room
a. If a patient is in an isolation environment, it is imperative to limit and control
exposure of staff and visitors to the contagious agent. This can be accomplished
by only bringing in the supplies the phlebotomist needs for a blood draw and
leaving any extras in the room. Bringing a phlebotomy tray into the room would
require taking it back out which would risk spreading infection. Isolation rooms
typically have an area between the room and the exit to the hallway in which PPE
can be removed and bagged. Hand washing facilities are also located in this
space.
33. Standard precautions and droplet precautions
a. In 1996 the CDC implemented two new levels of infectious control standards.
The first, Standard Precautions, replaced Universal Precautions, and stated that
all blood and body fluids are to be presumed infectious. The second,
Transmission Based Precautions, are established by how infectious agents are
spread and are used in addition to Standard Precautions when a specific disease
is suspected or known in a patient. Three categories are provided: Airborne,
Droplet and Contact. Airborne infections (requiring a mask or respirator) are
carried by droplet nuclei particles smaller than 5 um and include tuberculosis,
measles, chickenpox and mumps. Droplet infections (requiring a mask) are
dispersed by coughing and sneezing and include meningitis, whooping cough,
influenza and respiratory syncytial virus. Examples of contagious agents spread
by Contact mode (requiring gown and gloves) are Clostridium difficile, rotavirus,
antibiotic resistant infections, and herpes simplex. See the following link:
http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan
-2011/transmission-based-precautions.html
34. Adenovirus, varicella, measles
a. Airborne infections (requiring a mask or respirator) are carried by droplet nuclei
particles smaller than 5 um and include tuberculosis, measles, chickenpox,
adenovirus (common cold) and mumps. RSV (respiratory syncytial virus) is
categorized as droplet transmission and MRSA (methicillin resistant
staphylococcus aureus) is considered a contact transmission.
35. 2.0 mm lancet
a. The lancet used for a heel puncture on a full term infant should not penetrate
beyond 2.0 mm (1.8mm for a premature infant). If the blade were to go deeper,
the heel bone (calcaneus) might be pierced leaving the child susceptible to a
serious bone infection known as osteomyelitis. Insufficient depth will not yield
adequate blood flow. A 21 gauge needle would be too large for venipuncture on
an infant and is not used for dermal puncture. The 18 gauge needle might be
used for collection of donor blood from an adult.
36. The incorrect needle angle was used.
a. Nerve damage typically occurs during a venipuncture when nerves are
accidentally pierced. This may happen if the basilic vein is chosen and the
correct angle of needle insertion (< 30 degrees) is not followed. The basilic vein
is always chosen last as it is located in an area of the antecubital fossa that
contains an artery and many nerves. If possible, the veins should be chosen in
the following order: median cubital which is well anchored in tissue, cephalic on
the outside and basilic if neither of the first two options is viable after examining
both arms. Inserting the needle with the bevel down may cause it to settle on the
vein wall and obstruct blood flow. Placing the needle too shallowly will miss the
vein.
37. The tube has lost its vacuum.
a. Evacuated blood collection tubes are a manufactured item. Despite good quality
control measures, tubes can become faulty due to production, transport or
storage issues and may lose all or part of the vacuum. It is good practice for the
phlebotomist to carry extra tubes for the requested tests in case a tube will not
fill. Trying a new tube is the first thing to do to recover the draw. If this doesn’t
work, slight repositioning the needle forward or backward may relocate the
needle in the vein. If these measures fail, the draw may have to be discontinued
and an attempt made to draw from another site. If the vein has an occlusion, it is
doubtful the first tube would have filled. The patient’s diagnosis, such as chronic
venous insufficiency should not affect the draw.
38. Probing to find a vein, inserting the needle near the basilic vein
a. If blood flow is not established immediately, especially if using the basilic vein,
advancing the needle further may result in entering the brachial artery. Also,
probing to find a vein can cause an arterial puncture. If the facility allows, the
venipuncture may be continued but extra direct pressure must be kept on the site
for at least 5 minutes (10 minutes if patient is on anticoagulant therapy) or until
bleeding has stopped. A pressure bandage with Coban should then be applied.
The tubes collected should be labeled as “arterial” blood, as some analyte values
are different in arterial and venous blood samples. Some facilities policies state
to immediately discontinue the draw if an artery is punctured, as this is
considered a risk for the patient. It is crucial to know and follow your facility
protocol. Prolonged tourniquet application and vigorous fist pumping may cause
hemoconcentration. Using too large a needle may cause the patient discomfort
but does not, in and of itself, cause arterial puncture.
39. Surgical mask
a. Droplet precautions are used in addition to standard precautions for patients
known to or suspected of having a disease transmitted by droplets (particles
larger than 5 um) generated by sneezing or coughing. Whooping cough
(pertussis) is one such infection. A surgical mask is part of PPE for these
precautions. A fluid resistant gown is used for contact precautions and an N95
respirator for TB. Sterile gloves are not necessary unless an invasive procedure
is being performed.
40. N95 respirator
a. Precautions for airborne infections include negative pressure patient rooms and
N95 respirators for healthcare workers. A surgical mask may not be sufficient.
Masks with a face shield or a full face / head mask are used in cases of potential
splashes or aerosols of body fluids
41. tight fitting gloves that are not irritable to the hands
a. Glove size has a large impact on the tactile sensitivity of the phlebotomist’s ability
to palpate a vein. The glove should fit snugly but not so tight as to inhibit
movement of the fingers. Too loose a fit makes the glove awkward to use. Most
gloves used in phlebotomy today are latex free to prevent allergic reactions in
either the patient or the phlebotomist. It is very important for the phlebotomist to
ask the patient about any latex allergy before beginning the procedure.
42. Gown, mask, gloves
a. 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. Gowns 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.
43. Gown, mask, gloves
a. Personal protective equipment (PPE) is provided to health care workers to help
keep them safe from infectious agents and other safety hazards. When donning
PPE the gown is put on first, then the mask and finally gloves which are pulled
over the cuffs of the gown. PPE is removed in an aseptic sequence to prevent
contamination of the wearer and promptly discarded or bagged. The order for
removing PPE is – gloves, gown and finally the mask. See:
http://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf
a. To remove PPE (personal protective equipment), the gloves are removed first as
these are considered likely to be most contaminated. Using a gloved hand, grasp
the palm area of the other gloved hand and peel off the first glove. Hold the
removed glove in a gloved hand. Slide fingers of ungloved hand under remaining
glove at wrist and peel off second glove over first glove. Discard gloves in a
waste container. The gown is then removed by pulling it from the shoulders,
turning it inside out and then rolling it into a bundle before disposal. The mask is
removed last by touching only the ties.
45. put the containers in a biohazard box and replace.
a. In an effort to reduce needlestick injuries, the needlestick Safety and Prevention
Act of 2001 mandates that all sharps (needles, lancets, broken glass, etc.) be
deposited into a puncture proof, lockable sharps container. When the container is
¾ full, the top is sealed and placed into a biohazard box for appropriate disposal.
The containers are not shaken down or placed into biohazard bags and never
emptied for reuse.
46. Airborne
a. Transmission based precautions are followed when a patient is known or
suspected of having a specific disease. Varicella (chickenpox) can be dangerous
for pregnant women, premature infants and immunocompromised patients.
Airborne protocols are followed including negative flow rooms and care provided
by staff with proven immunity. See:
http://www.cdc.gov/chickenpox/hcp/healthcare-setting.html Isolation is defined as
the act of separating someone from others if they are known to or have a specific
disease and deemed capable of spreading the infection. Reverse isolation
protects a patient from contracting infections from caregivers and staff.
47. Changed when it is ¾ full.
a. Sharps containers are designed to be puncture proof for the disposal of needles,
lancets and objects that pose a “sharps” injury risk. OSHA states they are to be
closed and locked for disposal at ¾ full. The lid will self lock when full. The length
of time is governed by the amount of sharp waste being generated. All medical
equipment should be kept out of reach of children.
48. Face shield
a. In this case, a face shield would be used to protect the healthcare worker from
splashes of body fluid. A mask would not cover the eyes which could be a
potential entry point for infectious material. A gown is used in contact precautions
and gloves are always worn as part of standard precautions.
49. Aliquoting specimens.
a. When uncapping tubes an aerosol of blood or body fluid may be created so face
shields are used to prevent these samples from being splashed onto the mucous
membranes of the face. An alternative to a face shield is a Clear Acrylic
Biohazard Shield which sits on a countertop or a hood with a barrier between the
specimen and the processor. Receiving, centrifuging, and batching specimens
will not create splashes or aerosols until the caps are removed. Gloves should be
worn whenever handling any bodily specimen.
50. Engage the safety and discard the tube holder with a needle.
a. When discontinuing a venipuncture, it is crucial to immediately activate the
needle safety device to prevent injury to the patient or the phlebotomist. The
holder and needle are then discarded as a unit into a sharps container. The unit
is not disassembled as this presents a safety risk.
51. After removing the needle.
a. To prevent accidental needlesticks and exposure incidents, the needle safety
device should be activated immediately upon removal from the venipuncture site.
This is done after the tourniquet is removed and before bandaging the patient. All
used needles and venipuncture equipment should be disposed of in a sharps
container.
52. The phlebotomist activated the needle safety device appropriately, but the needle and
tube holder/adapter should not be separated.
a. Upon completing a blood draw by venipuncture, the needle safety device is
immediately activated to prevent an accidental needlestick injury to the
phlebotomist or the patient. OSHA then advises that the holder and needle be
placed into a sharps (puncture proof) container as a unit. Both pieces of
phlebotomy equipment are “single use”.
53. ¾ Full
a. The needlestick Safety and Prevention Act (2001) was passed to reduce sharps
injuries in the healthcare field. Part of this law dictates that a puncture proof and
self closing container be used for the disposal of needles and other sharps.
These containers are closed when ¾ full and placed into biohazard waste boxes
for disposal.
Study Guide - Orders and Equipment Selection

40 Q’s Answer
1. Glucose
a. Glucose is stable in a gray top tube for 24 hours at room temperature and 48
hours when refrigerated at 4-8oC. In addition to the anticoagulant potassium
oxalate, the gray topped tube contains sodium fluoride which is an antiglycolytic.
Sodium fluoride delays the metabolism of glucose by the red and white blood
cells and platelets, helping to stabilize the glucose level until it can be analyzed.
Potassium, creatinine and cholesterol have different stabilities depending on the
tube type used for collection and storage temperatures.
2. Oxalate, heparin
a. Anticoagulants are added to certain blood collection tubes to keep the specimen
from clotting. These samples can then be used for testing as whole blood or
centrifuged to recover the plasma. Oxalate and heparin are anticoagulants.
Sodium fluoride is an antiglycolytic used to preserve glucose levels. Sulfate is a
component of blood (DHEA sulfate test) and thrombin is an enzyme that aids in
clotting.
3. Prevent coagulation, inhibit calcium, prevent glycolysis
a. There are two additives in a gray top ETS tube – potassium oxalate which
prevents coagulation of the blood by inhibiting calcium and sodium fluoride which
prevents the glycolysis of glucose to lactic acid. Heparin is used as the
anticoagulant in green top tubes and acts by inhibiting the formation of thrombin.
Fibrin is the end product of the coagulation process resulting in a clot.
4. EDTA, sodium citrate, oxalate
a. Anticoagulants prevent blood from clotting by several chemical mechanisms.
Calcium is necessary along with many clotting factors for coagulation to occur.
Inactivation of calcium interrupts the “coagulation cascade” and prevents
fibrinogen from becoming fibrin (clot). Oxalate forms insoluble calcium salts,
while EDTA and sodium citrate chelate or bind this element. Lithium heparin
prevents clot formation by inhibiting thrombin. Sodium fluoride is an antiglycolytic
used to stabilize the glucose level in a blood sample.
5. Ensure the correct blood to additive ratio.
a. For accurate results in coagulation testing, the light blue top tubes must be filled
to the line marked on the tube. This ensures a proper 9 parts of blood to 1 part of
anticoagulant (sodium citrate) ratio. The line does not indicate the level of sodium
citrate in the tube, allow the phlebotomist to adjust the blood level in the tube or
indicate the placement of the tube in the holder.
6. Microclotting.
a. Anticoagulants are contained in many ETS blood collection tubes to keep blood
specimens from clotting. If the tubes are not adequately mixed after collection,
micro clots can form. These clots can cause inaccurate patient results and
interference with instrument operation. Hemolysis is the rupture of red blood cells
in a specimen caused by too much mechanical pressure from too small a needle,
too much vacuum on the vein or pulling too hard on the plunger of a syringe.
Hemoconcentration is the alteration of amounts of components in the blood
caused by leaving the tourniquet on too long.
7. A falsely low blood cell count.
a. Underfilling the EDTA blood collection tube can lead to erroneously low blood cell
counts and hematocrits, morphologic changes to RBCs, and alteration in cell
staining. Excess EDTA can shrink red cells. Hemolysis or the rupture of red blood
cells is unlikely in an underfilled tube unless it is shaken very hard or from a
difficult draw. Hemoconcentration (the change in ratio of analytes to cells in
plasma) can be caused by leaving the tourniquet on too long (more than 1
minute).
8. Light blue top and fill to at least 90%.
a. A light blue tube is used for coagulation tests. It contains sodium citrate as an
anticoagulant which preserves the clotting factors to be measured. The tube must
be filled adequately as the correct patient result depends on a ratio of 9 parts
blood to 1 part anticoagulant. The light blue tube does not need to be refrigerated
– it should be kept at room temperature. If there is to be a delay in testing, the
tube should be spun and the plasma placed in a properly labeled aliquot tube
then frozen. Lavender tops (K EDTA) are not used for coagulation testing, but for
hematology testing requiring whole blood such as complete blood counts (CBC).
9. Microclots will form.
a. Failing to adequately mix the blood in a lavender top (EDTA) with the
anticoagulant may cause the formation of microclots and give inaccurate patient
results. These tiny clots interfere with instrument operation, cause specimens to
be redrawn and delay patient treatment. If they are not detected during the
analysis, the inaccurate results may cause the patient to be incorrectly treated.
Incorrect mixing does not cause hemolysis unless the specimen is forcefully
shaken. If the red blood cells are ruptured (hemolyzed), potassium would be
released into the plasma. EDTA acts to anticoagulate blood by binding calcium
but it is not precipitated in the specimen.
10. Blood to additive ratio.
a. The phlebotomist collected the correct tubes for the tests ordered, citrate (blue)
for the PT and EDTA (lavender) for the H&H. They were drawn in the correct
order. The number of inversions was adequate to mix the blood well with the tube
additives. The blue top may have not been adequately filled. For accurate
coagulation testing there must be a ratio of nine parts of blood to one part of
sodium citrate. Incorrect filing will result in rejection and a request for the
specimen to be redrawn.
11. 2 x 2 gauze and Coban
a. Patients with multiple tears or fragile skin are not candidates for the usual
bandages applied after venipuncture procedures. Paper tape or bandages may
injure the skin when removed and leave the area open to infection or bleeding.
All venipuncture wounds should be covered with 2 x 2 gauze after the
phlebotomist has checked that bleeding has stopped. In this case, Coban would
be the best bandage to use. It is self adhesive and does not stick to the skin. Roll
up gauze would not apply enough pressure to the site.
12. Coban
a. Coban is a flesh colored, water-vapor permeable, non-woven polyester fabric
made of polyester urethane. The fabric is coated with a self-adherent substance
that gives the bandage the ability to stick to itself but not to skin or clothing. It
stays in place once applied. Coban can maintain limited but significant levels of
bandage pressure. It is primarily used in patients on anticoagulant therapy, those
with bleeding disorders or fragile skin. Gauze, bandaids or ace bandages do not
have these properties.
13. 2x2 gauze pad and wrap with Coban.
a. It is the phlebotomist’s responsibility to assure bleeding has stopped at the
venipuncture site before applying an appropriate dressing and releasing the
patient. Typically, an adhesive bandage over a 2x2 gauze pad is used. In this
case, since the patient suffers from contact dermatitis, a better choice would be
the 2x2 gauze pad wrapped with coban as this is less likely to aggravate the skin.
Any kind of tape including paper or nylon may cause a skin reaction.
14. Hold pressure for the patient until bleeding is controlled.
a. It is the phlebotomist’s responsibility to assure the stoppage of bleeding after
performing a venipuncture. All other activities should be postponed until this is
achieved. Elevation of the arm or the placement of a cotton ball are not as
effective as direct pressure. The use of cotton balls has been discouraged as the
cotton fibers may stick to the platelet plug formed at the wound site. Dislodging
the clot on removal of the bandage might reactivate bleeding.
15. Doctor’s name, patient’s date of birth, type of test
a. Test requisitions must contain certain information as they become part of the
patient’s medical record. The ordering doctor’s name is needed to ensure the test
results are sent to the correct physician and facility. The patient’s date of birth is
used to confirm the right person is being drawn. The type of test tells the lab
which analysis to perform. Social security numbers and the patient’s address are
not needed on a test requisition.
16. 21
a. A range of needle gauges (sizes) is needed to accommodate the different sizes
of veins and tissues the phlebotomist may incur. The smaller the number, the
larger the needle. Typically used are 21, 22 and 23 with the 21 being most
appropriate and commonly used. A needle smaller than 23 might hemolyse the
red blood cells and the sample could not be used for testing. A 15 would be too
large and could cause injury to the patient. 18 gauge needles are used for blood
transfusion and IV fluid administration. 25 gauge needles are used for IM
injection.
17. multi-sample needle
a. Multi-sample needles are standard equipment on phlebotomy trays. An 18 gauge
needle is very large and not used for standard blood draws, as it would be
unnecessarily painful. Neither tongue depressors or culture swabs are used for
blood collection.
18. Orange
a. Typically a serum tube requires clotting in the upright position at room
temperature for at least 30 minutes to produce the volume and clarity of serum
necessary for testing. These are not usually used for STAT tests. However, a
serum tube containing thrombin that clots in 5 minutes has recently been offered
by a manufacturer. It is called an orange RST (rapid serum tube). The royal blue,
pink and lavender tubes each contain EDTA and produce plasma after
centrifugation.
19. Lavender, blue, red
sodium fluoride & potassium oxalate (gray). In this case, the phlebotomist should
draw a blue first (PT/INR), a red next (BMP) and a lavender (CBC) last.
20. winged infusion 23g ¾”
a. Patients who are elderly or have received chemotherapy may have fragile veins
and thin skin. They may easily bruise or develop hematomas compromising
available venipuncture sites. It is prudent to balance the use of the smallest
needle that will allow for a good specimen with equipment that guards against
damage to the vessels and tissues. A winged infusion set with a 23 g needle and
a syringe might be the best choice. Using a multi sample (ETS) system with
either a 21g or 22g would exert too much pressure on the vein. A winged infusion
set with a 21g needle might be too large for the vein.
21. A 23 gauge butterfly with syringe
a. It is not uncommon for patients on various medical protocols including
chemotherapy to develop venous access issues. In this case, using an ETS
system might induce too much pressure on the vein either causing it to collapse
or the blood to hemolyze. A butterfly with a luer adaptor would present the same
issue. A syringe set allows the phlebotomist to control the pressure and might
suffice depending on how much blood is to be collected. The butterfly with a
small needle attached to a syringe allows for a lower angle of insertion and more
control.
22. A butterfly with a syringe
a. Patients who have received chemotherapy treatments frequently have fragile
veins. The use of vacuum tubes on these veins may apply too much pressure,
causing them to collapse. A syringe and butterfly would offer more control and
the prospect of a successful draw. A 23g needle is a good option in this case.
23. 23G butterfly needle and three pediatric evacuated tubes.
a. A 23 G butterfly needle would be used with three pediatric evacuated tubes in
this case as one would need one “discard” tube to fill the line of the butterfly with
blood, one blue (PT, PTT) and one lavender (ESR). If a discard is not used, the
blue tube will not be filled correctly, giving incorrect patient results. A heel lancet
would not be used as there are no blue (sodium citrate) microtainers.
Coagulation tests (PT, PTT) are not done from dermal punctures. Also, the ESR
requires 1 ml of whole EDTA blood which is too large a volume to be collected
from a heel stick.
24. 23g butterfly needle, light blue tube
a. The light blue tube (sodium citrate) is used for PT/PTT testing. If a patient has
fragile veins the vacutainer system is contraindicated as the vacuum might put
too much pressure on the vessel, causing it to collapse or the blood to become
hemolyzed. Therefore, a 23 g butterfly may be used with a light blue tube as long
as a discard tube that allows the butterfly tubing to be filled before attaching the
light blue tube is used. Failure to fill the tubing with blood will cause incorrect
filling of the light blue tube and incorrect patient results. Light blue tubes (sodium
citrate) require a ratio of 1 part citrate to 9 parts of blood for accurate results.
Lavender tubes are typically used for Hematology tests such as the CBC
(Complete Blood Count).
25. 2.0 mm
a. The lancet used for a heel puncture on a full term infant should not penetrate
beyond 2.0 mm (1.8mm for a premature infant). If the blade were to go deeper,
the heel bone (calcaneus) might be pierced leaving the child susceptible to a
serious bone infection known as osteomyelitis. Insufficient depth will not yield
adequate blood flow.
26. Chlorhexidine
a. A patient with a shellfish allergy is sensitive to anything containing iodine.
Therefore, 2% iodine, betadine or povidone solutions should not be used as an
antiseptic for blood culture collection. The best choice would be chlorhexidine.
27. Wash hands, change to non-latex gloves and use a new tourniquet.
a. Latex allergies can be life threatening. It is important to ascertain this information
from the patient before initiating the procedure. In this case, the phlebotomist
should remove the latex gloves, wash hands, change to latex free gloves and use
a non latex tourniquet for the collection.
28. Discard the needle and obtain a new one.
a. As with any manufactured device, a certain number of items are expected to
have defects. The vendor’s good quality control program should find and prevent
these from getting out into the market. However, it is the phlebotomist’s
responsibility to assure the equipment to be used for blood collection is
acceptable before use on a patient. This is why the needle is inspected after
removing the cap for any defect including straightness, burrs and an open lumen.
Needles are never recapped. The needle and the holder, syringe or butterfly to
which it is attached should be placed in a sharps container. Documenting the
occurrence is always a good idea and if there are more instances within a certain
lot or shipment, the manufacturer should also be notified.
29. 2% benzalkonium chloride
a. To minimize the risk of contamination by normal skin flora, sites for blood culture
collection require a 30 – 60 second scrub to access the bacteria beneath the
dead skin cells in the area. Friction and letting the site air dry are important
factors. Although not appropriate for children under 2 years of age, 2%
benzalkonium chloride can be used as an antiseptic to clean blood culture
venipuncture sites. Isopropyl alcohol may be used but requires a longer scrub
with at least two pads. Isopropyl alcohol is used to clean the tops of the cultures
bottles before inoculation with blood. Hydrogen peroxide or antibacterial soap
and water are not considered effective for blood culture site cleansing.
Preparations of iodine or betadine are not commonly used as they may provoke
allergic reactions. Whichever antiseptic is used, it is important to allow the area to
air dry and not to retouch the site before performing the venipuncture.
30. Chlorhexidine gluconate
dead skin cells in the area.Friction and letting the site air dry are important
factors. Although not appropriate for infants under 2 months of age, chlorhexidine
gluconate has become the antiseptic of choice. Isopropyl alcohol may be used
but requires a longer scrub with at least two pads. Isopropyl alcohol is used to
clean the tops of the cultures bottles before inoculation with blood. Soap and
water or antibacterial gels would not afford the antisepsis needed to prevent
contamination. Preparations of iodine or povidone are not commonly used as
they may promote allergic reactions. Whichever antiseptic is used, it is important
to allow the area to air dry and not to retouch the site before performing the
venipuncture.
31. sodium citrate
light blue top contains sodium citrate. The lavender top contains EDTA, the green
heparin and the gray potassium oxalate.
32. Royal blue
a. The royal blue tube contains EDTA as an anticoagulant. The yellow is a sterile
tube containing SPS and liquid culture media. A gray tube has potassium oxalate
and sodium fluoride. The red tube is for serum and does not contain an
anticoagulant.
33. Gray
a. The gray tube has a glycolytic inhibitor (sodium fluoride) to maintain glucose
levels along with potassium oxalate as the anticoagulant. A green tube contains
heparin, a lavender has EDTA and the light blue contains sodium citrate.
34. Light blue
a. Contains sodium citrate to prevent blood from clotting.
35. Antiglycolytic
a. The primary function of the sodium fluoride found in gray topped tubes is to act
as an antiglycolytic which prevents the metabolism of glucose to lactic acid by the
red blood cells in the specimen. If not prevented, glycolysis may decrease the
level of glucose of as much as 10 mg/dl per hour leading to inaccurate patient
results and possible medical mistreatment. The anticoagulant in the gray top is
potassium oxalate which keeps the blood from clotting and makes the plasma
available for testing after centrifugation. An antibiotic (used to treat bacterial
infections) or an antihemolytic (an agent used to prevent hemolysis of red blood
cells) are not included in vacuum blood collection tubes.
36. Sodium citrate
a. Sodium citrate (light blue tube) is used as an anticoagulant for coagulation
studies. EDTA (lavender top) is used for hematology testing, heparin (green top)
and potassium oxalate (gray top) for chemistry analyses.
37. Sodium fluoride
a. The addition of sodium fluoride (gray top tube) acts as a preservative of the
glucose level. This is accomplished by preventing the red blood cells from
metabolizing glucose to lactic acid (glycolysis) and reducing the glucose level by
as much as 10 mg/dl per hour. Heparin (green top) , EDTA (purple top) and
sodium citrate (blue top) are used as anticoagulants to prevent blood from
clotting in the tube.
38. Sodium fluoride
a. Sodium fluoride (gray top tube) is an antiglycolytic agent that preserves glucose
levels after they are drawn. EDTA and sodium citrate are both anticoagulants but
neither is used for glucose testing. Thixotropic gel forms a barrier in a tube
between the fluid and cells after centrifugation.
39. Potassium oxalate tube
a. In addition to the anticoagulant potassium oxalate, the gray topped tube contains
sodium fluoride which is an antiglycolytic. The sodium fluoride delays the
metabolism of glucose by the red and white blood cells and platelets, helping to
stabilize the glucose level until it can be analyzed. Lavender tops contain EDTA,
Blue tops contain sodium citrate and gold tops contain a gel to separate the
serum from the cells after clotting has taken place.
40. Sodium citrate, clot activator, heparin, EDTA
The order is sterile (blood cultures), sodium citrate (blue), serum ( red or gold
with or without clot activator or gel separator), heparin (green), EDTA (purple or
pink), sodium fluoride & potassium oxalate (gray).
Study Guide - 39 Q’s Answer
1. Chlorhexidine
dead skin cells in the area. Friction and letting the site air dry are important
factors. Although not appropriate for infants under 2 months of age, chlorhexidine
gluconate has become the antiseptic of choice. Isopropyl alcohol may be used
but requires a longer scrub with at least two pads. Isopropyl alcohol is used to
clean the tops of the cultures bottles before inoculation with blood. Preparations
of iodine or Betadine are not commonly used as they may provoke allergic
reactions. Whichever antiseptic is used, it is important to allow the area to air dry
and not to retouch the site before performing the venipuncture.
2. Antiseptic soap.
a. When drawing a blood specimen for an alcohol (ETOH) level, it is imperative not
to use any solution containing alcohol to clean the venipuncture site. It can be
argued that this practice would falsely elevate the patient’s result - invalidating its
use in a court of law. Therefore, the solution used to clean the skin must be
aqueous. Using antiseptic soap or a vigorous scrub with water to clean the site is
preferred. Chlorhexidine is used in addition to 70% isopropyl alcohol to
decontaminate the venipuncture site for drawing blood cultures. When drawing
an alcohol level, the site does not have to be sterile.
3. Isopropyl alcohol and clean from inside to outside in a circular motion.
a. The antiseptic used for a routine venipuncture is 70% isopropyl alcohol. A
phlebotomist should begin cleaning at the intended site and proceed to the
outside area in a circular motion. Moving from outside would pull contaminants
back onto the site. Chlorhexidine may be used if the patient is allergic to alcohol,
but the same inside to outside motion should be used.
4. Cleanse the site by using a circular motion from center to periphery.
a. To perform a venipuncture for routine lab work, the phlebotomist should scrub the
skin of the intended site with antiseptic in a circular motion from the inside to the
periphery. Scrubbing from the periphery to the inside of the site would introduce
skin bacteria into the site. Skin is not sterilized for routine venipunctures.
5. Cephalic vein
a. When a larger amount of blood is needed from a child, the veins of the
antecubital area may be used. If the medial cubital vein is not usable, the
cephalic would be chosen next. The basilic vein is selected last as it lies near the
brachial artery and many nerves. Once a child begins to walk, the heel becomes
too calloused to use for dermal blood collection. Scalp veins are only used in
neonates and usually only by nursing personnel.
6. Betadine, and draw the aerobic followed by the anaerobic.
a. The collection of blood cultures requires skin cleansing at the intended
venipuncture site. Unless the patient is allergic to iodine preparations, betadine
may be used. When using a butterfly for these collections, it is imperative to fill
the aerobic bottle first, filling the line of the infusion set with blood before filling
the anaerobic bottle. Introduction of air into the anaerobic container would render
it aerobic and reduce the chance of recovering anaerobic organisms for which
that culture bottle is intended.
7. “Tell me what brings you in today.”
a. Facilitates communication of the patient’s own perceptions to gain valuable
information, and encourages expression of feelings. All other statements require
a yes/no answer (closed-ended).
8. Asking both patients to state their DOB.
a. 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. MRN and SSN are considered to be unique identifiers since no
two patients can have the same MRN or SSN. Whenever possible, confirm the
patient's unique identifier(s). 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. Obtaining DOB from each patient will help
distinguish patients with the same exact name and eliminate confusion between
specimens. It is imperative to obtain as many identifiers as possible in order to
minimize patient misidentification and specimen mislabeling. Since both patients
have the same exact name, asking them to state their names is not sufficient to
prevent confusion between different specimens. Medical records are protected by
HIPAA and must not be accessed by a phlebotomist unless necessary to provide
quality of care. Identification must be verified with the patient and not through
medical records.
9. Date of birth
a. The Joint Commission (TJC) lists date of birth (DOB) as a “person specific”
identifier. The medical record number may not be available in an outpatient
setting. Race or religion are not used as identifiers.
10. Patient’s name, phlebotomist's identification number
a. CLSI recommends five pieces of information that should appear on the label of a
specimen. These include: patient’s name, date of birth, unique identification
number (such as medical record number), time and date of collection, and the
initials or identifying number of the collector. While the patient’s gender and age
are usually included, they are not necessary. Phlebotomists do not have a
“department” number but may have an identifying number instead of initials.
11. Check the ID bracelet and ask the patient to verbally confirm her identity.
a. The National Patient Safety Goals established by The Joint Commission
recommend at least the confirmation of two patient identifiers before proceeding
with any medical procedure including phlebotomy. Errors in patient identification
lead to medical mistreatment and possibly death. Having the patient state his
name and date of birth (DOB) will suffice for an outpatient. For inpatients, in
addition to stating name and DOB, the phlebotomist should match the medical
record number on the test requisition to that on the patient’s armband. A
specimen should never be drawn from a patient without an armband. Any
discrepancy in the information must be corrected before proceeding. Relying on
the electronic medical record, the name on the white board or just the ID band is
not sufficient. It is the responsibility of the phlebotomist to provide complete and
correct patient identification.
12. Spoken name, spoken date of birth
recommend at least the confirmation of two unique patient identifiers before
going forward with any medical procedure including phlebotomy. Errors in patient
identification lead to medical mistreatment and possibly death. Having the patient
state his name and date of birth (DOB) will suffice for an outpatient. For
inpatients, in addition to stating name and DOB, the phlebotomist should match
the medical record number on the test requisition to that of the patient’s armband.
A specimen should never be drawn from an inpatient without an armband. Any
discrepancy in the information must be corrected before proceeding.
Identification by a family member may be used if the patient is unconscious or
incompetent. It is important to document with whom the phlebotomist spoke.
Room numbers are not used as patients are frequently transferred based on their
condition. Use of social security numbers might be considered a HIPAA
infraction.
13. Ask the patient to state name and date of birth.
a. The National Patient Safety Goals of The Joint Commission require the
confirmation of at least two unique identifiers before performing any medical
procedure including phlebotomy. Asking the patient to state her name and date of
birth would satisfy this requirement. Any discrepancy in either patient
identification or tests ordered must be resolved with the caregiver before
proceeding. Questions about the tests, requests information or explanation of
those tests, should be referred by the phlebotomist to the nurse or doctor. After
this step has been accomplished, the patient’s identity still needs to be confirmed
with the statement of name and date of birth.
14. Ask the family member to identify the patient.
a. For patient safety the identifying armband must be attached to the patient – not
the bed rail, chart or anywhere else in the room. Asking a family member to
identify the patient may be acceptable but the safest approach is to notify the
caregiver (nurse) and request a new armband be attached to the patient. Due to
changes in condition and therapies, patients are frequently transferred to different
rooms so the room number is not a reliable source. Returning to the lab to check
the orders only wastes time and provides no accurate identification of the patient.
15. Go to the nurse’s station to have the information corrected.
a. It is the responsibility of the phlebotomist to assure complete and accurate
identification of the patient. Any discrepancy with labels, armbands or requisitions
must be corrected before proceeding with collecting a specimen. The
phlebotomist should go to the nurse’s station, explain the problem and have a
new armband with correct information placed on the patient. At no time should
the phlebotomist change or update any information on labels, requisitions,
armbands or charts – those changes are the job of the patient’s caregiver.
16. The first urine of the morning after fasting for 8 hours
a. A fasting urine specimen may be used to monitor glucose metabolism. This
specimen differs from a first morning specimen in that it is the second specimen
voided after the fasting period. This helps assure the specimen is not affected by
food ingested before the fasting period began. Fasting is usually considered 8 –
12 hours after a meal. The glucose level in any urine collected during the fasting
period would reflect food having been metabolized from the last meal. Waiting to
collect the specimen until after the patient has had another meal would invalidate
the fasting order.
17. What time did you eat or drink last?
a. For accurate baseline results, fasting for 8 to 12 hours is important when having
a BMP (includes a glucose) and lipid panels. It is important to confirm the
patient’s compliance with fasting for these tests. Alcohol consumption,
medications or the timing of the last blood draw are not important factors for
these test orders.
18. Cortisol sample
a. Cortisol is a steroid hormone produced by the adrenal gland and peaks very early
in the morning. A baseline is drawn when the patient has been at rest and then
another in the evening to assess if the analyte has dropped to its lowest level.
This is called diurnal variation. The time of the draw should be noted on the tube
label. A stat sample requires an immediate draw and results within an hour of the
order. Timed samples are typically ordered with medication levels or tolerance
tests. A glucose sample may be timed or require fasting but not resting.
19. Leukocytes
a. Stress or crying will elevate the white blood cell (WBC) count. This makes it
difficult to assess if the elevated count is due to stress or a disease process.
Crying will not elevate the erythrocytes (red cells) or thrombocytes (platelets).
20. that the patient was fasting.
a. A milky appearance of serum or plasma is called lipemia and is usually caused
by elevated triglycerides. This can happen when the patient is non-compliant with
fasting instructions. Lipemia is not typically caused by medications, alcohol
consumption or fever.
21. 1600
a. A fasting specimen is collected after a period of no food or drink (except water)
for a period of 12 hours. In this case, the patient consumed black tea at 4 AM.
Therefore, adding 12 hours to 4 AM makes the fasting period end at 1600 (or 4
PM). Most hospitals observe military time.
22. Make a note on the requisition form and proceed with the draw.
a. To accurately interpret laboratory test results, the physician must know if the
patient has been compliant with dietary instructions and lifestyle restrictions.
Smoking immediately prior to blood collection can affect cortisol, cholesterol,
glucose, wbc, growth hormone and triglyceride levels. Chronic smoking will
elevate the rbc count and hemoglobin. Therefore the phlebotomist should note on
the requisition that the patient has recently smoked tobacco. To proceed with the
draw without this documentation risks misinterpretation of the results. If the client
is an outpatient, it is unlikely that there would be a nurse to consult. The decision
to reschedule and to refrain from smoking 12 hours before the draw would
depend on the test ordered and the doctor’s requirements.
23. It increases localized blood flow.
a. Warming a site for a venipuncture or capillary draw will increase the localized
blood flow and assist with specimen collection. Blood does not necessarily flow
more quickly but the yield is increased. Veins roll when they are not properly
anchored before inserting the needle into the site. Hemoconcentration is the
change in analyte values within the blood by leaving the tourniquet on for more
than 1 minute.
24. Hemoconcentration.
a. Hemoconcentration is the change in analyte values within the blood by leaving
the tourniquet on longer than 1 minute. It can be defined as the rapid increase of
the ratio of blood components to plasma. A hematoma is a collection of blood
under the skin. Hematuria is the presence of blood in the urine. Thrombosis is the
development of a blood clot in a vessel.
25. Apply a warm compress for about 3-5 minutes.
a. It is not uncommon to have difficulty locating a vein for a blood draw. Patients can
be dehydrated, hypotensive or on medications that affect the patency of the
vascular system. Applying a warm (not to exceed 42o C) for 3-5 minutes can
increase the blood flow in the area. A cool compress will have the opposite effect.
Pumping the fist is contraindicated as it will cause hemoconcentration and affect
the lab results.
26. Leaving the tourniquet on longer than two minutes
a. Leaving the tourniquet in place for longer than one minute can cause
hemoconcentration. This is a change in the ratio of blood components to plasma
and affects cell counts, coagulation studies and protein levels. Having the patient
make a fist will help distend the veins. Releasing the tourniquet before
completing the draw might allow the vein to collapse, rendering the draw
unsuccessful. If the patient’s hand falls asleep while opening and closing the fist,
the tourniquet may be too tight or vein location is taking too long.
27. Type, expiration date, size
a. When selecting equipment for venipuncture, it is important to choose the
appropriate type and size for the test ordered and the patient involved. Also,
tubes used beyond the expiration date might not have adequate vacuum or
functional additives. The manufacture date is not significant. Tubes should be
stored at room temperature and not exposed to excessive heat or cold.
28. dorsal hand vein
a. A hematoma is a bruise caused by bleeding from a blood vessel under the skin.
These may be caused by insufficient pressure applied to the site after a
venipuncture or the patient’s medication or condition. These areas should be
avoided because they are painful and the blood may be clotted or hemolyzed,
causing inaccurate patient results. The best choice would be a hand vein.
29. Tattoos, edema, scarring
a. When selecting a site for venipuncture, some areas should be avoided if
possible. Blood drawn from an edematous area may contaminate the sample
with tissue fluid. Scarred and tattooed skin is more susceptible to infection and
has decreased circulation. Veins in these locations may be difficult to palpate or
penetrate. Also, the dyes from tattoos can interfere with testing. Unless directed
not to do so, a site with a rash or a healed and unbruised previous venipuncture
site can be used.
30. Ask a coworker for help.
a. If no palpable, patent vein can be found in either arm or hand, it is sometimes
helpful to ask a coworker for assistance. Depending on the test ordered and the
amount of blood needed, a capillary puncture may suffice. Alternate sites such as
foot and ankle veins require a physician’s written permission. Removing a
fingertip of a glove to palpate for a vein should not be done. Gloves are thin
enough not to compromise the sensitivity of the fingertips.
31. Ring finger (fourth digit)
a. A capillary blood collection is appropriate for a lead screen test on a toddler as
very little blood is needed. The distal segment of the ring or middle finger can be
used but not the thumb (may be calloused), pointer finger (increased nerve
endings) or little finger (too close to bone). The heel is not used once the child
begins to walk as heel tissue thickens and becomes hard to penetrate.
32. Lateral side of the heel.
a. Capillary blood samples may be taken from the lateral side heel of children until
they begin to walk at which time the heel becomes tougher and more difficult to
penetrate. The center portion of the heel is not used as it is too close to the bone
(calcaneus) which may cause osteomyelitis if punctured. The inside of the central
arch of the heel is not used.
33. Capillary using heel puncture lancet
a. Neonatal screening for metabolic disorders is done with a dermal puncture to the
medial or lateral plantar surface of the heel using a special lancet that penetrates
no more than 2.0 mm. The blood collected is transferred directly to a special filter
paper card. A dermal puncture lancet used for fingersticks might not generate
enough blood flow. Venipunctures are not used because, for accurate testing in
this case, blood cannot be transferred from a tube to the card.
34. 3rd or 4th fingers.
a. The fleshy part of the distal segment of the middle (3rd) or index finger (4th) may
be used for an adult dermal collection. Placing the lancet perpendicular to the
fingerprint will ensure blood will form a drop and not run down the finger. The
thumb, index or little finger are never used. The thumb may be more calloused,
the index finger is more sensitive and the little finger may result in hitting the
bone.
35. Distal segment of the middle finger
a. Capillary blood samples may be taken from the heel of children until they begin to
walk at which time the heel becomes tougher and more difficult to penetrate. The
fleshy part of the distal segment of the middle or index finger may then be used.
Placing the lancet perpendicular to the fingerprint will ensure blood will form a
drop and not run down the finger. The thumb, index or little finger are never used.
The thumb may be more calloused, the index finger is more sensitive and the
little finger may result in hitting the bone.
36. lateral or medial plantar surface of the heel
a. The heel of an infant is the recommended skin puncture site. 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.
37. Let the alcohol air dry before inserting the needle.
a. Using a 70% isopropyl alcohol pad cleansing in a back and forth motion over the
venipuncture site then allowing the site to dry is the optimal way to achieve
bacteriostasis for a routine venipuncture. Wiping the alcohol off with sterile gauze
is less effective than air drying. Studies have shown that a back and forth motion
is superior to cleansing in concentric circles. Waving air onto the site may
introduce new contamination to the skin.
38. back-and-forth friction, in a horizontal or vertical motion
a. 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. If the
specimen is for a blood alcohol level, a non-alcoholic cleanser would be used.
39. Wrap the patient's arm with gauze and apply the tourniquet.
a. A tourniquet is used during the venipuncture procedure to distend the vein,
making it easier to see and providing adequate pressure to assist in collecting the
specimen. The tourniquet should be applied 3 to 4 inches above the intended
venipuncture site. If applied too closely, the vein may collapse during the
procedure and if too far away, not enough pressure will be generated to distend
the vein adequately. If the skin is irritated or very thin, the tourniquet may be
applied over clothing, a clean dry washcloth or length of gauze. Typically,
tourniquets are a flat strap made of an elasticized material. The current trend is to
use them once and discard them. This practice aids in preventing transmission of
infection. If the tourniquet is reused, it must be disinfected regularly.
Study Guide - Problems and Correction 40Q’s -
Answers
1. Below the IV in the left arm.
a. It is very important for the phlebotomist to have an understanding of potential
hazardous venipuncture sites for accurate results and patient safety. An ESRD
(end stage renal disease) patient would have an AV fistula for vascular access
during dialysis procedures. It is never acceptable to draw from the arm with this
device. In this case, the best choice would be below the IV in the left arm.
Drawing above the IV would risk contaminating or diluting the blood sample with
the contents of the fluid being administered.
2. Within one minute
a. Prolonged tourniquet time can cause hemoconcentration. Hemoconcentration is
the change in analyte values within the blood by leaving the tourniquet on for
more than 1 minute.
3. Hemolysis.
a. In preparing a site for venipuncture or dermal collection, the 70% alcohol should
be allowed to completely dry. This accomplishes two things: it gives the solution
time to destroy bacteria and prevents the aqueous alcohol solution from causing
hemolysis of the red blood cells which might affect the test results.
Hemoconcentration occurs when a tourniquet is left on too long and the quantity
of analytes in the blood changes. Hemodilution is the opposite of
hemoconcentration where the ratio of cells to fluid decreases. Hemostasis is the
act of stopping blood flow or bleeding.
4. WBC’s may be elevated.
a. Stress or crying will elevate the white blood cell (WBC) count. This makes it
difficult to assess if an elevated count is due to a disease process or if it's
stress-induced. Crying will not make the specimen hemolyzed,
hemoconcentration or platelets more likely to clump.
5. Light blue
a. A light blue tube is used for coagulation tests. It contains sodium citrate as an
anticoagulant which preserves the clotting factors to be measured. The tube must
be filled adequately (90%) as the correct patient result depends on a ratio of 9
parts blood to 1 part anticoagulant. While the green, pink and lavender tubes
should be completely filled if possible, the 90% requirement is not necessary.
6. QNS
a. If the amount of sample is not adequate for the test requested it is considered
“QNS” (quantity not sufficient) and would have to be recollected. Quality
assurance (QA) programs monitor outcomes to provide the best possible service
to customers. Quality Control (QC) is a set of procedures that assure a specific
process is within acceptable standards. Hemolysis of a blood sample allows the
contents of the red blood cells to spill into the plasma, affecting patient results.
7. Excessive heat and moisture
a. Proper storage and handling conditions for reagents and equipment in a test
system are paramount in ensuring accurate results. Excessive heat and moisture
can negatively affect glucose test strips. Bright light and being shaken should not
affect the strips if the container is kept covered.
8. Hemolyzed.
a. Most likely the specimen was hemolyzed due to the use of the 21 g needle which
may have been too large for the vein and a vacuum tube which put too much
pressure on the vessel. Collection of a potassium level in an SST tube is
acceptable and it is not affected by light. QNS (quantity not sufficient) means that
there was not enough of a sample for testing.
9. The needle gauge was too small.
a. The color of the serum (pink) after centrifugation indicates the specimen was
hemolyzed. This may happen if too small a needle was used to collect the
sample or if the phlebotomist pulled too hard on the syringe plunger, forcing the
blood into the device. Allowing the blood to clot 20 minutes before centrifugation
should be sufficient. The volume of blood in the tube, if collected properly, should
not contribute to hemolysis. The introduction of oxygen also has no effect on the
test.
10. Syringe.
a. A syringe is a good choice for those with fragile veins as the amount of pressure
applied in withdrawing blood is easily controlled. A vacuum might apply too much
force and collapse the vein. If a very small amount of blood is needed, a capillary
tube with a lancet could be used for a dermal collection.
11. BP cuff
a. A tourniquet is applied to an arm before a venipuncture to restrict blood flow and
distend the veins allowing for easier location. There are many types available.
Commonly latex is not used, as allergies to this substance are becoming more
common and can be fatal. Nitrile is a better choice as it is latex free. Velcro bands
are not single use and must be frequently disinfected, a practice not allowed at
many facilities. A BP (blood pressure) cuff may be used on obese patients as it
does not roll into a “cord” as a strap tourniquet would when placed on a very
large arm. To accomplish this, the patient’s blood pressure is taken and the
pressure of the cuff is maintained below the diastolic (no more than 40 mmHg)
for no more than a minute.
12. Left hand
a. It is wise to avoid drawing blood from an arm with an active IV. Above the site
would risk contaminating the sample with the contents of the fluid being
administered. Below the site is an option, but if other areas are available, these
should be investigated first. Sclerosed veins are hard to penetrate and may have
poor circulation. In this case, venipuncture should be attempted in the left hand.
13. Move the needle slightly forward or back.
a. If the needle misses the vein, the phlebotomist should slightly readjust forward or
backward to see if venous access can be achieved. Probing from side to side is
contraindicated as this might cause injury. If the slight readjustment does not
work, the venipuncture may have to be discontinued and a second attempt made.
14. Gently squeeze and release the finger.
a. When the dermal puncture does not yield a good blood flow, the phlebotomist
should gently squeeze the finger then release the pressure to allow blood flow to
re-establish. If this is not successful, a second stick in another area may have to
be performed. Warming the site is a good way to encourage good blood flow.
Resticking the same site (double sticking) is painful and may damage tissue.
Scraping the test strip against the puncture site will contaminate the sample with
tissue fluid or clotted blood.
15. Remove the tourniquet, pull out the needle, and select a different vein.
a. Elderly patients often have fragile veins that easily collapse under the pressure of
a vacuum tube collection system. In this case, the best option would be to
discontinue the draw and select a different vein. On the second attempt, a
syringe might be used as it offers better control of the blood flow. Once the vein
has collapsed, repositioning the needle backward or forwards will not recover the
draw. Feeling for the vein with the needle in the arm is likely to injure the patient.
16. The bevel is partially out of the skin.
a. Insertion of the needle should be done with the bevel up and at the correct angle
(less than 30 degrees). If the bevel is partially out of the skin when the vacuum
tube is engaged, part or all of the vacuum may be lost. A small spurt of blood
might start, then stop. Inserting the needle at too steep an angle may cause the
bevel to go completely through the vein, causing a hematoma. An expired tube
may not fill completely. The collapse of a vein is usually caused by too much
pressure from a vacuum tube or pulling too hard on the plunger of a syringe.
17. Small volume tubes.
a. Dorsal hand veins are prone to collapse. The use of a butterfly and regular sized
ETS tubes may put too much pressure on these veins and compromise the draw.
Small volume tubes containing less vacuum exert less pressure on the vein.
Also, a syringe with the 23g butterfly might be a good choice. A 22g needle is
larger than the 23g being used and might be too large. The use of a very small
needle (25g) might lead to hemolysis of the specimen.
18. Change the blood tube.
a. Evacuated blood collection tubes are a manufactured item. Despite good quality
control measures, tubes can become faulty due to production, transport or
storage issues and may lose all or part of the vacuum. It is good practice for the
phlebotomist to carry extra tubes for the requested tests in case a tube will not
fill. Trying a new tube is the first thing to do to recover the draw. If this doesn’t
work, slight repositioning the needle forward or backward may relocate the
needle in the vein. If these measures are not successful, the draw may have to
be discontinued and an attempt made to draw from another site. Removing the
tourniquet might cause the vein to collapse. Palpating the vein while the needle is
in place may cause injury or a hematoma.
19. Sample from the dorsal hand vein., Draw a capillary sample from a finger., Replace the
tube.
a. The first step to try would be to replace the tube as it may be defective. A dorsal
hand vein might be a good choice as the hand is easily held still. Should the
venipuncture be unsuccessful, a capillary sample from the third or fourth finger
may suffice if a small amount of blood is needed. Releasing the tourniquet might
cause the vein to collapse. The heel is not used once the child begins to walk.
20. Remove the existing tube and try another tube of the same type.
a. Vacuum tubes are a manufactured item and as such, may be defective if not
handled or stored properly. The phlebotomist should always have extra tubes
within reach to replace one that is not drawing correctly. The draw may be saved
with this action or the needle may need slight repositioning. If neither of these
work, the draw may have to be ended and a second attempt made. Removing
the faulty tube and continuing with the order for the others would still leave the
defunct tube to be drawn, requiring another venipuncture. The physician expects
the phlebotomist to solve the problem and complete the draw.
21. Release tourniquet and stop the procedure.
a. Whenever a hematoma begins to form during a venipuncture, the procedure
should be terminated and direct pressure applied to the area. A hematoma can
cause injury to vessels, nerves and tissues in the area and even cause
compartment syndrome if not controlled. Also, future use of the area for
venipuncture may be compromised. Once the bruise begins to develop, adjusting
the needle will only aggravate the situation. The needle should be inserted bevel
up and is never turned while in the vein.
22. Sclerosed veins
a. When venipunctures are repeated on the same veins in the same area, scar
tissue (sclerosing) can develop. This makes veins difficult to puncture and can
affect patient results due to impaired circulation. Although thrombosis may be
produced in a sclerosed vein, it is not a typical result of venipuncture. Varicose
veins are not induced by venipunctures. Petechiae are small red spots under the
skin formed by lengthy tourniquet time or bleeding disorders.
23. Petechiae.
a. Petechiae are small red dots appearing on the skin upon tourniquet application
most commonly caused by capillary or platelet defects. Purpura is bruising under
the skin caused by defective platelets. A hematoma is a bruise caused by
bleeding under the skin. Hemolysis is the destruction of red blood cells releasing
hemoglobin into the plasma.
24. Osteomyelitis
a. Puncturing the calcaneus (heel bone) on an infant can cause the child to acquire
a serious bacterial infection known as osteomyelitis. It is imperative to use the
correct lancet and safety measures to prevent this from occurring. If difficulty in
safely restraining a child is anticipated, the phlebotomist should ask for help
before beginning the procedure. Petechiae are tiny red dots resulting from
ruptured capillaries that form under the skin. This may be the result of prolonged
or too tight tourniquet application or a patient’s clotting deficiency. An Achilles
tendon rupture is an injury to the back of the leg – most commonly from
recreational sports. An osteoma is a surgical instrument for cutting bone, typically
resembling a chisel and is not used for collecting blood by dermal puncture.
25. Lay the patient on the floor.
a. It is not uncommon for patients to feel lightheaded when having blood drawn.
This is especially true for those who have been fasting. After the tourniquet has
been loosened and the needle removed, it is important to place the patient in a
prone position so that he does not fall and suffer an injury. Checking the glucose
level or giving orange juice can only be done with a doctor’s permission.
Assistance should be called for, if needed.
26. Apply firm pressure at the site for at least five minutes.
a. Upon release of the tourniquet and removal of the needle, direct pressure should
be applied to the wound site for 5 minutes until bleeding is stopped, especially in
the case of hematoma formation. Holding the patient’s arm in a downward
position and applying ice will not help in resolving this situation. All patients
should be cautioned not to lift heavy items after having blood drawn. Unless the
patient is feeling faint, it is not necessary to have them lie down.
27. Bruising
a. The bevel of a venipuncture needle is very sharp and can act like a scalpel blade,
cutting through tissues , veins and nerves in its path. In this case, bruising may
occur. After the needle is removed, direct pressure should be applied to the site
to prevent hematoma formation. While hemolysis might occur under the skin, it is
unlikely to be present in the tube unless it was a difficult draw. Petechiae are
small red spots under the skin formed by lengthy tourniquet time or bleeding
disorders. The best outcome from this situation would be nothing happening.
28. Release the tourniquet and discontinue the draw.
a. If a patient is experiencing pain during the venipuncture, the only appropriate
step to take is discontinue the draw. Were the patient not feeling pain, the draw
might be recovered by repositioning the needle slightly forward or back.
Releasing the tourniquet and repositioning the needle, may collapse the vein and
render the draw unrecoverable.
29. Remove the needle immediately.
a. The immediate action would be to loosen the tourniquet and remove the needle
from the child’s arm to prevent injury. Asking the parent to regain control would
be futile as the draw is most likely not recoverable. Before making another
attempt, get help from a coworker. Asking the parent to leave might upset the
child even more.
30. Failure to remove tourniquet prior to removing the needle, insertion of the needle
through the vein, excessive probing to locate the vein
a. A hematoma may form as blood leaks from a vessel under the skin. Likely
causes may be failure to remove the tourniquet before removing the needle,
inserting the needle through the vein or excessive probing in an attempt to
establish blood flow. Unless the patient is on anticoagulant therapy, medication is
not likely to contribute to hematoma formation. Using the wrong needle gauge
may result in pain for the patient (too large) or hemolysis of the specimen (too
small).
31. Continue with the procedure.
a. The appearance of petechiae after the application of a tourniquet is not a cause
for discontinuing the venipuncture. These small red dots usually resolve
themselves after the procedure is completed. Using the other arm is likely to
produce the same occurrence. Consulting the nurse or physician is not
necessary.
32. Discontinue the draw.
a. Sweating and pallor are symptoms of syncope (fainting). Failure to recognize and
act on an impending syncopal episode can result in serious patient injury. The
draw should be immediately discontinued and the patient treated. Calling for
assistance may be required. Reassuring the patient and pausing the collection
are contraindicated as if the patient is injured, the phlebotomist may be open to a
lawsuit.
33. Maintain pressure until the bleeding stops.
a. The phlebotomist is charged with post venipuncture wound care which includes
confirming that the site has stopped bleeding. If the patient is on aspirin or other
anticoagulant therapy, this may require applying pressure for five minutes or
longer and the application of a pressure bandage before releasing the patient.
The phlebotomist should perform a “two point check”, visually inspecting the
surrounding tissue for mounding or swelling—a sign of hematoma
formation—and for bleeding at the skin’s surface. The patient may be able to
assist with this process, but it remains the phlebotomist’s responsibility to assure
bleeding has stopped.
34. Make sure adequate pressure is held over site until bleeding stops.
a. It is the responsibility of the phlebotomist to assure that bleeding has stopped
after completing a venipuncture procedure. This is accomplished by applying
direct pressure to the wound site with a gauze pad. If the patient is capable, he
may be enlisted to apply the pressure and allow the phlebotomist to complete
other tasks. 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 after bleeding has completely stopped but not
before. If the pressure held is too tight, bruising or injury might result.
35. Replace the gauze and hold pressure.
a. It is the responsibility of the phlebotomist to assure that bleeding has completely
stopped after completion of the venipuncture before bandaging (use a pressure
bandage such as Coban) and releasing the patient. The gauze should be
replaced and extra pressure applied for at least 5 minutes. An ice pack will not
help stop bleeding but may keep a hematoma from forming. Elevating the arm
while applying pressure might help as long as bleeding does not resume when
the arm is lowered. The phlebotomist should not hesitate to call for assistance if
needed.
36. Apply site pressure for a prolonged time.
a. Patients are given heparin therapy to prevent the formation of venous thrombi
(clots). When venipunctures are performed, these patients tend to bleed longer
after the procedure. Additional pressure should be applied to the site and the
patient should not be released until stoppage of bleeding has been confirmed.
The basilic vein should be avoided if possible, not because of heparin therapy,
but due to the fact that it is located close to an artery and nerves. A 21 gauge
needle is typically used but a 22 or 23 might suffice, leaving a smaller puncture at
the venipuncture site. Light to moderate tourniquet pressure might not render the
veins adequately accessible.
37. Hold direct pressure until the bleeding stops, apply a bandage, and notify the nurse.
a. It is the responsibility of the phlebotomist to ensure bleeding has stopped before
leaving the patient then notifying the nurse. In addition, if bruising had occurred at
the site, nursing staff will want to know the source for documentation and follow
up purposes.
38. Collect PT/INR in a light blue tube., Apply firm and direct pressure to the venipuncture
site for at least 5 minutes., Inform the patient about possible hematoma formation.
a. The test that monitors coumadin (warfarin) therapy is the prothrombin time
(PT/INR) which is drawn into a light blue tube. Patients receiving this therapy
tend to bleed longer after venipuncture, so applying firm and direct pressure to
the site for at least 5 minutes is necessary. A pressure bandage such as Coban
may be applied before releasing the patient, who should be informed about
possible hematoma formation. Applying the pressure bandage immediately after
the venipuncture leaves the patient open to formation of a hematoma and
possibly compartment syndrome.
39. Do not collect the specimen until the difference is resolved.
a. The Joint Commission requires the confirmation of at least two unique identifiers
before performing any medical procedure including phlebotomy. Any discrepancy
between the requisition, the armband or what the patient states must be resolved
before proceeding. Collecting the specimen and then reporting the error to the
patient’s nurse leaves the patient open to medical mistreatment. It is the
phlebotomist’s responsibility to see that the problem is corrected before the draw.
Proceeding on the basis of only the medical record number can be problematic
as it could have been inaccurately assigned to this patient and only represents
one of the two required identifiers.
40. Inform the patient and perform a 2nd collection of the missing tube.
a. Accepting responsibility for one’s mistakes is crucial in healthcare. Physicians
and patients rely on accurate laboratory results for diagnosis and treatment. If the
phlebotomist missed a tube, the only ethical choice is to inform the patient and
perform a second draw. It is not necessary to redraw all the tubes or have the
patient reschedule. Transferring blood from a full tube to the missing tube is not
acceptable as the test results could be negatively affected.
Study Guide - Quality and Professional Issues
42Q’s - Answers
1. Collect a tissue sample.

a. The scope of practice for a health care worker includes tasks and duties for
which they have been trained or certified to perform. For a phlebotomist,
processing blood samples, performing capillary punctures and point of care
testing all fall into this category. Collecting a tissue sample would be the
responsibility of the medical staff.
2. POCT.
a. Procedures considered within the phlebotomist’s scope of practice include:
inspection of equipment for defects, sterility and expiration dates, documenting
refrigerator & freezer temperatures, performing QC on glucometers and other
waived point of care test systems, correct patient identification, specimen labeling
and other assessments of the preanalytic phase of laboratory testing. If there are
questions about the patient’s test orders, the phlebotomist must contact the
ordering physician and resolve the problem before collecting the specimen. Blood
is never drawn from an IV site as the specimen would be contaminated with IV
fluid and cause incorrect patient results. Calling critical values to providers is the
responsibility of the technologist who performed the test.
3. Yes, because it was out of the phlebotomist’s scope of practice.
a. Moving a patient is not within the phlebotomist’s scope of practice. If the patient
requests to be moved, the phlebotomist may relay this information to the
caregiver. The patient does have the right to receive help, but it must be from
someone with the knowledge and training to correctly assist the patient. The
number of persons required to move a patient is governed on a case by case
basis. The Joint Commission establishes standards of care but is not involved in
legal responsibilities.
4. accession number
a. When a test order is entered into the laboratory information system (LIS), a
unique identifying number is assigned to that order. This is called the accession
number. This number establishes an electronic trail for all paperwork and
processes attached to that test request from order to result and allows that
specimen to be retrieved for additional testing. The DOB (date of birth) and
patient ID are associated with all orders generated for each patient but remain
the same for any order. The health facility number does not identify patients.
5. unique patient identifier
a. At a minimum, the label on a specimen label should include: patient’s first and
last names, unique identification number, date of birth, date and time of
collection, phlebotomist’s initials or numeric identification number and any
pertinent additional information such as “fasting” or “line draw”. The social
security number and diagnosis are not used as these might pose a HIPAA
infraction. Although usually included, the physician’s name is not necessary.
6. Container identification number (CID)
a. The container identification number is generated for each tube in the test order. It
differs from the accession number which is associated with the entire order. The
CID allows retrieval of an individual tube within the test order. The medical record
and accession numbers would be printed on each label in that order. Federal
Identification numbers (FIN) numbers are not used in healthcare.
7. Tell the medical technologist in the lab to perform the test.
a. After the phlebotomist completes a draw, it is necessary to document that
procedure in the computer system. This allows tracking of the time, special
comments (e.g. line draw or below IV) and phlebotomist’s initials in case there
are questions. If the LIS is interfaced with the lab's instruments, the test will show
up on the queue so the technologist can expect the specimen to arrive in the lab.
The doctor gets the results after the test is completed and signed off by the
technologist. The billing procedure is separate from the phlebotomy.
8. All subsequent orders will be entered under her password and initials.
a. When the phlebotomist enters a test order into the LIS, it automatically assigns
her initials (through her username and password) to the order. If she does not
“sign out”, the next order will also be under her name, even if someone else
placed the order. The computer assumes the order is placed by whomever
signed into it . This makes it difficult to track who has placed the order if there are
questions and could have legal ramifications. Regardless of who enters the order,
it will be transmitted to the lab and the results available to the nursing unit.
9. HIPAA.
a. Under the HIPAA law, the patient has the right to specify who is to see their PHI
(Protected Health Information). CLIA is the law that governs the testing standards
and certification of medical testing laboratories that receive federal funding.
Implied and written consent are two forms of informed consent whereby the
patient agrees to a medical procedure after having the procedure explained to
them.
10. diagnosis code, date of birth, phone number
a. The HIPAA law defines protected health information (PHI) as any documentation
that can identify an individual and that is stored or transmitted electronically or by
other means. The diagnosis code, date of birth or phone number could be traced
to a person. The year of admission or hospital name could not.
11. Addressing patient complaints in private.
a. The HIPAA (Health Insurance Portability and Accountability Act) law was enacted
in 1996 to protect medical records and other personal health information (PHI). It
provides for the privacy and security of a person’s health documents by requiring
the patient to state who is allowed to access their records. Addressing patient
complaints in private would be an example of compliance with HIPAA. Explaining
the procedure to the patient is part of obtaining informed consent. Properly
drawing the patient helps assure patient safety and accurate results. Billing only
for services performed is part of avoiding medical fraud and abuse.
12. Let her know the information can’t be released over the phone.
a. According to HIPAA the patient’s protected health information (PHI) cannot be
released without their written permission. This would include whether testing had
been drawn or if the patient has presented to the lab. Having a nurse return the
call or transferring the call to an integrity officer would fall under the same
infraction, as HIPAA regulates all healthcare workers.
13. No, because the phlebotomist breached confidentiality.
a. Under the HIPAA law, the patient has the right to state who may or may not have
access to their PHI ( protected health information). The phlebotomist did not have
the patient’s permission to disclose the patient’s admission to the hospital which
is considered a breach of confidentiality. Negligence has more to do with the
performance of duties within the scope of practice.
14. Negligence.
a. Negligence is defined as the failure to exercise due care. Repeated mistakes
after counseling or re-education are grounds for termination. Assault is the threat
of harm. Fraud is deception by words or conduct. Liability is being responsible for
one’s actions.
15. misidentifying a patient
a. A sentinel event is an unexpected occurrence that leads to death or serious
physical or psychological injury. The Joint Commission (TJC) maintains a list of
reportable sentinel events and TJC must be notified of these events. The most
serious of these for a phlebotomist is miss-identification of a patient which can
cause misdiagnosis, incorrect treatment or death. While not good laboratory
practice, failing to document QC, using the wrong gauge needle or ETS tube may
require re-training but are not considered sentinel events.
16. It could cause erroneous lab results.
a. A hematoma (bruise under the skin) may form due to improper draw technique,
clotting disorders or very fragile veins. Drawing through a hematoma may cause
erroneous test results due to hemolysis, clotted blood or disturbance of the
coagulation process. The site should not be used until it completely heals as
while it may cause the patient pain, a larger concern is the introduction of
compartment syndrome that may cause permanent nerve damage.
17. The tube will not fill completely., The tube may give questionable results., The additive
may not work.
a. Evacuated tubes have expiration dates to assure the viability of their contents,
their sterility and the strength of the vacuum. Decreased vacuum may not allow
the tube to fill properly. Outdated additives may not keep the blood from clotting
or adequately preserve the analytes to be measured. A vein collapses due to too
much vacuum or pressure. It is doubtful that a tube could infect a patient as the
blood is being withdrawn, not injected.
18. Centrifuge.
a. A centrifuge is used to “spin down” blood samples to allow for separation of
serum or plasma from cells. These instruments need regular maintenance and
calibration to assure optimum operation. The patient’s blood type, needles and
tubes, or temperature do not affect the volume of fluid recovered after
centrifugation of specimens.
19. Use a timer for serum clotting and use a timed centrifuge.
a. Serum tubes should be allowed to clot in an upright position for at least 30
minutes at room temperature. Each lab must establish the amount of time for
centrifugation to yield the best volume and clarity of serum for testing. The use of
a timer for both of these procedures is recommended. The exact temperature of
the blood or the lab will not affect centrifugation. The lab should document room
temperature each day.
20. Number of needlestick injuries, blood culture contamination rates
a. Quality indicators are monitors of patient care. Goals are set and outcomes
measured to assure they are being met. Two quality indicators commonly used in
phlebotomy are the number of needlestick injuries and blood culture
contamination rates. The number of butterfly sets used per month is dependent
on the types of patients being drawn. Performance of proficiency testing and the
number of CAP inspection deficiencies are considered quality indicators for
technologists.
21. document results in the log.
a. Quality control (QC) is a set of procedures conducted before patient testing to
assure the test system is performing correctly. A test system includes all aspects
of the test to be performed including equipment and instrumentation. The quality
control results must be documented to prove they have been done and be within
certain preset limits. If they haven’t been properly documented, it will be assumed
the QC was not run and therefore the patient results are not valid. Ensuring the
specimen is collected properly is an equally important part of the test process,
but not considered part of quality control. The QC results are not documented on
either the requisition form or progress report but internally within the Laboratory
to monitor accurate and medically useful patient results.
22. Daily on a log sheet.
a. Recording temperature checks for refrigerators and freezers is part of a quality
control (QC) program. QC is a set of procedures conducted before patient testing
to assure the test system is performing correctly. A test system includes all
aspects of the test to be performed including equipment used to collect, store and
process specimens. The quality control results must be documented to prove
they have been completed and are within certain preset limits. If not properly
recorded, it is assumed the QC was not checked and therefore the patient results
are not valid. The manufacturer’s instructions may dictate how often the
temperature must be recorded. Only documenting QC checks if the temperature
is out of range does not provide a daily record of performance. The use of
external liquid controls does not apply to refrigerated instruments.
23. expiration & temperature
a. Evacuated blood collection tubes are a manufactured item and are given an
expiration date beyond which the vacuum and integrity of the contents are not
guaranteed. When restocking tubes, the oldest are used first to avoid costly
wasting of outdated equipment. The tubes are maintained at room temperature
(approximately 22 degrees C). The types and quantities of tubes would be
governed by the testing needs of the laboratory.
24. Report to a supervisor.
a. The temperature of laboratory equipment (refrigerators, freezers, instruments,
rooms) is monitored to ensure proper specimen handling to produce accurate
test results. Temperatures out of range should be reported to a supervisor and
corrective action documented on the temperature log.
25. Obtain another pregnancy test cartridge and repeat the test.
a. Quality control (qc) is performed to assure that a test system is working correctly
before patient results are reported. If the quality control indicator does not
function properly, the patient results cannot be released. In this case, the
phlebotomist should obtain a new cartridge and repeat the test. A new urine
specimen will not change the qc results if the cartridge is not reliable.
26. Patient results will be compromised.
a. Quality control can only be considered valid if it is documented. Just checking the
temperatures but not writing them down is not sufficient. Documentation serves
two purposes. First, it assures that the instrument has been checked and second
it allows for observation of shifts or trends that indicate the need for maintenance
or repair. A refrigerator or freezer used for storage of reagents or patient
specimens is just as much a part of the testing process as the actual test. Patient
results can be affected if any part of the testing process is not temperature
controlled. It is doubtful that the phlebotomist who neglected to document will be
fired unless it is a repeated offense, but retrained and monitored. The lab is likely
to get a deficiency from the inspection agency for the omissions. Filling in the
documentation is unethical and not good laboratory practice.
27. Discussing the lab results with the patient.
a. The Patient Care Partnership published by the American Hospital Association
outlines the steps necessary to provide the patient with quality care. Obtaining
implied consent or drawing a child with parental consent conforms to these
guidelines. A phlebotomist should not discuss lab results with a patient. All
questions regarding test results should be referred to the patient’s nurse or
doctor. The choice of vein for venipuncture is guided by the phlebotomist’s
competence and experience.
28. Assault.
a. Threatening or coercing a patient to have any medical procedure is considered
assault. Battery would be the actual performance of the venipuncture against the
patient’s will. If a patient refuses a procedure, it is best to consult the health care
provider as to how to proceed. Assault and battery are covered under tort or civil
laws. Libel is a published false statement that is damaging to a person's
reputation.
29. Attempt to gently wake the patient.
a. Performing a venipuncture on a sleeping patient can result in injury to the patient
or the phlebotomist. The patient should be gently awakened and alerted to the
impending procedure. If unable to wake the patient, the nurse should be
consulted as to how to proceed.
30. speak slowly and loudly, make eye contact, take time and listen carefully
a. Taking the time to explain the procedure is very helpful in assuring good
communication and understanding. This is especially true for elderly patients who
may have hearing or understanding impairments. Making eye contact, speaking
slowly with a stronger voice and using visual aids can help. If necessary, write out
what you are trying to say. Also, asking the patient to repeat what you have
stated can assist in knowing if they understood what you have said.
31. pediatric tubes (short draw tubes), butterfly, Coban
a. Geriatric patients often have thin skin and small veins that are close to the
surface. The use of a regular ETS multi sample needle and tubes may exert too
much pressure on the vein, causing it to collapse. A better choice might be a
butterfly set with pediatric or short draw tubes which contain less vacuum. Coban
is commonly used to bandage the patient as the adhesive from a Band-Aid might
damage the skin when removed.
32. active listening
a. Effective communication involves the interaction of two people. The listener must
focus on what is being said and give feedback to the speaker to assure
understanding. This is known as active listening. Making eye contact and non
threatening use of personal space are aspects of body language. Studies have
shown that 55% of communication is body language, 38% is the tone of voice,
and 7% is the actual words spoken.
33. Move closer and speak louder so the patient can hear through the N95 respirator.
a. Effective communication is crucial in obtaining a satisfactory blood specimen for
analysis. This includes accurate patient identification and informed consent. If the
patient is in airborne precautions, it is essential for the phlebotomist to wear an
N95 respirator for proper PPE protocol. The phlebotomist can move closer and
speak more loudly and distinctly to make himself understood. Another option
would be to write out the necessary information. For infection control purposes,
pulling the N95 respirator away from the face is not acceptable. Neither is
shouting. Continuing the procedure without proper identification and consent
could be construed as assault and battery.
34. prevent testing errors.
a. Quality control (QC) is performed before patient testing to assure that a test
system is operating correctly. If QC is out of range or does not function within the
accepted criteria, the test system cannot be used for patient testing until the
problem is corrected and QC performed again. Reporting patient results from a
test that has failed QC leads to medically invalid results that may cause a patient
to be treated incorrectly. It is important to follow the manufacturer’s instructions in
all the test system steps. These can be found in the package insert. Following
these steps and incorporating them into the lab’s policy manual will assure the
proper handling of lot numbers and prevention of errors such as
cross-contamination.
35. Gently slap the area to make veins more prominent.
a. Slapping the potential venipuncture site is never an acceptable practice and can
be construed as assault and battery. To increase blood flow to the area, a warm
cloth may be applied(not to exceed 42o C for 3-5 min.). The use of a blood
pressure cuff in place of a tourniquet is acceptable as long as the cuff holds
adequate pressure. Using the same cuff for different patients might impose an
infection control risk. Allowing the arm to “hang down” might help and the arm
should be placed in a supported, downward position to prevent reflux of tube
additives into the patient’s vein.
36. Yes, glucose specimens collected in gray top tubes are stable for 24 hours at room
temp.
a. Blood specimens collected in a gray top tube (sodium fluoride & potassium
oxalate) for glucose analysis are stable for 24 hours at room temperature and 48
hours if refrigerated at 4-8 oC. Sodium fluoride acts as a preservative to delay the
metabolism of glucose in the specimen by red and white blood cells and
platelets. If collected in a gel barrier tube without the benefit of sodium fluoride as
a preservative, the serum should be separated from the cells within an hour.
37. CLIA
a. The CLIA (Clinical Laboratory Improvement Amendment) law describes the
education and training required for each level of laboratory testing. A
phlebotomist may perform the chemical analysis (dipstick) portion of a urinalysis
(UA) which falls under the waived category, but not the microscopic examination
of the sediment. COLA (Commission on Office Laboratory Accreditation) grants
official approval to physicians office laboratories. CLSI (Clinical and Laboratory
Standards Institute) establishes benchmarks for laboratory testing procedures.
OSHA (Occupational Safety and Health Administration) creates guidelines to
assure employee safety.
38. Identify the patients correctly., Improve staff communication., Prevent infection.
a. The Joint Commission has outlined goals to achieve a high level of patient safety.
Among these are correct patient identification, improving intra staff
communication and the prevention of spread of infection. Speaking directly to a
patient in a calm, friendly way and inquiring about allergies are examples of good
professional behavior.
39. A receipt is signed and dated.
a. A chain of custody (signed and dated receipt) must be established in legal cases
such as DUI to establish a traceable “paper trail” of all persons who handled the
specimen. In court, those persons may be called upon to verify the correct
collection, processing and testing of the sample. A breach in the chain of custody
can invalidate the legal case. Sample identification is of the utmost importance
but not part of the chain of custody which applies to sample transport. Any
photography of verification of search warrants would be handled by law
enforcement – not the phlebotomist.
40. pull the plunger steadily.
a. Syringes are typically used when the vacuum of an evacuated tube system (ETS)
is thought to be too much for the vein to be punctured. The pressure that the
plunger of the syringe applies to the vein when extracting the blood can be
controlled so as not to collapse the vein. The needle is always withdrawn quickly
after releasing the tourniquet when the procedure is complete to avoid further
injury. The needle should be inserted into the vein quickly at less than a 30o
angle. The thumb is used below the puncture site to anchor the vein which helps
hold it in place and stretch the skin which reduces discomfort for the patient.
None of these actions would cause a vein to collapse.
41. ask the patient for his name and qualifying information.
recommend at least the confirmation of two patient identifiers before proceeding
with any medical procedure including phlebotomy. Errors in patient identification
lead to medical mistreatment and possibly death. Having the patient state his
name and date of birth (DOB) will suffice for an outpatient. For inpatients, in
addition to stating name and DOB, the phlebotomist should match the medical
record number on the test requisition to that of the patient’s armband. A
specimen should never be drawn from a patient without an armband. Any
discrepancy in the information must be corrected before proceeding. Matching
the wrist band to the requisition is not sufficient as the patient may have the
wrong band. The same is true for the chart. The patient does not complete
anything on the requisition – it is the responsibility of the phlebotomist to provide
complete and correct patient identification.
42. phlebotomist’s initials, patient’s D.O.B., date of draw
a. CLSI recommends five pieces of information that should appear on the label of a
specimen. These include: patient’s name, date of birth, unique identification
number (such as medical record number), time and date of collection, and the
initials or identifying number of the collector. Placing the ICD-10 diagnosis code
on the specimen can be considered an infraction of the HIPPA law. Also the lab
ID is not necessary for patient identification.
13 Case Scenarios - Answers
Compare your response to our suggested response below.
Are you making the right decisions?
Case Scenario 1 Answers:

1. A patient under airborne precautions can transmit an infectious agent (e.g. TB) through
spraying droplets while coughing. Hospital staff and other visitors should utilize an N95
respirator to protect themselves.
2. Before entering the patient room, don (put on) the proper Personal Protective Equipment
(PPE): N95 respirator, gloves, and gown.
3. Avoid contact with droplet spray if possible (i.e. coughing in face).
4. Handle carefully, as per standard precautions. Avoid breakage.
5. No. Alcohol is still just fine.

1. The right arm
2. One lavender top for the CBC; plus a red topped tube*
a. *Although serum tubes (red or speckled) would usually be drawn for the other
tests, many labs will ask for green top tubes for STAT testing. Since the tubes
contain anticoagulant, green top tubes can be spun and the plasma tested
without having to wait for clot formation.
3. LYTES=checks electrolyte balance of blood stream, CBC= Complete Blood Count
provides cell counts, hemoglobin (Hb), hematocrit (Hct), and other tests for things like
anemia, BILI= Bilirubin levels check liver function
4. Hepatitis (from the yellow tinge to his eyes and skin)
5. Renal (kidney) function
6. Coagulation function
7. Bone
8. Anemias
9. To determine if a patient had a myocardial infarction (MI), i.e. heart attack

1. Respiratory
2. Skeletal (bones and joints) - Integumentary (skin, hair, nails, teeth, etc) - Muscular -
Nervous - Digestive - Urinary - Reproductive - Endocrine - Lymph - Cardiovascular
(including Circulatory System)
3. Median cubital, cephalic, and basilic
4. Tip of the 3rd or 4th finger (also known as the middle finger or the ring finger)
5. Most medial or lateral sections of the plantar, or bottom, surface of the heel should be
used.
6. Heart (cardiac) patients and diabetic patients.
1. No. Patient Identification always matters. It’s the #1 concern.
2. Check with Mr. Jones if he is still there. Ask for his middle initial. You already have his
“numeric identifier”, so you should check that as well. Unless both patients have the
same birthdate, the patient is now correctly identified.
3. Patient ID; patient identification and correct labeling are of utmost importance—without
the right patient, even if everything else is done perfectly, the lab test results are of no
value.
4. Getting a middle initial or middle name never hurts, especially if people have common
surnames, like Jones or Smith.
5. Some outpatient sites will allow Social Security Numbers to be used in identification.
Inpatient hospital numbers are generally the preferred numeric identifiers for patients
admitted to hospitals. They must match number for number. If they do not, blood cannot
be drawn because patient identification needs to be confirmed before collecting a
specimen.

1. Not well. You forgot to wash your hands in between patients. Hand hygiene is to be
performed after removing gloves and before putting on new gloves. Changing gloves
alone is not enough.
2. Perform hand hygiene.
3. Routine venipuncture requires cleansing the site with alcohol. Blood culture specimen
collection requires a different cleansing technique to minimize the chance of
contaminating the blood specimen with bacteria from the skin. Two commonly used
cleansing methods are chlorhexidine gluconate and alcohol/iodine. When chlorhexidine
gluconate is used it is generally a one-step procedure: The solution is released from the
sponge and a back and forth friction scrub is performed for at least 30 seconds. The site
must be allowed to air-dry before a venipuncture is performed. When alcohol and iodine
are used for cleansing it is a two-step method: First, an alcohol wipe or alcohol sponge
is used to gently rub the venipuncture area in a back and forth method for 30 seconds.
The site is allowed to dry. The iodine solution is then applied at the center of the
venipuncture site and moved outward in concentric circles to the periphery. The site
must be allowed to air-dry before a venipuncture is performed.
a. NOTE: The cleansing procedure may vary among healthcare facilities.
Chlorhexidine is recommended for infants two months and older and patients
with iodine sensitivity.
4. Treating all patient samples as if they are both hazardous and infectious, and capable of
transmitting something you don’t want, is the basis for the philosophy of safety known as
using “Standard Precautions”. By treating all samples the same and handling them all
with standard precautions, we are protected from the most infectious and hazardous
agents just like any other.
5. Yellow SPS
Case Scenario 6
1. 23 gauge needle and the small volume lavender top tube; maybe the syringe if needed
(**the higher the gauge number, the smaller the needle bore)
2. 21 gauge needle and an adult speckled top tube (a plain red top tube would also be
acceptable in this scenario)
3. Lancet, less than 2.0 mm depth and microcollection containers
4. Venules and Arterioles
5. The vessel may collapse under the pressure; you might consider a syringe draw to
control the amount of vacuum exerted.
6. Draw red first, then lavender (since it has an additive). The tube order recommended by
CLSI* is blood culture tubes/bottles; coagulation tube (light blue); serum tube with or
without clot activator (red, gold, or red/black); heparin with or without gel plasma
separator (green); EDTA (lavender or pink); and glycolytic inhibitor (gray); yellow top (A
or B) ACD tubes; all others.
a. * Clinical and Laboratory Standards Institute
7. Tubes = Additive
a. Red top = nothing; speckled (gray and red) polymer barrier
b. Lavender top and pink top = EDTA
c. Light Blue top = Sodium Citrate
d. Green = Heparin
e. Gray = Potassium Oxalate +/or Sodium Fluoride
Case Scenario 7
1. Depending upon the location of the items on the floor to your own location, you would
assess the needs that should be addressed first. If the needle is closed, you might very
carefully pick it up and dispose of it in your own sharps container. Next, you would
assess the spill danger. You would want to make sure that no one would slip on the
spilled liquid, including yourself, the patient, and any visitors—while awaiting cleanup.
You must assume the liquid is hazardous since you do not know its origin, and whoever
cleans the spill must use universal precautions. Finally, with gloved hands, you could
pick up the used gloves and dispose of them as you would your own.
2. They must be spill-proof, tamper proof, and puncture resistant.
3. You could bleed the wound slightly and then clean it with soap and water or an alcohol
swab.
4. OSHA (universal precautions, etc); Right to Know law (MSDS sheets); JCAHO
regulations for patient and employee safety.
Case Scenario 8
1. Blue top(s)
2. Lavender top for the CBC; an additional red for the Crossmatch (and some people might
want another lavender for typing) most use lavender or pink tubes as plasma is
acceptable for crossmatch & there is no waiting for serum tube to clot. PLEASE
INCLUDE THE SPECIAL ID BAND FOR THE CROSSMATCH; several glass slides for
the DIFF.
3. The order of draw is not affected in this example. Sodium citrate (light blue) is drawn
first, then lavender and pink.
4. The patient may need surgery or may require a blood transfusion.
5. Blood flows freely in the bloodstream unless the coagulation mechanism is activated for
some reason.
6. When skin is “cut”, “tissue factors” activate the extrinsic clotting system that is measured
by the Prothrombin Time (protime) test. The coagulation factors interact in a sequence
that is known and predictable. At the same time, platelets form a plug to shore up the
vessel break until the body can do more permanent repairs. This also activates the
“intrinsic” coagulation pathway, and sets yet another series of coagulation factors to work
activating one another in sequence that can be tested by an aPTT. Together, the
intrinsic and extrinsic pathways of coagulation combine to activate a common pathway,
which eventually leads to the conversion of prothrombin to thrombin. Thrombin then
activates fibrinogen to form fibrin—which is the framework for the formation of a more
permanent plug—which remains until tissue repair is complete. Calcium is needed for
this to occur, which is why blood does not clot in the presence of EDTA, as it binds up all
the calcium.
a. There is also a natural body system for getting rid of products of clotting or
coagulation. This is called the fibrin-lysis or fibrinolytic system.
Case Scenario 9
1. You can call the medical laboratory scientists or medical technologists for advice, or look
in a service directory, to determine specimen collection requirements for the three tests
ordered. They may perform the Mono test, but ask for recollection for the others. Make
sure the draw time is easily noted in any case.
2. A test result is only as good as the sample upon which it is performed. If the sample is
too old, it won’t give the same results as a fresh one and the patient might get the wrong
treatment or diagnosis.
3. YES. This is an example of Quality practice. Controlling the quality of each step in the
collection and performance of laboratory tests is crucial. Obviously, this process has a
flaw—these samples were somehow overlooked for days or weeks. The process must
be fixed so that it won’t happen again. We wouldn’t investigate to place blame, but to
make the process work better.
Case Scenario 10
1. Collect the blood from the left side. Blood is never collected from the side of a
mastectomy and/or the side from which lymph nodes have been removed.
2. Stop the collection, apply steady pressure on the hematoma until the swelling stops,
place a pressure bandage on the site, and use the other arm to complete the blood
collection.
3. Identify the patient using other information available such as the full name (first, last,
middle initial), address (street, city, state, zip code), and date of birth (month, day, and
year). If a Social Security number is available, that can also be used.
4. Draw the blood specimens from the right arm. If there are no suitable veins in the right
arm, have the nurse discontinue the IV in the left arm, and after two minutes, collect a
blood specimen from a site distal from the IV location.
5. Pre-warm the fingers with a warm washcloth, paper towels, infant heel warmer, or other
appropriate warming device.
6. Take your time locating a vein. The antecubital veins will be under a layer of
subcutaneous fat so it is necessary to palpate deeply. Allow the arm to extend fully in a
downward position and use a warming technique. Instead of a tourniquet, use a bariatric
blood pressure cuff with the pressure up to no more than 40 mm Hg. Ask the patient
where successful collections have occurred. It may be necessary to use hand veins or
veins on the side of the wrist. It may be necessary to collect the specimens via capillary
puncture.
7. Assemble the phlebotomy equipment before entering the area. Use a soothing and
reassuring style of communication to lessen the child’s fear and to assure that s/he will
cooperate as much as possible. Obtain assistance from a nursing staff member or a
fellow phlebotomist to hold the patient’s arm still.
8. Ask the patient if he/she has been fasting 8-12 hours and document accordingly.
9. Do not touch the patient. You can explain the procedure and why you are there, but the
patient ultimately has the right to refuse treatment.
10. Before collecting blood from a foot or ankle vein, obtain physician approval to assure
there are no contraindications. Individuals with circulatory problems such as those with
diabetes, cardiac disease, thrombophlebitis, deep vein thrombosis, and more should not
have venipunctures performed in the lower extremities.
Case Scenario 11
1. Take it seriously. It doesn’t matter whether you believe he will faint. The safest thing to
do is place him in a reclining position for the draw.
2. Protect the patient from harm. Try to keep him from falling and injuring himself further.
Make sure to remove the tourniquet and needle as quickly and safely as possible. Help
move him into a position to get blood circulating to his head as quickly as possible; i.e.,
head between knees if still seated or bend knees if patient has been moved to the floor.
A cold compress on the back of the neck or forehead will help. Get medical assistance
as needed.
3. These can be symptoms of shock. Seek medical help as quickly as possible.
Case Scenario 12
1. No!
2. Any time tubes are labeled before a sample is collected, there is an elevated risk of
specimen identification errors. If a patient sample is collected in a tube that is pre
labeled with a different patient's label, it puts BOTH patients at risk of having inaccurate
test results. A physician might enact a treatment protocol based on results that don't
even belong to that patient.
3. The phlebotomist who draws the sample, and whose initials are on the paperwork.
4. The patient’s diagnosis and/or treatment may depend upon it.
Case Scenario 13
1. Key points:
a. Some risk, but kept low because of the use of standard precautions and isolation
procedures as needed. The greatest infectious risks for laboratory workers are
hepatitis B and C, although people hear more in the news about the risk of HIV
(the virus that causes AIDS).
b. The spread of disease from patient to patient is very possible unless standard
precautions are used. The single most important clinical practice to prevent the
spread of infection is the performance of hand hygiene and the use of gloves.
c. Working while infected with any communicable disease or illness is never
advised for any healthcare worker. Respiratory or skin diseases would be among
the most easily spread. Because of that, there is very little risk of the patient
catching anything from the phlebotomist who responsibly stays home while ill.
2. Healthcare acquired infection (previously called nosocomial infection)
3. Hepatitis B vaccination
Practice Exam - Answers 150Q’s
1. Light blue, SST
a. Rationale: The order of draw is designed to prevent carryover of additives from
one tube to the next thereby affecting patient results. CLSI states the order of
draw for ETS tubes to be: SPS (sterile), sodium citrate (blue, serum, red or gold),
heparin (green), purple (EDTA), oxalate / fluoride (gray). In this case the order
would be light blue then SST (serum separator tube). Royal blue tubes are used
for heavy metal screens and the red (serum tube) is never drawn before a light
blue.
2. Malpractice
a. 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.
3. Blood pressure cuff
a. 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.
4. light blue, green, lavender.
a. Rationale: The correct order of draw would be: two light blue top tubes (one
waste and one for PT which is a coagulation test), green top tube (for the Chem
7), and the lavender top tube (for the CBC).
5. right arm distal to the IV site.
a. 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.
6. Insurance number
a. Rationale: An insurance number is not a common means of positive patient
identification (entire families can share the same insurance policy number).
Patients must be positively identified for medical services, whether they have
insurance or not. Insurance information is necessary for billing purposes. The
only true unique identifier listed among these choices is the social security
number. Patient name and date of birth are also commonly used to confirm
identification.
7. Apply a warm compress to the area for 5 minutes.
a. nRationale: The phlebotomist should apply a warm compress to the area for 5
minutes. Warm moist heat promotes circulation and vasodilation and will help
make the vein more visible. Tapping the arm or dangling the arm will not cause
the vein to be as prominent as applying a warm compress. Applying firm
pressure to the arm will occlude the blood flow and will not make the vein more
prominent.
8. Decreased red blood cell count
a. 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.
9. Microcollection container
a. 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.
10. 23-gauge butterfly needle and syringe
a. 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.
11. Brachial artery
a. 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.
12. The phlebotomist may perform venipuncture provided he is wearing a mask and afebrile.
a. 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.
13. Gloves only
a. 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.
a. 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.
15. Explain the procedure and reassure the child that the parent can stay with her.
a. Rationale: Performing a venipuncture on a school age child requires age related
competencies and understanding of the needs of various age groups. It is best to
explain the procedure in simple terms and reassure the child that the parent can
stay with her. It is important to always speak directly with the patient regardless of
patient’s age and status in order to demonstrate professionalism, respect and
establish trust. Telling the child that she has to do this may make the child more
apprehensive and more frightened. Never tell the child or any patient that the
procedure will not hurt. Every patient experiences pain differently and has
different pain tolerance. It is best to tell the child that they may feel a little pinch or
relate the procedure to something a child might have experienced. Telling the
child the procedure will not hurt will only lead the child to no longer trust the
phlebotomist when it does hurt. It is acceptable to allow the child to handle or
look at the tubes and packaged alcohol swabs before the procedure to become
more comfortable, but it is imperative that any sharps are kept out of reach and
that the phlebotomist performs the entire procedure.
(EOP1)
16. Rotates to separate components of a patient's blood
a. Rationale: Centrifugation refers to specimen handling/processing during
centrifugation. It causes the specimen to rotate at high speeds, thereby creating
a centrifugal force that causes heavier elements to sink to the bottom of a test
tube and lighter substances to stay on top of the specimen tube. Depending on
specimen requirements for a particular test, certain samples must be processed
by centrifugation to maintain the integrity for testing. A centrifuge does not serve
as a specimen warmer, nor does it magnify sample components (microscopes
are used for magnification). Glucose measurements are obtained by analyzing
the sample on a glucose meter or designated laboratory instrument, not the
centrifuge.
17. Drawing multiple tubes.
a. Rationale: The rubber sleeve maintains a closed system while switching tubes.
18. Cephalic
a. 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.
a. 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.
20. "May I have your name please?"
a. 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.
21. Draw blood from the hand using a winged infusion set.
a. 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.
22. 5 min
a. 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.
23. Immerse the specimen in an ice and water slurry.
a. 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
ultraviolet light.
24. Patient prep to lab arrival pre-analytical phase.
a. Rationale: Approximately 50-70% of all laboratory errors occur during the
pre-analytical phase. The pre-analytical phase begins when the physician orders
the tests and end just before specimen analysis (testing) begins. Patient
preparation, specimen collection, handling and processing are all part of the
pre-analytical phase. Specimen hemolysis, micro clots formation and specimen
mishandling are common sources of pre-analytical errors that can significantly
alter test results. Analytical testing phase includes specimen testing by the
Clinical Laboratory Technician or Clinical Laboratory Scientist. Post-analytical
phase includes reporting of results and specimen storage for reflex testing or
add-on testing (tests added on to the original specimen by physician request).
Data processing and record keeping phase is not a laboratory phase.
25. Light blue, lavender
a. 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.
26. Capillary blood
a. 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.
27. Destroys many enzymes.
a. Rationale: The sodium fluoride in gray-topped tubes can destroy many enzymes.
Since ALT and AST are enzyme tests, sodium fluoride should be avoided.
28. Refer the patient to the physician for interpretation of all results.
a. Rationale: The phlebotomist is able to collect blood specimens via capillary
puncture and venipuncture, process specimens and perform CLIA waived point
of care tests. Phlebotomists are not able to interpret or analyze results whether
the tests are categorized as waived, moderate or high complexity. It is always
best to instruct the patient to consult with the physician for interpretation of the
results.
29. Explain to the patient that a bruise may be likely, but it should be gone within a few days.
a. 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.
30. MSDS
a. Rationale: A Material Safety Data Sheet (MSDS) is a hazardous chemical
reference. It provides healthcare workers with procedures for working with
substances safety to ensure regulatory compliance. Clinical Laboratory
Improvement Amendments (CLIA) of 1988 are United States federal regulatory
standards that apply to all clinical laboratory testing performed on humans in the
United States, except clinical trials and basic research. HIPAA (Health Insurance
Portability and Accountability Act) requires medical professionals to protect the
confidentiality of patients’ health information. The National Institute for
Occupational Safety and Health (NIOSH) makes recommendations for preventing
illness and injury acquired on the job.
31. Do not bandage.
a. 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.
32. Latex sensitivity
a. Rationale: A test requisition includes the following required information: ordering
physician’s name, patient’s first & last name, medical record number (inpatient),
date of birth, room number (inpatient), test ordered, date (& time, if applicable) to
be performed, billing information, test priority & status (fasting, timed, STAT) and
special precautions such as latex sensitivity. An admission date may be included
if the patient is scheduled for a certain procedure or surgery. The patient’ blood
type is not necessary and could be a HIPPA infraction. Sample storage
requirements are the responsibility of the laboratory once the sample arrives for
testing.
33. Annual employee safety training
a. 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.
34. Red
a. Rationale: A plain red tube and an SST tube both will yield serum once clotted
and centrifuged. Therefore, it is possible to share the plain red top specimen for
the SST test. There is no need to re-stick the patient. The lavender and blue top
tubes both contain anticoagulant, thus they produce plasma (not serum) when
centrifuged. They would not be good substitutes for an SST specimen.
a. Rationale: Venipuncture on a non-responsive patient in an emergency
department constitutes implied consent. Implied consent is not a verbal consent
and is not explicitly given by the patient; instead it is implicitly given by the
patient’s body language, actions or situation. Non-responsive patient in an
emergency department constitutes a situation where all measures are taken with
the patient’s best interests in mind and permission is assumed. Expressed
consent is a consent that requires verbal and often written agreement to receive
treatment involving high-risk surgeries and experimental medication after all the
risks and benefits have been discussed with and understood by the patient.
Informed consent is a consent that requires verbal agreement to receive
treatment for a medical procedure or a treatment. Refusal of consent is an
explicit denial to receive medical and is supported by the Patient’s Bill of Rights.
36. Petechiae.
a. Rationale: Small red spots near the tourniquet on a patient’s arm are most likely
indicative of petechiae. Petechiae are small, red, non-raised spots that appear in
response to pressure from the tourniquet. They do not pose a health risk to the
patient. Petechiae may indicate poor capillary integrity and poor platelet function.
A collapsed vein normally occurs in response to excessive vacuum in the
evacuated tube or excessive pressure created with the plunger of a syringe
during a venipuncture. A hematoma is a bruise under the skin resulting from
blood pooling into the surrounding tissues during or after a venipuncture. Edema
is swelling of tissues due to accumulation of interstitial (tissue) fluid.
37. Hepatitis B
a. 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.
38. Release the tourniquet.
a. 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.
39. Light blue, sodium citrate
a. Rationale: An INR test refers to an International Normalized Ratio, which
provides a standardized method of reporting prothrombin time results by
comparing the ratio of the patient prothrombin time to the control prothrombin
time. This, in turn, helps to standardize the method of reporting the effects of oral
anticoagulant therapy on blood clotting. It uses the light blue tube with sodium
citrate as it would for a regular prothrombin time (Pro Time) test.
40. Apply direct pressure with cotton gauze
a. 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.
41. Before putting on gloves prior to venipuncture
a. 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.
42. Check controls on urinalysis reagent strips daily.
a. Rationale: Proper Quality Control ensures accuracy and reliability of test results
while detecting and eliminating errors. It is an important component of patient
care to make sure results are accurate, therefore it is important to check controls
on urinalysis dipsticks daily. Supplies (in venipuncture trays or anywhere) should
never be used beyond the expiration date. Recycling is not a quality control
measure. Glucometer controls should be checked at least daily (or more
frequently). It is important to follow whatever quality control protocols are in place
NCCT Phleb. Review Answers PG
100
for each piece of equipment or manual test you perform. Always check to make
sure quality control is up to date before running any patient samples.
43. Folding the arms across the chest
a. Rationale: There are numerous behaviors that project professionalism. Smiling,
maintaining eye contact, listening with compassion (nodding the head and taking
notes to demonstrate active listening), etc. are ways to let patients know they are
being heard.
44. Lancet
a. 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).
45. Povidone-iodine
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.
46. N95 respirator
a. 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.
47. Choose a different collection site.
a. Rationale: The detection of a vibration sensation indicates the presence of an
arteriovenous (AV) fistula. AV fistulas can develop almost anywhere in the body,
but they are often created through a surgical procedure and are used for patients
101
who require dialysis. AV fistula is a surgical fusion of an artery and a vein that
allows for the vein to increase in diameter and develop thicker walls. Since veins
have a tendency to develop scar tissues after repeated venipunctures, an AV
fistula with thicker walls and larger size allows for easy needle entry even with
repeated venipunctures. The AV fistula is considered to be the patient’s “lifeline”
as it allows for blood to be filtered through an “external kidney” machine called a
hemodialyzer, which will maintain electrolyte balance, remove waste, and help
maintain normal blood pressure. Only trained dialysis technicians and physicians
are allowed to access the AV fistula. Phlebotomists must not access the AV
fistula or any veins located on the same arm as the AV fistula. Instead, use the
opposite arm for venipuncture.
48. The Patient's Bill of Rights.
a. 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.
49. Butterfly needle
a. 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).
50. 21-23
a. 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).
51. Sheathed.
a. 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.
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52. Discontinue the venipuncture and call for help.
a. Rationale: If the needle is still in the arm as the patient falls it could cause serious
injury.
53. Falsely elevated K levels from tissue damage
a. 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.
54. 3 to 4 inches
a. Rationale: Tourniquets are used to make it easier to locate veins by causing them
to become distended and easier to palpate. This occurs because the tourniquet
impedes venous blood flow right (i.e., below the application site) but does not
impede arterial blood flow. Most phlebotomy experts recommend a tourniquet be
applied approximately 3 to 4 inches above the site of blood collection for optimum
palpation in venipuncture. Placing a tourniquet too far away will not impede blood
flow sufficiently to help with palpation, but too close may cause
hemoconcentration, possibly affecting the ratio of cellular components to plasma
and laboratory test results.
55. Use a broom and dust pan to sweep up the glass and fragments and place in a sharps
container.
a. 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.
56. The first drop of blood may contain traces of tissue fluids.
a. 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.
103
57. Perform QC on the instrument.
a. 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).
58. 1.00 mm lancet
a. 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.
59. Light blue top
a. Rationale: Sodium citrate (light blue top tube) is the anticoagulant of choice for
coagulation studies such as PT/INR (Protime/International Normalization Ratio)
because it does not bind to calcium or inactivate heparin, which may be required
to be present in such testing. Lavender top tubes contain EDTA as the
anticoagulant, which does bind calcium. Green top tubes contain heparin and
could lead to inaccurate coagulation studies.
60. 2.0 mm.
a. 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
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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.
61. Up
a. 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.
62. The Patient’s Bill of Rights
a. 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.
63. OSHA
a. 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.
64. Hold pressure on the draw site until bleeding has stopped.
a. 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,
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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.
65. Hematoma
a. 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.
66. Blood borne pathogens.
a. Rationale: The Needlestick Safety and Prevention Act requires reporting and
documentation of all sharps injuries. In compliance with OSHA standards, log or
report must be kept in the medical facility describing the incident, type of device,
time, date, location, and follow up. This also includes minor incidents that do not
result in injury or illness.
67. Re-position the needle and recollect the lavender tube.
a. 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).
68. Hemolysis
a. 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.
69. Blood alcohol, Drug testing
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a. 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.
70. Perform regular hand hygiene
a. 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.
71. An elbow splint.
a. 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).
72. Failing to mix tubes
a. Rationale: The most common pre analytical error made at the time of blood
collection is failing to adequately mix the tubes. If the blood is not well mixed with
the anticoagulant, partial clotting can occur leading to microscopic fibrin strands
and inaccurate test results. An incomplete requisition is also a preanalytic error
but would be resolved before collection. Delay in transport or centrifugation are
errors that occur after collection.
73. Collapsing vein
74. Collapsing vein
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75. Blood culture, red top, lavender top
a. Rationale: To avoid cross-contamination.
76. Identify the patient
a. 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.
77. CLIA
a. 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).
78. "I will wear a gown, gloves, and mask for inpatient collections.“
a. Rationale: In a healthcare setting, the staff wears Personal Protective Equipment
(PPE), not the patients. The purpose of following contact-droplet isolation
precautions are to contain the patient’s environment and prevent the spread of
infection. Since they have contact with multiple patients, medical professionals
must wear proper PPE and perform proper hand hygiene when caring for every
patient. Antimicrobial wipes can be utilized to clean exam rooms between
patients. In order to limit potential for accidental exposure/puncture, Sharps
containers should be replaced when 2/3 full.
79. Heel stick lancet
a. 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.
80. Name of the physician
a. 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.
81. 8-12 hours
a. Rationale: To ensure accuracy of the blood test results. Gum chewing, eating
mints, and/or smoking are not allowed. Sips of water may be permitted
depending on provider NPO policy.
82. Pulling the skin taut using gentle and sufficient pressure to anchor the vein
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a. Rationale: Blood collection from a geriatric patient can be more difficult due to
fragile skin and poorly anchored veins. The best technique for a successful
venipuncture on a geriatric patient is to pull the skin taut and firmly anchor the
vein. Pulling the skin taut helps stretch the skin and tissues underneath, which in
turn stabilizes the vein and allows the needle to enter the skin more easily. A
tighter tourniquet will only cause more discomfort, potential bruising and skin
tearing, as well as hemoconcentration of the blood specimen. Vigorous
massaging of the arm can cause bruising and hemoconcentration of the blood
specimen. The needle angle used during venipuncture is directly related to the
depth of the vein. Deep veins require a steeper angle, while superficial veins
require a shallower angle.
83. Test priority
a. 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.
84. The blood specimen will be hemoconcentrated.
a. 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.
85. Left ring finger
a. 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.
86. Lavender, green, red
a. 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.
87. To pull the skin toward the wrist.
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a. 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.
88. Standard precautions.
a. 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.
89. Maintain the specimen at 37 degrees Celsius.
a. 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
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.
92. Disposing of extra patient tube labels in a regular trash can
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a. 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.
93. Increased risk of nerve damage, Increased risk of arterial involvement
a. 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.
94. Are extremely obese.
a. 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.
95. The type or absence of an additive
a. Rationale: There are a variety of blood collection tubes. The colors of the caps
indicate the presence or absence of additive. Particular laboratory tests may
require a specific additive. For instance, if a test requires serum, a red top tube
that allows the blood to clot would suffice. A lavender/purple top tube contains K3
EDTA anticoagulant that will keep blood from clotting, allowing for whole blood
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testing such as a CBC and Differential. Depending upon the type of tube and
additive therein, a minimum blood volume may be required.
96. The type or absence of an additive
a. Rationale: There are a variety of blood collection tubes. The colors of the caps
indicate the presence or absence of additive. Particular laboratory tests may
require a specific additive. For instance, if a test requires serum, a red top tube
that allows the blood to clot would suffice. A lavender/purple top tube contains K3
EDTA anticoagulant that will keep blood from clotting, allowing for whole blood
testing such as a CBC and Differential. Depending upon the type of tube and
additive therein, a minimum blood volume may be required.
97. Checking the expiration dates of venipuncture supplies, Monitoring temperatures of
specimen refrigerators, Perform daily glucose meter control checks
a. 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.
98. Strep test and urine reagent strip
a. Rationale: CLIA (Clinical Laboratory Improvement Amendments of 1988) is a
federal law that regulates all laboratory testing in the United States and sets the
minimum requirements for laboratory practices to ensure the minimum standards
of quality. The three categories of test complexity include waived, moderate
complexity (which also includes provider performed microscopy procedures or
PPMP), and high complexity testing. The FDA (Food and Drug Administration)
determines test complexity based on the level of difficulty required to perform the
test, level of skill required to perform the test, and the level of potential harm to
the patient should the test be performed incorrectly. Waived tests are considered
to be simple tests with minimal risk of error requiring no or minimal education
about the instrument. Therefore, waived tests are within the CLIA defined scope
of practice for a phlebotomist. Strep test and urine dip are very simple tests that
require minimal training and have low risk of harm to the patient. Both tests are
non-invasive and simple enough for a phlebotomist to perform. Strep test
requires a throat swab and a urine dip test requires a urine reagent strip dipped
into a urine cup. Cell differential and urine sediment are more complex and
require microscopic analysis of the specimen, thus require higher skill level and
can present greater risk to the patient if performed incorrectly.
99. The small amount of tissue between the skin and bone in the finger makes an injury to
the bone likely.
a. 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.
100. Medical asepsis
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a. 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.
101. Patient with meningitis
a. 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.
102. Lavender, Light blue, Green
a. 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)
103. Contaminated needlestick injury evaluation process
a. 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.
104. OSHA.
a. 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.
a. 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
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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
106. Try another tube.
a. 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.
107. Performing CLIA high complexity tests.
a. Rationale: CLIA refers to the Clinical Laboratory Improvement Amendment,
which specifies personnel requirements for performing laboratory testing based
upon their complexity. Moderate and high complexity testing are outside the
scope of practice for a phlebotomist. Medical assistants may perform
CLIA-waived testing, such as Point of Care Testing, with proper training.
108. While in the patient’s room, after drawing the blood
a. 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.
109. A patient who contracts a MRSA infection from a venipuncture.
a. Rationale: A nosocomial infection is a “hospital-acquired” infection acquired by a
patient who enters the hospital without any symptoms of it and appears to have
acquired the infection during the hospital stay. A female patient who develops a
urinary tract infection after having a urinary catheter inserted is a perfect
example. The other patients were exposed prior to admission or were never
admitted, in the case of the healthcare worker.
110. Should have kept the specimen at 37˚C.
temperatures for accurate test results to be obtained by the laboratory.
slurry are ammonia, lactic acid, pH & blood gases among others. Consult your
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111. Aerobic must be drawn first.
a. Rationale: The aerobic must be drawn first as the line of the winged infusion set
(butterfly) contains air and must be filled with blood before filling the anaerobic
container. A discard tube would contaminate the draw as it is not sterile and is
unnecessary. For maximum possibility of recovering any circulating bacteria that
might be present in the blood stream, 10 ml in each of the aerobic and anaerobic
bottles is recommended.
112. A yellow tube with SPS
collection. If ChloraPrep and benzalkonium chloride are used, the venipuncture
site must be cleansed using 30-60 second friction scrub. Higher degree of skin
antisepsis ensures that normal flora from the skin will not contaminate blood
culture bottles and thus prevents false positive blood culture results. 70%
isopropyl alcohol can be used to clean the venipuncture site prior to collecting a
lavender tube, light blue tube, and yellow tube with ACD.
113. Contact Droplet
a. 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.
114. Yellow, light blue, lavender, gray
a. 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
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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.
115. And end with an empty bladder.
a. Rationale: The collection must begin and end with an empty bladder as a specific
time frame is required. The patient should empty the bladder and then begin the
24-hour timing. At the end of the 24-hour cycle, the patient saves the last urine
and ends the collection.
116. Sodium citrate, non-additive, lithium heparin, potassium EDTA
patient results. The order is sterile (blood cultures), sodium citrate (blue), serum
(red or gold with or without clot activator or gel separator), heparin (green), EDTA
(purple), sodium fluoride & potassium oxalate (gray). In this case, the light blue
would be drawn first for the D-dimer, the non-additive (serum) tube second
(estrogen), lithium heparin (STAT electrolytes) third and potassium EDTA (type &
screen) last.
117. Middle finger of non-dominant hand
a. Rationale: Capillary blood samples may be taken from the lateral side heel of
children until they begin to walk at which time the heel becomes tougher and
more difficult to penetrate. In this case the middle finger of the non-dominant
hand may be used. The great toe is not used and the index finger would be more
sensitive and painful.
118. Place the needle with safety device activated immediately in a sharps container.
a. 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
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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.
119. Finger.
a. 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.
120. Blood culture bottles, Light blue, Red, Lavender
a. 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.
121. Explain the procedure.
a. 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.
122. Newborn with hyperbilirubinemia
a. Rationale: The person collecting a blood sample from a newborn with
hyperbilirubinemia would not use an adhesive bandage post-stick. Bleeding
would be stopped by direct pressure and no bandage would be utilized. It is not
recommended to use a bandage on children under two years of age because it
could introduce a choking hazard if the child works the bandage loose.
Bandaging a newborn’s foot is a controversial issue because of skin sensitivity
and potential bandage aspiration. Sensitivity is of particular concern in newborns
with hyperbilirubinemia as they must endure multiple sample collections. Still, the
incision should be monitored for bleeding and inflammation. It would be
acceptable to use an adhesive bandage on the other patients in this example
unless there was an indication specified, such as a latex allergy. After drawing an
adult with hemophilia, the phlebotomist should monitor the venipuncture site to
ensure a platelet plug has formed to stop bleeding before bandaging the patient.
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There are no additional requirements for using a sterile adhesive bandage on an
immunocompromised child or an adolescent with sickle cell anemia.
123. Release the tourniquet, remove the needle, and immediately apply pressure at the
site.
a. 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.
124. Use back-and-forth friction, applied horizontally or vertically.
a. 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.
125. Create a hematoma.
a. Rationale: If adequate pressure is not applied following a venipuncture, a
hematoma can form via the transfer of blood from the vein into the surrounding
tissue. Proper procedure would be to keep the arm straight and apply direct
pressure until bleeding stops.
126. The Patient’s Bill of Rights.
a. Rationale: It is within a patient's bill of rights to be provided a translator if one is
available. If a patient requests a translator, that translator becomes a part of the
health care team. By requesting a translator, the patient essentially agrees to the
translator knowing private, confidential, protected medical information and
therefore it would not violate HIPAA.
a. 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.
128. Call for help., Protect the patient’s head and lower her to the floor.
a. 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
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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.
129. Heel of the foot
a. 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.
130. The specimen is hemolyzed
a. 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).
131. Gently invert the tube after collecting the specimen.
a. Rationale: Since an EDTA tube contains anticoagulant, it is important to
immediately mix the blood as soon as it is collected to ensure that it doesn't clot.
The phlebotomist should gently invert the tube after collecting the specimen to
maintain specimen integrity and prevent rupture of RBC’s in the sample. The
smaller gauged needles would introduce a higher likelihood of hemolysis, not
prevent it. Refrigerated storage would not necessarily prevent immediate
hemolysis (but would slow down the breakdown of RBCs that would cause
hemolysis over time). The tube should be gently mixed immediately after
collection and can be processed and run as soon as needed (it does not need to
stand for 20 minutes).
132. Elevate the arm while applying pressure.
a. 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.
133. Biohazard waste container
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a. 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.
134. Communicate the test order to the nursing staff and wait for one of them to collect
the sample.
a. Rationale: A central port is a central venous catheter inserted into a vein in the
chest and threaded through until it reaches the heart. Central ports and other
vascular access devices (VADs) provide direct access to patient’s circulation in
order to administer medication and fluids as well as to withdraw blood on routine
basis. Any vascular access device poses an infection risk and every measure
must be taken to reduce the risk of nosocomial/healthcare associated infections
(HAIs). It is critical that only trained healthcare professionals withdraw blood from
vascular access devices. Nurses and physicians are generally the ones to
perform this task as they are trained to care for and maintain vascular access
devices in order to maintain patency (prevent occlusion) in the catheter and
reduce risk of infection. Therefore, it is best to communicate the test order to the
nursing staff and wait for one of them to collect the sample. Orders must be
confirmed with nurses and physicians, not the patient. Proper and effective
communication is critical in a healthcare setting and is one of The Joint
Commission’s annual National Patient Safety Goals. Phlebotomists must
communicate with the nursing staff before proceeding to the next patient.
135. Report the incident to a supervisor.
a. 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.
a. Rationale: A tourniquet left in place for longer than 60 seconds predisposes the
formation of blood clots due to slow blood flow (a.k.a. venous stasis). Venous
insufficiency (VI) is a state in which the veins do not adequately send the blood
from the extremities back to the heart. Fibrinolysis refers to the breaking down of
a clot. Hemangioma is a term used to describe a condition in which blood vessels
abnormally congregate in a place on the body, causing a non-cancerous tumor.
137. Review the requirements for collecting and handling the blood specimen.
120
a. 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.
138. Informed
a. Rationale: Informed consent means the patient agrees to and signs a document
in regards to a procedure after the provider explains the risks and consequences.
Expressed consent is when the patient clearly gives permission to the procedure
either verbally or non-verbally. Implied consent means consent is understood by
the patient’s actions even though the patient did not directly express consent.
Verbal consent means the patient has said he/she agrees to the procedure even
though it is not written down in contract.
139. Use disinfectant to moisten the droplet, absorb with paper towel, then clean with
disinfectant.
a. 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.
140. Lateral or medial plantar surface of the heel
a. 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.
141. Right antecubital fossa
a. Rationale: Due to the mastectomy, avoid any left side sites. The right antecubital
fossa is the best collection site. Blood samples should not be collected from the
arm on any side a patient has had breast cancer surgery (a mastectomy or a
lumpectomy with lymph node removal). The presence of lymph fluid dilutes the
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blood in this area, causing erroneous patient test results. The lymph fluid may
also make the patient’s arm swell, thus making tourniquet application painful.
Additionally, all skin punctures should be avoided on the side of breast cancer
surgery. Not only could test results be altered, but the performance of
venipuncture, skin puncture, injections, etc. on breast cancer surgery patients
may lead to the development of a bacterial infection. The right saphenous vein in
the leg would not be a good choice (use the antecubital in the arm instead).
142. Distal to the IV in the left arm
a. Rationale: Drawing in the antecubital area of the right arm or above the IV in the
left arm would lead to contamination of the sample with the fluid being
administered. The test results would then reflect the contents of the fluid or dilute
the analyte to be measured. Incorrect patient treatment might result. In this case,
the safest place to draw would be distal to (away from) the IV left arm. The
middle or ring finger could be used for a dermal puncture but not for venous
blood.
143. Protect the specimen from light.
a. Rationale: Bilirubin is a photo-sensitive analyte (can degrade by as much as 50%
with an hour of light exposure). A specimen submitted for bilirubin testing should
be collected in an amber tube which will protect it from light (a regular tube
wrapped in aluminum foil could also be acceptable). It is not necessary to keep
the specimen warm with a heel warmer, nor is it necessary to chill the specimen
to slow metabolism and stabilize the specimen. As long as the specimen is
properly collected, protected from light, and handled according to normal serum
protocol, it can be run as routine, thus Stat analysis is not necessary.
144. Apply a warm compress.
a. Rationale: The heat from a warm compress will encourage capillary vasodilation
resulting in increased blood flow. Warming helps make blood collection easier
and faster. Warm the heel for 3-5 minutes, which allows sufficient time for the
capillaries to dilate. Squeezing can create discomfort and will not necessarily get
more blood (it may also extract serous fluid that would dilute an already small
amount of blood sample). The only content to be added to a microtainer
collection tube is blood (adding a diluent would skew the results). The fingers of
infants should not be used for collection since lancets are too long (and would
puncture bones and nerves).
145. Remove the hypodermic needle from the syringe after activating the safety device
and transfer the blood into capped evacuated tubes using a syringe transfer device.
a. Rationale: To safely move blood from a syringe to evacuated tubes, a syringe
transfer device is used. Upon completing the venipuncture, the needle safety
device is activated then the needle may be removed from the syringe and
discarded into a sharps container. A transfer device is attached to the syringe
and the tubes may be placed into it as if it were an ETS holder in the correct
order of draw. After the tubes are filled, the syringe and transfer device are
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discarded into the sharps container as one unit. Tubes are never uncapped and
blood is not pushed out of the syringe through the needle. Doing such would risk
hemolyzing the blood.
146. An expired tube was collected.
a. 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.
147. Dorsal side of the hand
a. 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.
a. 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.
149. Coban
a. Rationale: Coban or rolled gauze is the best method to secure 2 x 2 gauze
sponge following a venipuncture on patients with existing skin tears as well as
those with very fragile, thin skin. Paper tape, adhesive tape, and band aid all
contain an adhesive that can tear the skin when removed. Skin tears, especially
in elderly and other immunocompromised patients, pose a significant risk for
infection. Phlebotomist must take great care to ensure patient safety and prevent
susceptibility to infection whenever possible.
150. Distal to the IV
a. Rationale: Drawing from an arm on the side which has had a mastectomy may
cause lymphedema and should not be used. If there is an active IV in the other
arm, blood may be drawn as far below it as possible. If the IV is close to the
hand, the phlebotomist may ask the nurse to turn it off for two minutes prior to the
draw. Another option, if a small amount of blood is needed and the test requests
allow, is a dermal puncture of one of the fingers of the right hand.

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Study Guide - Collections - 92 Q’s Answers

Study Guide - Orders and Equipment Selection

1. Collect a tissue sample.

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