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Last updated: August 2026. Written from: National Healthcareer Association (NHA).

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NHA Phlebotomy Technician (CPT) Exam Cram Sheet (2026)

Q: Is there a free printable NHA Phlebotomy Technician (CPT) cram sheet?

Yes. A free, printable NHA Phlebotomy Technician (CPT) exam cram sheet: the 150 highest-yield points to know, grouped into 5 sections that follow the exam's content areas, each section with its published weight. Free to read, print and keep — no signup, no email, no paywall.

A free, printable NHA Phlebotomy Technician (CPT) exam cram sheet: the 150 highest-yield points to know, grouped into 5 sections that follow the exam's content areas, each section with its published weight.

Free to read, print and keep — no signup, no email, no paywall.
70 of the 150 points carry a citation to the rule they come from.
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300 free NHA Phlebotomy Technician (CPT) practice questions on the same material, every one explained.
Last updated: August 2026.

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Collection Procedures

35% of the exam

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Requisition first: Confirm the ordered tests, the tubes and volumes they require, fasting or timed-draw instructions, and any special handling before you approach the patient, because the requisition determines what you carry to the bedside.· CLSI GP41
Cleanse and let it dry: Scrub the site with 70% isopropyl alcohol for about 30 seconds and allow it to air-dry completely; fanning, blowing, or wiping it dry cancels the antisepsis, and wet alcohol under the needle causes stinging and hemolysis.· CLSI GP41
Anchor below, never above: Pull the skin taut with your thumb one to two inches below the puncture site; anchoring above or across the needle path puts your own finger in line with the needle.
Tourniquet off before the needle out: Release the tourniquet once the final tube begins filling and always before withdrawing the needle, because pulling a needle out of a pressurized vein forces blood into the tissue and creates a hematoma.· CLSI GP41
Pressure, then bandage: Hold firm direct pressure with the arm straight for at least two minutes, and longer for patients on anticoagulants, before applying gauze and tape; bending the elbow over the gauze is a leading cause of bruising.
Label in the patient's presence: Tubes are labeled immediately after collection, at the bedside or chair, before you leave the patient. Pre-labeled tubes and tubes labeled later at the bench are both unacceptable.· The Joint Commission NPSG.01.01.01
1. Blood culture (yellow SPS or culture bottles): Sterile collections are always drawn first so that skin flora and tube additives cannot contaminate the culture; the additive sodium polyanethol sulfonate inhibits complement, phagocytes, and some antibiotics.· CLSI GP41
2. Light blue: sodium citrate: Buffered 3.2% sodium citrate binds calcium reversibly and serves PT/INR, aPTT, fibrinogen, D-dimer, and factor assays. The nine-to-one blood-to-additive ratio makes a complete fill mandatory, so a short draw is rejected.· CLSI H21
3. Red and gold SST: clot activator, with or without gel: Plain red tubes contain no additive or only a silica clot activator; gold or tiger-top serum separator tubes add a thixotropic gel. Both produce serum for chemistry panels, serology, hormone levels, and therapeutic drug monitoring.· CLSI GP41
4. Green: heparin: Lithium or sodium heparin inhibits thrombin and yields plasma with no waiting for a clot, which suits stat chemistries, ammonia, and lactate. Use lithium heparin routinely, but sodium heparin when a lithium level is ordered.
5. Lavender and pink: EDTA: K2 or K3 EDTA chelates calcium irreversibly and preserves cell shape, so it serves CBC, differential, ESR, reticulocyte count, and hemoglobin A1c. Pink-top EDTA is the usual blood bank tube for type and screen or crossmatch.· CLSI GP41
6. Gray: sodium fluoride with potassium oxalate: Fluoride is an antiglycolytic agent that stops red cells from consuming glucose in the tube, and oxalate is the anticoagulant. Gray tops serve glucose, glucose tolerance testing, lactate, and blood alcohol.
Median cubital vein is first choice: It sits centrally in the antecubital fossa, is well anchored by surrounding tissue, is largest and closest to the surface, and is farthest from major nerves and arteries, so it is both the easiest and the safest stick.· CLSI GP41
Cephalic vein is second choice: It runs along the lateral or thumb side of the arm and is often the only palpable vein in patients with more subcutaneous tissue, though it tends to roll and needs firm anchoring.
Basilic vein is last resort: It lies on the medial or little-finger side directly over the brachial artery and median nerve, so it carries the highest risk of nerve injury and arterial puncture and is used only after the other two are ruled out.· CLSI GP41
Never draw above an infusing IV: Blood drawn upstream of running fluid is diluted and chemically wrong. If no other site exists, have the nurse stop the infusion for at least two minutes, draw below the IV, discard the first 5 mL, and document what was done.· CLSI GP41
Restricted arms: Avoid the arm on the side of a mastectomy without provider approval, an arm with a fistula, graft, or vascular access device, and any site with edema, burns, scarring, tattoo over the vein, hematoma, or active infection.
Hand and lower extremity rules: Hand and wrist dorsal veins are acceptable with a 23-gauge winged set at a shallow angle, but the underside of the wrist is never used because of nerve and tendon proximity, and foot or ankle draws require a provider order in most facilities.
21-gauge is the routine standard: A 21-gauge multisample needle is the default for adult antecubital venipuncture; it fills evacuated tubes at a rate that avoids both hemolysis and vein collapse.· CLSI GP41
22 to 23-gauge for small or fragile veins: Use a 22-gauge needle or a 23-gauge winged infusion set for hand veins, pediatric patients, and elderly patients with fragile vessels. Needles thinner than 23-gauge shear red cells and produce hemolyzed specimens.
Insert at 30 degrees or less: Enter bevel up at an angle of 30 degrees or less relative to the skin; a shallower 10 to 15 degrees is used for superficial hand veins with a winged set.· CLSI GP41
Tourniquet placement and time: Apply the tourniquet three to four inches above the intended site and keep it on no longer than one minute. If more time is needed, release it, wait two minutes, and reapply.· CLSI GP41
No fist pumping: The patient may make a fist once, but vigorous pumping releases potassium and lactate from muscle and falsely elevates potassium, ionized calcium, and lactate results.· CLSI GP41
Two attempts, then hand off: Standard practice limits a phlebotomist to two unsuccessful attempts on a patient before notifying a supervisor or another collector, both for patient comfort and to prevent tissue injury.
Heel stick site and depth: In infants use only the medial or lateral plantar surface of the heel, and never exceed 2.0 mm depth. The posterior curvature of the heel is avoided entirely because the calcaneus lies directly beneath it.· CLSI GP42
Heel versus finger by age: The heel is the required capillary site for infants under one year of age; finger puncture is reserved for children old enough to walk and for adults, because an infant fingertip has too little tissue over the bone.· CLSI GP42
Finger puncture technique: Use the palmar surface of the distal segment of the third or fourth finger, puncture slightly off center and perpendicular to the fingerprint lines so the drop forms rather than running along a groove, and stay within 2.0 mm depth.· CLSI GP42
Discard the first drop, never milk: Wipe away the first drop because it contains excess tissue fluid, and apply only intermittent gentle pressure; squeezing or milking the site dilutes the sample with interstitial fluid and causes hemolysis.· CLSI GP42
Capillary order of draw is different: For dermal collections the sequence is blood gas specimens first, then EDTA, then other additive tubes, then serum tubes, so that the platelet-sensitive EDTA specimen is filled before clotting begins in the puncture.· CLSI GP42
Warming and newborn screening cards: Warm the site for three to five minutes with a device no hotter than 42 degrees Celsius to increase blood flow. Newborn screening filter paper circles are filled from one side with a single free-flowing drop each, never layered or filled from both sides.· CLSI NBS01

Safety and Compliance

22% of the exam

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Exposure control plan reviewed annually: Every employer with at-risk staff must maintain a written exposure control plan, review and update it at least once a year, and document consideration of safer sharps devices.· OSHA 29 CFR 1910.1030
Hepatitis B vaccine offered free: The employer must offer the hepatitis B vaccine series at no charge within 10 working days of the employee's assignment to duties with exposure risk. An employee who declines signs a written declination and may accept later at any time.· OSHA 29 CFR 1910.1030
Standard precautions apply to everyone: All blood and all body fluids except sweat are handled as potentially infectious, so precautions do not vary by the patient's known or suspected diagnosis.· CDC Guideline for Isolation Precautions (2007)
Controls come before equipment: The hierarchy is engineering controls first (self-sheathing needles, sharps containers), then work practice controls (no recapping, no eating in the work area), and only then personal protective equipment as the last barrier.· OSHA 29 CFR 1910.1030
Biohazard labeling and containers: Containers of regulated waste, refrigerators holding specimens, and transport containers carry the fluorescent orange or orange-red biohazard symbol, or use red bags or containers.· OSHA 29 CFR 1910.1030
Free training at hire and yearly: Bloodborne pathogens training is provided at no cost during working hours at initial assignment and at least annually thereafter, with records retained.· OSHA 29 CFR 1910.1030
Alcohol rub versus soap and water: Alcohol-based hand rub is preferred for routinely decontaminating hands, but soap and water are required when hands are visibly soiled and after exposure to spore-forming organisms such as Clostridioides difficile, which alcohol does not kill.· CDC Hand Hygiene Guideline (2002)
Scrub time: Rub all hand surfaces with alcohol product until dry, roughly 20 to 30 seconds, or lather with soap and friction for at least 20 seconds before rinsing with fingertips pointed downward.· WHO Guidelines on Hand Hygiene in Health Care (2009)
Donning order: Put on gown first, then mask or respirator, then goggles or face shield, and gloves last so the glove cuff covers the gown sleeve.· CDC Guideline for Isolation Precautions (2007)
Doffing order: Remove gloves first, then goggles or face shield, then gown, and mask or respirator last, performing hand hygiene after removal and again after leaving the room.· CDC Guideline for Isolation Precautions (2007)
Gloves are single patient, single use: Change gloves between patients and whenever torn or contaminated, and perform hand hygiene after removal; gloves are never washed, disinfected, or reused, and they do not replace hand hygiene.
Latex alternatives: Nitrile or vinyl gloves are provided for staff and patients with latex sensitivity, and latex-free tourniquets and bandages must be available at the drawing station.
Never recap: Recapping, bending, breaking, or shearing a used needle is prohibited. If a procedure absolutely requires recapping, use a one-handed scoop technique or a mechanical device, never two hands.· OSHA 29 CFR 1910.1030
Activate immediately, dispose at point of use: Engage the safety shield or retraction the instant the needle leaves the skin, then drop the whole assembly into a puncture-resistant, leakproof, closable sharps container located as close as practical to the work area.
Replace sharps containers before they overflow: Sharps containers are closed and replaced when they reach the manufacturer's fill line, generally about two-thirds to three-quarters full, and are never forced down or reached into.
Sharps injury log and worker input: Employers must keep a sharps injury log recording the device type and brand, the department, and how the incident occurred, and must involve frontline staff in choosing safer devices.· Needlestick Safety and Prevention Act (2000)
First action after a stick: Wash the wound immediately with soap and running water; flush mucous membranes or eyes with water or saline for about 15 minutes. Do not squeeze the wound or apply caustic agents such as bleach.· CDC/USPHS post-exposure guidance
Report and evaluate without delay: Report to the supervisor and employee health at once so that source-patient testing, baseline testing of the exposed worker, and post-exposure prophylaxis can begin; HIV prophylaxis is most effective within hours and is not started beyond 72 hours.· CDC/USPHS post-exposure guidance
Contact precautions: For organisms spread by touch or contaminated surfaces, such as MRSA, VRE, and C. difficile, wear gown and gloves on room entry and use dedicated or disinfected equipment.· CDC Guideline for Isolation Precautions (2007)
Droplet precautions: For agents carried in large respiratory droplets, such as influenza, pertussis, and meningococcal disease, wear a surgical mask when working within about three to six feet of the patient.· CDC Guideline for Isolation Precautions (2007)
Airborne precautions: For tuberculosis, measles, and varicella, the patient is placed in a negative-pressure room and the collector wears a fit-tested N95 or higher respirator, not a surgical mask.· CDC Guideline for Isolation Precautions (2007)
Protective environment: Severely immunocompromised patients, such as stem cell transplant recipients, are protected by positive-pressure rooms; the precaution protects the patient from you rather than you from the patient.
Fire and chemical response: Use RACE for a fire (rescue, alarm, contain, extinguish or evacuate) and PASS for an extinguisher (pull, aim, squeeze, sweep). For chemical splashes, flush at an eyewash or shower for at least 15 minutes and consult the safety data sheet.· OSHA Hazard Communication Standard 29 CFR 1910.1200
Spill cleanup: Blood spills are covered with absorbent material, then decontaminated with an EPA-registered tuberculocidal disinfectant or a freshly prepared 1:10 dilution of household bleach, wearing gloves and other appropriate barriers.· OSHA 29 CFR 1910.1030
HIPAA minimum necessary: Protected health information is disclosed only to those who need it for treatment, payment, or health care operations, and only the minimum amount needed. Discussing a patient in an elevator or leaving a requisition in view is a violation.· HIPAA Privacy Rule, 45 CFR Part 164
Patient rights under HIPAA: Patients may inspect and obtain a copy of their records, request corrections, receive an accounting of certain disclosures, and be given a notice of privacy practices; electronic records carry additional safeguards under the Security Rule.· HIPAA Privacy Rule, 45 CFR Part 164
Chain of custody: Forensic and legal specimens, including drug screens and blood alcohol for law enforcement, require an unbroken written record of every person who handled the specimen with date, time, and signature, plus a tamper-evident seal applied in the donor's presence.· SAMHSA Mandatory Guidelines for Federal Workplace Drug Testing Programs
Blood alcohol antiseptic: For a legal blood alcohol collection, clean the site with a nonalcoholic antiseptic such as aqueous benzalkonium chloride or soap and water, because an alcohol prep pad can be challenged in court and may affect the result.
CLIA governs testing complexity: The Clinical Laboratory Improvement Amendments classify tests as waived, moderate, or high complexity and set personnel, proficiency testing, and quality standards for every facility that tests human specimens.· CLIA 1988, 42 CFR Part 493
Quality control is documented daily: Point-of-care and analyzer controls are run and recorded on the required schedule, results are plotted and reviewed against acceptable limits before patient results are released, and refrigerator and centrifuge temperatures and equipment maintenance are logged.· CLIA 1988, 42 CFR 493.1256

Specimen Handling and Processing

20% of the exam

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Two identifiers, both patient specific: Use the patient's full name plus a second identifier such as date of birth or medical record number. Room number, bed number, and floor are location data, not identifiers, and may not be used.· The Joint Commission NPSG.01.01.01
What goes on the label: The label carries the patient's full name, the identification number, the date and time of collection, and the collector's initials or identification code.· CLSI GP33
Label after collection, at the patient: Tubes are labeled after the draw is complete and in the patient's presence, before leaving. Prelabeling risks putting a label on a tube that is never drawn or drawn from the wrong patient.· CLSI GP33
Blood bank labeling is stricter: Type and crossmatch specimens require the collector to verify identification at the bedside, label at the bedside, and often attach a dedicated blood bank armband; a discrepancy triggers automatic recollection.· AABB Standards for Blood Banks and Transfusion Services
Never correct a label by writing over it: If a label is wrong, the specimen is either recollected or corrected only through the laboratory's documented relabeling procedure by the person who drew it; altering a label without that process invalidates the specimen.
Label placement matters: Apply the label lengthwise along the tube so the technologist can still see the specimen level and the color of the serum or plasma through the tube wall.
Invert gently, do not shake: Mix by slow, complete end-over-end inversions immediately after filling each tube; shaking causes hemolysis and foaming. Typical counts are 3 to 4 for citrate, 5 for serum separator tubes, and 8 to 10 for heparin, EDTA, and fluoride oxalate tubes.· CLSI GP41
Transport upright: Carry and rack tubes stopper up. Upright transport promotes complete clotting in serum tubes, reduces agitation-related hemolysis, and keeps blood off the stopper where it can be aerosolized on opening.· CLSI GP44
Separate serum or plasma within two hours: Cells and serum or plasma must be physically separated within two hours of collection for most analytes, because glucose falls and potassium, LDH, and phosphorus rise while cells sit in contact with the fluid.· CLSI GP44
Serum tubes need a full clot first: Allow plain and gel serum tubes to clot undisturbed for about 30 minutes at room temperature before centrifuging; spinning early produces fibrin strands that clog analyzer probes.
Common test windows: Blood cultures go to the incubator as soon as possible, EDTA specimens for CBC are stable roughly 24 hours refrigerated, aPTT specimens are run within about 4 hours, and PT specimens within about 24 hours at room temperature.· CLSI H21
Stat and timed specimens: Stat and timed collections such as glucose tolerance samples, therapeutic drug peaks and troughs, and blood cultures must record the actual collection time, because the result is interpreted against that clock.
Chilled specimens: Transport in an ice and water slurry, not on solid ice cubes, for ammonia, lactic acid, arterial blood gases, gastrin, parathyroid hormone, homocysteine, and catecholamines; slurry gives even cooling without freezing the cells at the contact point.· CLSI GP44
Do not chill potassium or CBC: Cooling whole blood causes potassium to leak out of red cells and falsely elevates the result, and refrigeration distorts cell indices, so routine chemistry and hematology tubes stay at room temperature.
Light-protected specimens: Bilirubin, vitamin B12, folate, vitamin A, carotene, and porphyrins degrade with light exposure and are wrapped in foil or collected in amber tubes; neonatal bilirubin is the classic exam example.· CLSI GP44
Body-temperature specimens: Cold agglutinins, cryoglobulins, and cryofibrinogen must be kept at 37 degrees Celsius from collection through separation, using a prewarmed tube or heat block, because the target protein precipitates when it cools.· CLSI GP44
Frozen aliquots: Some send-out analytes require the plasma or serum to be separated and frozen; freeze the aliquot, never the original whole blood tube, since freezing whole blood hemolyzes it completely.
Temperature during transport: Courier and pneumatic tube transport must hold specimens within the range the test requires, and the receiving lab documents arrival condition; a specimen that arrived warm when it needed ice is a rejection.
Balance opposing positions: Place tubes of equal size and equal fill directly across from each other; an unbalanced rotor vibrates, hemolyzes specimens, damages the instrument, and can break tubes.
Standard spin: Most serum and plasma tubes are spun with the stoppers on for about 10 minutes at the relative centrifugal force specified by the tube manufacturer, commonly in the range of 1000 to 1300 g.· CLSI GP44
Never open a moving centrifuge: Let the rotor come to a complete stop on its own; braking or opening the lid early resuspends cells, and a tube that broke during the spin can aerosolize infectious material.
Do not respin a gel tube: Once the gel barrier has formed, respinning can trap analytes below the gel or drive cells through it, producing falsely altered chemistry results. Respin only per the laboratory procedure and never after the gel has set.
Aliquot with care: Transfer serum or plasma to a labeled aliquot tube carrying the same identifiers and specimen number as the parent tube, without disturbing the cell layer, and never pour serum from one patient's tube into another patient's container.
Handle stoppers safely: Open tubes behind a shield or with a stopper removal device and point the opening away from the face, because aerosol released on decapping is a documented exposure route.· OSHA 29 CFR 1910.1030
What hemolysis does to results: Red cell rupture releases intracellular contents, so potassium, LDH, AST, magnesium, phosphorus, and iron read falsely high, while sodium is diluted downward and the red pigment interferes with bilirubin and other colorimetric methods.
Collection causes of hemolysis: Alcohol not allowed to dry, a needle finer than 23 gauge, vigorous shaking, forcing blood from a syringe through a needle into a tube, prolonged tourniquet time, milking a capillary site, and underfilled additive tubes all shear or lyse cells.· CLSI GP41
Lipemia and icterus: Lipemia is milky turbidity from recent fat intake or nonfasting collection and blocks optical readings; icterus is yellow-brown from high bilirubin. Both interfere with photometric assays and are noted at processing.
Clotted anticoagulant specimen: A clot in an EDTA or citrate tube means mixing was delayed or incomplete; the cell count and coagulation results are invalid and the specimen must be recollected, not filtered or shaken back into suspension.
Quantity not sufficient and short draws: A specimen below the volume the method requires is rejected as QNS. For citrate coagulation tubes any underfill is rejected outright because it changes the fixed nine-to-one ratio.· CLSI H21
Standard rejection list: Laboratories reject specimens that are unlabeled or mislabeled, in the wrong tube or preservative, hemolyzed, clotted, QNS, collected in an expired tube, leaking or contaminated, transported at the wrong temperature, or delivered past the analyte's stability limit.· CLSI GP44

Patient Preparation and Care

13% of the exam

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Ask open-ended, never leading: Ask the patient to state and spell their full name and give their date of birth. Asking are you Mr. Garcia invites a confused or hard-of-hearing patient to agree with a wrong name.· CLSI GP33
Three-way match: The information the patient gives must match the wristband and the requisition or label exactly, including middle initial and spelling. Any discrepancy stops the draw until it is resolved by the nurse or provider.· CLSI GP33
The wristband must be on the patient: For inpatients the identification band has to be attached to the patient. A band lying on the nightstand or taped to the bed rail cannot be used to identify anyone.
When the patient cannot respond: For a sleeping, sedated, cognitively impaired, or pediatric patient, verify identity with a nurse, caregiver, or parent who states the name and date of birth, and document who provided the verification.· CLSI GP33
Unidentified emergency patients: Trauma patients without known identity are given a temporary identification number that stays with them through admission; the specimen is labeled with that number and it is never replaced retroactively without a documented merge procedure.
Introduce and explain first: Identify yourself, state your department, and say why you are there before asking for identifiers; this satisfies both professional courtesy and the patient's right to know who is collecting their blood.
Fasting definition and duration: Fasting means no food, no caloric beverages, no gum, and no smoking for the specified interval, usually 8 to 12 hours, while plain water is allowed and encouraged for hydration.
Which tests require fasting: Fasting blood glucose typically requires 8 hours; a traditional lipid panel requires 9 to 12 hours, though many current protocols accept nonfasting lipids. Nonfasting collection produces lipemic serum that interferes with multiple assays.
Glucose tolerance test protocol: Draw a fasting baseline first, give the measured glucose load to be finished within about five minutes, then draw at the exact intervals ordered. The patient stays on site, drinks only water, and does not eat, smoke, chew gum, or exercise during the test.
Basal state and diurnal variation: Basal state samples are collected in the early morning after overnight rest and fasting. Analytes with strong diurnal variation, such as cortisol and serum iron, must be drawn at the time the provider ordered because the reference range depends on it.
Peak and trough drug levels: A trough is drawn immediately before the next dose and a peak at the interval specified for the drug and route. Record the exact collection time and the time of the last dose, because the level cannot be interpreted without both.
Verify, then document: Ask the patient when they last ate, drank anything besides water, or took the drug in question, and document any deviation on the requisition so the laboratory can flag the result appropriately.
Types of consent: Informed consent follows a full explanation of the procedure and its risks, expressed consent is stated verbally or in writing, and implied consent is inferred from the patient's cooperative actions such as extending an arm.
The right to refuse: A competent patient may refuse at any point, even after the tourniquet is on. Do not proceed; notify the nurse or ordering provider, document the refusal and the time, and never attempt a draw over an objection, which can constitute battery.
Minors and legally incapacitated adults: Consent comes from a parent, legal guardian, or authorized representative, while an older child is still asked for assent and given an age-appropriate explanation.
Screen before you stick: Ask about latex allergy, adhesive sensitivity, any history of fainting during blood draws, a preferred arm, and any restrictions such as a mastectomy, fistula, or IV, and act on the answers.
Explain briefly and honestly: Tell the patient what you will do, roughly how long it will take, and how many tubes you need. Say that they will feel a quick stick rather than promising no pain.
Interpreters and communication barriers: Use the facility's interpreter service rather than a family member for anything beyond simple greeting, and use written or demonstrated instructions for patients with hearing loss so that identification and consent remain valid.
Never draw a standing patient: Seat the patient in a chair with arm supports or have them lie down. Do not collect from a patient perched on a stool or standing, and never let a patient with a fainting history sit upright without support.
Take a fainting history seriously: If the patient reports previous syncope during blood draws, recline them before you begin, apply a cold compress to the back of the neck if they feel warm, and keep them under observation for 15 to 30 minutes afterward.
Talk it down, do not argue: Use a calm, unhurried voice, give the patient something to focus on such as slow breathing or looking away, and avoid displaying the needle. Rushing a frightened patient increases movement during the stick.
Pediatric approach: Explain in age-appropriate terms, never say it will not hurt, allow the caregiver to hold and comfort the child, and use a winged set with the smallest adequate volume. Immobilization requires a second trained person, not the phlebotomist alone.
Geriatric and fragile veins: Older adults may have thin skin, loose tissue, and fragile vessels, so use a smaller gauge or winged set, apply the tourniquet loosely or use blood pressure cuff pressure below diastolic, anchor firmly, and hold pressure longer afterward.
Know when to stop: After two failed attempts, or whenever the patient is in distress, stop and hand off to another collector or the supervisor. Persisting causes tissue injury, distrust, and often still no specimen.
Syncope and presyncope: Pallor, sweating, dizziness, and nausea signal an imminent faint. Remove the tourniquet and needle at once, lower the head between the knees or lay the patient flat, apply a cold compress, and never leave them alone. Ammonia inhalants are not recommended because they can trigger bronchospasm.
Hematoma: Swelling and rapid bluish discoloration at the site mean blood is escaping into the tissue. Discontinue the draw, remove the needle, and hold firm pressure for at least two minutes, or five or more for anticoagulated patients, then apply ice for the first 24 hours.
Nerve involvement: Sudden shooting, electric, or burning pain, or numbness and tingling radiating down the arm, indicates nerve contact. Withdraw the needle immediately, do not reposition it, report the event, and document it; symptoms that persist require provider evaluation.· CLSI GP41
Arterial puncture: Bright red blood that pulses or fills the tube rapidly on its own suggests an artery. Remove the needle and hold continuous firm pressure for at least five minutes with the arm elevated, notify the nurse, and mark the specimen as possible arterial sample.
Petechiae and prolonged bleeding: Small red spots below the tourniquet suggest a platelet or capillary defect, and bleeding that continues past five minutes should be reported to nursing. Do not release the patient until bleeding has stopped.
Iatrogenic anemia and volume limits: Repeated collection can itself cause anemia, which is a particular risk in neonates and critically ill patients; institutional limits cap the volume drawn per collection and per period based on patient weight.

Anatomy, Physiology, and Terminology

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Four chambers, two circuits: Deoxygenated blood enters the right atrium, passes the tricuspid valve to the right ventricle, exits through the pulmonary valve to the lungs, returns to the left atrium, passes the mitral valve to the left ventricle, and leaves through the aortic valve into the aorta.
The pulmonary exception: Arteries usually carry oxygenated blood and veins deoxygenated blood, but the pulmonary artery carries deoxygenated blood to the lungs and the pulmonary veins carry oxygenated blood back to the heart.
Three vessel layers: Arteries and veins share a tunica intima lining, a tunica media of smooth muscle and elastic tissue, and an outer tunica adventitia. The media is thickest in arteries, which is why they are elastic and palpably pulsatile.
Veins have valves: Veins carry blood back to the heart at low pressure and rely on one-way valves and skeletal muscle contraction to prevent backflow, which is why the tourniquet distends veins below it rather than above.
Capillaries are the exchange site: Capillary walls are a single endothelial cell thick, which allows oxygen, carbon dioxide, nutrients, and waste to diffuse between blood and tissue.
Related body systems: The circulatory system works alongside the lymphatic system, which returns interstitial fluid and houses immune cells, and the hemostatic process that stops bleeding when a vessel is injured.
Arterial versus venous blood: Arterial blood is bright red, oxygen rich, under high pressure, and uniform in composition throughout the body; venous blood is darker, carries carbon dioxide and waste, flows under low pressure, and varies slightly by drainage bed.
Capillary blood is a mixture: A dermal puncture yields a blend of arterialized capillary blood, venous blood, and interstitial fluid, so glucose tends to run slightly higher and potassium, total protein, and calcium slightly lower than in a venous specimen.· CLSI GP42
Plasma versus serum: Plasma is the liquid portion of anticoagulated blood and still contains fibrinogen and the clotting factors; serum is the liquid left after blood clots, so it has no fibrinogen. Plasma tubes therefore yield more fluid volume than serum tubes of the same size.
Composition of whole blood: Whole blood is about 55 percent plasma, which is roughly 90 percent water plus proteins, electrolytes, and waste, and about 45 percent formed elements. After centrifugation the thin buffy coat between the layers holds the white cells and platelets.
The formed elements: Erythrocytes carry oxygen on hemoglobin and live about 120 days, leukocytes provide immune defense in five types (neutrophils, lymphocytes, monocytes, eosinophils, basophils), and thrombocytes are cell fragments that begin clot formation.
Hemostasis in four phases: Injury triggers vascular constriction, then a platelet plug, then the coagulation cascade that converts fibrinogen to fibrin, and finally fibrinolysis that dissolves the clot as the vessel heals. PT reflects the extrinsic pathway and aPTT the intrinsic pathway.
H pattern and M pattern: In the H pattern, seen in roughly seven of ten people, the median cubital connects the cephalic and basilic veins at an angle that looks like an H. In the M pattern the median cephalic and median basilic branch upward from the median antebrachial vein in an M shape.
Median cubital vein: Located centrally, largest, most superficial, best anchored by surrounding tissue, and farthest from the brachial artery and median nerve, which makes it both the easiest to enter and the safest choice.· CLSI GP41
Cephalic vein: Runs along the lateral, thumb side of the arm and continues up the outer upper arm. It is often the only palpable option in patients with more subcutaneous tissue but tends to roll under the needle.
Basilic vein: Runs along the medial, little-finger side and sits directly above the brachial artery and median nerve, so it is the last choice and is the vein most often implicated in nerve injury and accidental arterial puncture.· CLSI GP41
What a good vein feels like: A suitable vein feels spongy, bouncy, and resilient and refills when depressed. A hard, cordlike, or nonresilient vessel is usually sclerosed or thrombosed, and a pulsating vessel is an artery and must not be entered.
Nearby structures to respect: The brachial artery, median nerve, and tendons of the antecubital fossa lie deep to the basilic vein, and the median and ulnar nerves run near the underside of the wrist, which is why that site is never used.
Hematology: CBC with differential, hemoglobin and hematocrit, reticulocyte count, ESR, and hemoglobin A1c are collected in lavender EDTA; some laboratories use a dedicated black tube for ESR.
Coagulation: PT with INR, aPTT, fibrinogen, D-dimer, and factor assays are collected in light blue sodium citrate, filled completely to preserve the nine-to-one ratio.· CLSI H21
Chemistry: Basic and comprehensive metabolic panels, liver and lipid panels, thyroid studies, cardiac markers, and therapeutic drug levels are collected in gold or red serum tubes or in green lithium heparin tubes depending on the platform.
Glucose and alcohol: Glucose, glucose tolerance samples, lactate, and blood alcohol go in gray sodium fluoride tubes; the fluoride prevents red cells from consuming glucose while the specimen waits.
Blood bank and microbiology: Type and screen and crossmatch use pink or lavender EDTA with strict identification requirements, and blood cultures use aerobic and anaerobic bottles or yellow SPS tubes collected first and with the strictest skin antisepsis.· AABB Standards for Blood Banks and Transfusion Services
Trace elements and lead: Trace metal studies use royal blue tubes manufactured to be metal free, supplied with EDTA or with no additive depending on the analyte, and lead levels typically use a royal blue or tan EDTA tube.
Roots worth memorizing: Phleb- and ven- mean vein, arteri- means artery, angi- and vas- mean vessel, hem- and hemat- mean blood, cardi- means heart, erythr- means red, leuk- means white, and thromb- means clot.
Suffixes that describe conditions: The suffix -emia means a blood condition, -penia means deficiency, -osis means abnormal increase or condition, -tomy means cutting into, -ology means the study of, and -stasis means stopping or controlling.
Prefixes of degree and position: Hyper- means above normal and hypo- below normal, inter- means between and intra- means within, peri- means around, and anti- means against. Hyperglycemia and hypokalemia are built entirely from these parts.
Directional terms: Proximal is closer to the trunk and distal farther from it, medial is toward the midline and lateral away from it, anterior is front and posterior is back, and superficial is near the surface while deep is farther in.
Patient positions: Supine is lying face up, prone is lying face down, and Fowler position is sitting up with the head of the bed raised. Supine is the safest position for a patient with a fainting history.
Abbreviations on requisitions: Common examples include CBC, BMP and CMP, PT with INR, aPTT, ESR, BUN, HbA1c, FBS, GTT, ABG, C and S for culture and sensitivity, TDM for therapeutic drug monitoring, POCT for point-of-care testing, STAT for immediately, and NPO for nothing by mouth.

Now prove you know them

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