CSLB General Building (B) — All Questions

A medical assistant is giving an intramuscular injection in the deltoid. At what angle should the needle be inserted?

• a.10 to 15 degrees, nearly parallel to the skin
• b.45 degrees to the skin surface
• c.90 degrees, perpendicular to the skin✓
• d.30 degrees with the bevel down

Intramuscular injections are given at a 90-degree angle so the needle passes through skin and subcutaneous tissue into the muscle. A 45-degree angle is used for many subcutaneous injections, and 10 to 15 degrees with the bevel up is the intradermal angle. Injecting IM medication too shallowly can cause irritation and poor absorption.

Which needle and technique is most appropriate for a subcutaneous insulin injection in an average-size adult?

• a.A 25 to 27 gauge, 5/8 inch needle inserted at 45 to 90 degrees depending on tissue thickness✓
• b.An 18 gauge, 2 inch needle inserted at 90 degrees
• c.A 21 gauge, 1.5 inch needle inserted at 15 degrees
• d.A 28 gauge needle inserted at 10 degrees with the bevel down

Subcutaneous injections use a short, fine needle, commonly 25 to 27 gauge and about 5/8 inch, inserted at 45 degrees or at 90 degrees when there is ample subcutaneous tissue. An 18 gauge, 2 inch needle is far too large and long and would enter muscle. A 15-degree or 10-degree bevel-down approach places medication in or above the dermis rather than the subcutaneous layer.

A medical assistant administers a tuberculin skin test on the inner forearm. Which finding indicates correct intradermal technique?

• a.The site bleeds freely after the needle is withdrawn
• b.No visible change appears at the site
• c.A soft, spongy area develops deep under the skin
• d.A small pale wheal about 6 to 10 mm forms just under the skin surface✓

A correctly placed intradermal injection of 0.1 mL raises a pale, taut wheal, confirming the fluid stayed within the dermis. Absence of a wheal or a deep, spongy pocket suggests the dose went subcutaneously and the test must be repeated at another site. Free bleeding indicates the needle went too deep or nicked a vessel.

A provider orders 2 mL of a medication to be given intramuscularly to an adult. Which injection site is most appropriate for this volume?

• a.Deltoid muscle
• b.Ventrogluteal site✓
• c.Inner forearm
• d.Abdomen two inches from the umbilicus

The ventrogluteal site is a large, well-defined muscle away from major nerves and vessels and can safely accept up to about 3 mL in an adult. The deltoid is generally limited to about 1 mL because of its small mass. The inner forearm is an intradermal site and the abdomen is a subcutaneous site, so neither is used for intramuscular injections.

Which sequence correctly describes the rights of medication administration that the medical assistant must verify?

• a.Right patient, right medication, right dose, right route, right time, and right documentation✓
• b.Right insurance, right copay, right pharmacy, right refill
• c.Right color, right smell, right texture, right container
• d.Right diagnosis, right prognosis, right referral, right specialist

The rights of medication administration center on verifying the patient, drug, dose, route, and time, with documentation completed immediately after the dose is given, and many facilities add right reason and right to refuse. Billing and pharmacy details are administrative and unrelated to safe administration. Judging a drug by appearance or making diagnostic decisions is not part of the verification process.

Just before giving an injection, the medical assistant notices the vial label does not match the medication written in the provider's order. What should be done first?

• a.Give the medication on the label, since it was pulled from the correct drawer
• b.Give a half dose to be safe and document the discrepancy
• c.Stop, do not administer, and clarify the order with the provider✓
• d.Ask the patient which medication they usually receive and follow that

Any discrepancy between the order and the medication must be resolved with the ordering provider before administration, because giving the wrong drug can cause serious harm. Administering the drug on the label ignores the order that authorizes the dose. Reducing the dose does not fix a wrong drug, and a patient's recollection is not a valid substitute for a verified order.

When performing a 12-lead EKG, where is lead V1 placed?

• a.Fifth intercostal space, left midclavicular line
• b.Fourth intercostal space, right sternal border✓
• c.Fourth intercostal space, left midaxillary line
• d.Second intercostal space, left sternal border

V1 is placed in the fourth intercostal space at the right sternal border, and V2 sits at the same level on the left sternal border. The fifth intercostal space at the left midclavicular line is V4, and V6 is at the midaxillary line. Misplacing chest leads distorts the tracing and can mimic or mask cardiac abnormalities.

An EKG tracing shows a wandering, wavy baseline with fuzzy spikes across all leads. The patient is shivering and talking. What is the most likely cause and correction?

• a.Electrical interference; unplug the machine and run it on battery only
• b.Machine malfunction; send the unit for repair before finishing
• c.Normal cardiac variation; no action is needed
• d.Somatic tremor artifact; warm and reassure the patient, ask them to relax and stay still, then repeat✓

Muscle movement from shivering, talking, or tension produces somatic tremor artifact, corrected by warming the patient, providing reassurance, and asking them to lie still. Alternating current interference typically appears as uniform small spikes rather than a jittery baseline tied to movement. The tracing is artifact, not true cardiac activity, and the machine does not need repair when the cause is patient movement.

What are the standard EKG paper speed and sensitivity settings used for a routine 12-lead tracing?

• a.25 mm per second at 10 mm per millivolt✓
• b.50 mm per second at 5 mm per millivolt
• c.10 mm per second at 25 mm per millivolt
• d.5 mm per second at 1 mm per millivolt

The standard settings are a paper speed of 25 mm per second and a gain of 10 mm per millivolt, so each small box equals 0.04 second horizontally and 0.1 millivolt vertically. Doubling the speed to 50 mm per second is only used for special situations such as very fast rhythms and must be noted on the strip. Nonstandard settings make rate and interval measurements invalid unless clearly documented.

A rhythm strip shows regular QRS complexes at a rate of 76 beats per minute, each preceded by an upright P wave with a consistent PR interval. How is this rhythm best described?

• a.Ventricular fibrillation
• b.Sinus bradycardia
• c.Normal sinus rhythm✓
• d.Asystole

Normal sinus rhythm is regular, between 60 and 100 beats per minute, with one upright P wave before every QRS and a constant PR interval, which matches the description. Sinus bradycardia would require a rate under 60. Ventricular fibrillation shows chaotic waveforms with no identifiable QRS, and asystole is a flat line with no electrical activity.

Following the standard order of draw, which tube is collected immediately after the light blue sodium citrate tube?

• a.Lavender EDTA tube
• b.Red or gold serum tube✓
• c.Gray sodium fluoride tube
• d.Blood culture bottle

The standard order of draw is blood cultures, light blue citrate, red or gold serum tubes, green heparin, lavender EDTA, and finally gray fluoride or oxalate, so the serum tube follows the citrate tube. Blood cultures always come first to protect sterility. Drawing lavender or gray tubes too early risks carrying additives such as EDTA or potassium into later tubes and skewing results.

A medical assistant applies a tourniquet and then has trouble locating a vein. After how long should the tourniquet be released?

• a.After 5 minutes, since the tourniquet keeps the vein visible
• b.It may stay on until the entire draw is finished, regardless of time
• c.After 10 minutes, then re-tightened immediately
• d.Within 1 minute, then reapplied after a brief pause before the puncture✓

A tourniquet left on longer than about 1 minute causes hemoconcentration and can falsely elevate results such as potassium and protein, so it should be released and reapplied after a short rest if more time is needed. Leaving it in place for 5 or 10 minutes greatly worsens the distortion and causes patient discomfort. The tourniquet should also be released as soon as blood flow is established during the draw.

Which vein is generally the first choice for routine venipuncture in an adult, and why?

• a.The median cubital vein, because it is large, well anchored, and lies away from major nerves and the brachial artery✓
• b.The basilic vein, because it is closest to the brachial artery and nerves
• c.A vein on the underside of the wrist, because it is most visible
• d.A vein in the foot, because it avoids arm bruising

The median cubital vein in the antecubital fossa is preferred because it is usually large, stable, and located away from the brachial artery and median nerve. The basilic vein is chosen last precisely because of its proximity to the artery and nerve. The underside of the wrist carries a high nerve injury risk, and foot veins require a provider's order due to clotting and infection risk.

A patient's lavender-top specimen is rejected by the laboratory for hemolysis. Which technique error most likely caused it?

• a.Letting the alcohol dry completely before puncture
• b.Filling the tube to the manufacturer's fill line
• c.Vigorously shaking the tube after collection and using an excessively small-bore needle✓
• d.Inverting the tube gently eight times

Hemolysis occurs when red cells rupture, commonly from shaking tubes, forcing blood through a needle that is too small, or drawing through a traumatic puncture. Letting alcohol dry, filling to the correct line, and gentle inversion are all correct steps that help prevent hemolysis and clotting. Hemolyzed specimens falsely raise values such as potassium and must be redrawn.

A patient scheduled for a blood draw had a left mastectomy with lymph node removal and has an IV running in the right forearm. What should the medical assistant do?

• a.Draw from the left arm, since the mastectomy was years ago
• b.Ask the provider for guidance, considering an alternative site such as a hand vein below the IV or a dorsal vein on the unaffected side✓
• c.Draw directly from the IV line to save the patient a stick
• d.Cancel the laboratory work permanently

Blood should not be drawn from an arm on the side of lymph node dissection because of lymphedema and infection risk, and drawing above or at an IV site contaminates the specimen with infused fluid. The safest approach is to consult the provider and use an approved alternative site, such as a hand vein distal to the IV, per facility policy. Cancelling needed laboratory work is not the medical assistant's decision.

What is the correct needle angle for a routine venipuncture in the antecubital fossa?

• a.90 degrees, straight down into the vein
• b.45 to 60 degrees with the bevel down
• c.5 degrees, nearly flat against the skin
• d.About 15 to 30 degrees with the bevel up✓

Venipuncture is performed at roughly a 15 to 30 degree angle with the bevel facing up, which lets the needle enter the vein lumen smoothly. A 90-degree angle would pass through the vein and into deeper tissue. A very flat 5-degree approach tends to slide along the surface without entering, and a bevel-down position can block blood flow against the vein wall.

Before running patient samples on a waived glucose meter, the medical assistant runs the low and high control solutions. Why is this step required?

• a.To confirm the meter and test strips are performing accurately before patient results are reported✓
• b.To warm up the patient's finger for the capillary stick
• c.To satisfy the patient's insurance company
• d.To calibrate the patient's own blood glucose target

Running quality control at the required intervals verifies that the instrument and reagent strips give accurate, reliable results, and patient testing should not proceed if controls are out of range. Controls have nothing to do with warming the puncture site or with insurance billing. A patient's glucose target is set by the provider and is unrelated to instrument quality control.

Which set of conditions represents standard steam autoclave sterilization for wrapped instruments?

• a.160°F at 5 psi for 5 minutes
• b.212°F at 0 psi for 60 minutes
• c.250°F, about 121°C, at 15 psi for roughly 20 to 30 minutes depending on the load✓
• d.300°F at 30 psi for 3 minutes

Standard gravity steam sterilization uses about 250°F, or 121°C, at 15 psi with an exposure time near 20 to 30 minutes for wrapped items, plus drying time. Boiling water at 212°F and 0 psi does not reach sterilization conditions and only disinfects. The very low and very high settings listed do not match accepted autoclave parameters and would either fail to sterilize or damage instruments.

Which method most reliably confirms that an autoclave is actually killing microorganisms?

• a.Autoclave indicator tape that changes color on the outside of the pack
• b.A biological indicator, or spore test, run at the intervals required by policy✓
• c.Checking that the door seal looks clean
• d.Observing steam escaping from the chamber during the cycle

A biological indicator containing resistant bacterial spores is the only method that proves sterilization conditions were sufficient to kill microorganisms, and it is run on a scheduled basis. Indicator tape only shows the pack was exposed to heat, not that sterilization was achieved. A clean door seal and visible steam are maintenance and operating observations, not proof of sterility.

While setting up a sterile field for a minor office surgery, which action maintains sterility?

• a.Reaching across the sterile field to place an instrument on the far side
• b.Turning your back to the field briefly to answer the phone
• c.Placing a sterile item within half an inch of the edge of the drape
• d.Keeping sterile gloved hands above waist level and in view at all times✓

Sterile items and gloved hands must stay above waist level and within sight, because anything below the waist or out of view is considered contaminated. Reaching across the field drops skin flora onto sterile items, and turning away breaks continuous observation. The outer one inch of a sterile drape is considered contaminated, so items must be placed inside that border.

The provider asks the medical assistant to prepare instruments for suture removal. Which instruments are needed?

• a.Suture removal scissors and thumb forceps, with antiseptic and sterile gauze✓
• b.Hemostats and a scalpel with a number 10 blade
• c.A vaginal speculum and cervical spatula
• d.A tuning fork and reflex hammer

Suture removal requires suture scissors with a hooked blade to slide under the stitch plus forceps to lift the knot, along with antiseptic and gauze for cleaning the site. Hemostats and a scalpel are used to create or clamp tissue, not to remove stitches. Speculums, spatulas, tuning forks, and reflex hammers belong to entirely different examinations.

A provider orders 500 mg of a medication and the vial is labeled 250 mg per mL. How many mL should be drawn up?

• a.0.5 mL
• b.1 mL
• c.2 mL✓
• d.5 mL

Using desired dose divided by dose on hand, 500 mg divided by 250 mg per mL equals 2 mL. Drawing 0.5 mL or 1 mL would give only 125 mg or 250 mg, a serious underdose. Drawing 5 mL would deliver 1,250 mg, more than double the ordered amount, so careful calculation and a second check are essential.

During a capillary puncture for a glucose test, which step improves specimen quality?

• a.Squeezing the finger hard and repeatedly to speed up flow
• b.Wiping away the first drop of blood and using the next free-flowing drop✓
• c.Puncturing the very tip center of the finger pad over the bone
• d.Using the same lancet again if the first stick yields too little blood

The first drop is wiped away because it contains tissue fluid and alcohol residue that dilute the sample, so the second free-flowing drop is used. Vigorous squeezing forces in tissue fluid and can hemolyze the sample. Puncturing the central tip over the bone risks injury, and lancets are single-use safety devices that are never reused.

A patient becomes pale and diaphoretic and says the room is spinning midway through a venipuncture. What should the medical assistant do first?

• a.Continue the draw quickly and finish all six tubes
• b.Step out to find the provider and leave the needle in place
• c.Have the patient stand and walk to fresh air
• d.Stop the draw, remove the needle and apply pressure, lower the patient's head or lay them down, and stay with them✓

Presyncope during a draw requires stopping immediately, removing the needle with pressure over the site, and positioning the patient with the head lowered or lying flat to restore cerebral blood flow while someone stays with them. Continuing the draw or leaving a needle in an unsteady patient risks nerve injury and a fall. Standing and walking a lightheaded patient greatly increases the chance of collapse.