CSLB General Building (B) — All Questions

A phlebotomist must collect a blood culture set, a PT/INR, a basic metabolic panel on a gel serum tube, and a CBC. Which collection sequence follows the standard order of draw?

• a.Light blue, blood culture, lavender, gel serum tube
• b.Blood culture, light blue, gel serum tube, lavender✓
• c.Gel serum tube, blood culture, light blue, lavender
• d.Lavender, light blue, blood culture, gel serum tube

The standard order of draw is blood culture (sterile) first, then the light blue sodium citrate coagulation tube, then serum tubes with or without gel, then heparin, then EDTA, then glycolytic inhibitor tubes. Drawing the blood culture first protects it from skin-flora contamination introduced by non-sterile tube handling. Every other sequence listed allows additive carryover into a tube where that additive causes error, most notably EDTA carried into a chemistry or coagulation tube.CLSI GP41

A phlebotomist accidentally draws the lavender EDTA tube before the light blue citrate tube. What is the most likely consequence for the coagulation results?

• a.The PT and aPTT will be falsely shortened by the added EDTA
• b.The specimen will clot in the light blue tube within seconds
• c.There is no effect because both tubes contain anticoagulants
• d.EDTA carryover chelates calcium and can falsely prolong the PT and aPTT✓

EDTA is a potent calcium chelator, and even a trace carried over on the needle into the citrate tube removes additional calcium and can falsely prolong clotting times. It may also falsely raise potassium and lower calcium if carried into a chemistry tube. The tubes are not interchangeable simply because both are anticoagulated; each anticoagulant works by a different mechanism and only citrate is validated for routine coagulation testing.CLSI GP41

A patient has small veins and the phlebotomist leaves the tourniquet in place while palpating for two full minutes. What analytic problem is most likely?

• a.Hemoconcentration with falsely elevated protein, calcium and potassium✓
• b.Complete clotting of the EDTA specimen
• c.Dilution of the specimen with interstitial fluid
• d.Loss of platelets from the sample

The tourniquet should stay on no longer than one minute; beyond that, plasma water leaves the vessel and protein-bound and cellular analytes concentrate. This produces falsely elevated total protein, albumin, calcium, potassium and hematocrit. Tourniquet time does not dilute the sample or cause the EDTA tube to clot, and platelets are not selectively lost.CLSI GP41

Which antecubital vein is the first choice for routine venipuncture in an adult?

• a.Brachial vein
• b.Basilic vein
• c.Median cubital vein✓
• d.Radial vein

The median cubital vein is selected first because it is usually large, well anchored, close to the surface and farthest from the brachial artery and median nerve. The basilic vein is the last antecubital choice precisely because the artery and nerve lie beneath it. The brachial and radial vessels are deep or arterial and are not used for routine venipuncture.CLSI GP41

At what angle to the skin should the needle be inserted for a routine antecubital venipuncture?

• a.5 degrees or less
• b.45 to 60 degrees
• c.15 to 30 degrees✓
• d.90 degrees

A 15 to 30 degree angle allows the bevel to enter the vein lumen without passing through the far wall. An angle that is too shallow causes the needle to ride on top of the vein and fail to enter; an angle of 45 degrees or more risks going through the vein and into underlying structures. A 90 degree insertion is used for dermal puncture devices, not for venipuncture.CLSI GP41

Which needle gauge range is standard for routine adult venipuncture with an evacuated tube system?

• a.21 to 23 gauge✓
• b.18 to 20 gauge
• c.16 to 18 gauge
• d.25 to 27 gauge

Gauges 21 to 23 are standard: 21 is the general-purpose size, 22 is used for smaller or fragile veins, and 23 is typical of a winged (butterfly) set. Larger bores such as 16 to 18 gauge are used for blood donation or infusion and are unnecessarily traumatic for diagnostic draws. Very small bores like 25 gauge force cells through a narrow lumen and cause hemolysis.CLSI GP41

A provider orders a lactate and a blood alcohol level. Which tube additive combination is designed to preserve these analytes?

• a.Sodium citrate
• b.Lithium heparin
• c.K2 EDTA
• d.Sodium fluoride and potassium oxalate✓

The gray-top tube contains sodium fluoride, an antiglycolytic agent that stops cells from consuming glucose or generating lactate, plus potassium oxalate as the anticoagulant. Citrate is for coagulation testing, heparin for stat chemistry, and EDTA for hematology; none of them inhibit glycolysis. Note that a non-alcohol antiseptic must also be used when collecting a blood alcohol.CLSI GP41

The light blue stopper tube used for PT/INR and aPTT contains which additive, and why must it be filled completely?

• a.Heparin, because it must be balanced against the plasma volume
• b.Sodium citrate, because a fixed 9:1 blood-to-anticoagulant ratio is required✓
• c.EDTA, because underfilling shrinks the red cells
• d.Thrombin, because clotting must be accelerated

Sodium citrate reversibly binds calcium and requires a 9 parts blood to 1 part anticoagulant ratio. An underfilled tube leaves excess citrate that binds reagent calcium during testing and falsely prolongs the PT and aPTT. Heparin and EDTA are not used for routine coagulation, and thrombin is found in rapid-serum tubes, not coagulation tubes.CLSI GP41

A comprehensive metabolic panel is ordered. Which tube is appropriate and what does it contain?

• a.Gold or tiger-top serum separator tube containing a clot activator and gel✓
• b.Light blue tube containing sodium citrate
• c.Lavender tube containing K2 EDTA
• d.Gray tube containing sodium fluoride

Chemistry panels are run on serum from a serum separator tube, which holds a clot activator plus a thixotropic gel that forms a barrier between serum and cells after centrifugation. Citrate tubes are for coagulation, EDTA for hematology, and fluoride for glucose and alcohol preservation. Using an anticoagulated tube in place of the SST changes several chemistry values.CLSI GP41

A stat ammonia level is ordered. Which tube is used and where does it fall in the order of draw?

• a.Lavender EDTA tube, drawn before the serum tube
• b.Light blue citrate tube, drawn first
• c.Green heparin tube, drawn after serum tubes and before EDTA✓
• d.Gray fluoride tube, drawn before heparin

Ammonia is collected in a heparin tube, and heparin tubes are drawn after serum tubes and before EDTA in the standard order. The specimen must also be placed on ice and delivered promptly because ammonia rises quickly at room temperature. EDTA, citrate and fluoride tubes are not appropriate for ammonia and none of them occupy the heparin position in the sequence.CLSI GP41

Which group of tests is collected in the lavender EDTA tube?

• a.PT, aPTT and fibrinogen
• b.CBC, hemoglobin A1c and ESR✓
• c.Comprehensive metabolic panel and lipid panel
• d.Glucose, lactate and blood alcohol

EDTA preserves cell morphology and prevents platelet clumping, so it is the tube of choice for the CBC, hemoglobin A1c and the erythrocyte sedimentation rate. Coagulation tests require citrate, glucose and alcohol require a fluoride tube, and chemistry panels require serum or heparinized plasma. Substituting EDTA for a chemistry tube falsely raises potassium and falsely lowers calcium.CLSI GP41

What is the maximum lancet penetration depth for a heel stick on a newborn?

• a.There is no depth limit if the heel is warmed
• b.3.5 mm
• c.5.0 mm
• d.2.0 mm✓

Penetration must not exceed 2.0 mm because the calcaneus in a newborn may lie only 2 to 3 mm below the plantar skin, and bone contact can cause osteomyelitis. Depths of 3.5 mm or 5 mm greatly increase that risk. Warming the heel improves blood flow but does not change the safe depth limit.CLSI GP42

A phlebotomist is preparing a heel stick on a two-day-old infant. Which site is acceptable?

• a.The posterior curvature of the heel
• b.The great toe
• c.The arch of the foot
• d.The medial or lateral plantar surface of the heel✓

Only the medial and lateral plantar surfaces of the heel are used, because the calcaneus does not extend into these areas. The posterior curvature sits directly over the bone, and the arch overlies nerves, tendons and cartilage. The great toe and other fingers or toes are not acceptable dermal puncture sites in a newborn.CLSI GP42

During a capillary collection the phlebotomist must fill a lavender microtube and a serum microtube. Which order is correct?

• a.Serum microtube first, then lavender
• b.Lavender microtube first, then serum✓
• c.Either order, because capillary blood has no additive carryover
• d.Both must be filled at the same time from separate punctures

The capillary order of draw differs from venipuncture: after any blood gas specimen, EDTA is collected first so that platelets are captured before they aggregate at the puncture site, followed by other additive tubes and finally serum. Filling the serum tube first would leave a clumped, unrepresentative platelet count. Carryover and clotting both occur in capillary work, so order does matter and a second puncture is not required.CLSI GP42

A phlebotomist cleans the site with 70% isopropyl alcohol and inserts the needle immediately while the skin is still wet. What is the most likely result?

• a.The specimen will clot faster in the tube
• b.The venipuncture will be less painful for the patient
• c.Stinging for the patient and hemolysis of the specimen✓
• d.The antiseptic effect will be improved

Alcohol must air dry for about 30 seconds so it can kill organisms and so residual alcohol is not carried into the vein. Wet alcohol stings on needle entry and lyses red cells, producing hemolysis that falsely raises potassium, LDH and AST. Drying is part of the antiseptic action, so puncturing early reduces rather than improves disinfection.CLSI GP41

Which skin antisepsis is appropriate before collecting blood cultures from an adult?

• a.Chlorhexidine gluconate applied with friction and allowed to dry completely✓
• b.A single wipe of 70% isopropyl alcohol
• c.Soap and water only
• d.No antisepsis is needed because the bottles are sterile

Blood cultures require an antiseptic effective against resident skin flora, and chlorhexidine gluconate applied with friction and fully dried is the standard for patients older than two months. A quick alcohol wipe alone does not reduce skin flora enough and leads to false-positive contaminated cultures. Sterile bottles do not protect against organisms carried in on the needle from unprepared skin.CLSI GP41

An inpatient has an IV infusing in the left forearm and no accessible veins in the right arm. What is the best action?

• a.Draw directly above the IV site with the infusion running
• b.Ask the nurse to stop the infusion, wait at least two minutes, then draw below the IV and discard the first 5 mL✓
• c.Draw from the IV line without flushing it
• d.Cancel the order and document that no site was available

When no other site exists, the infusion is stopped by licensed personnel, a short wait allows the fluid to clear, the draw is made distal to the IV so blood has not passed the infusion point, and a discard volume clears residual fluid. Drawing above a running IV dilutes the specimen with infusate. Drawing from a line without flushing gives contaminated results, and simply canceling the order abandons a resolvable problem.CLSI GP41

A patient had a right mastectomy with lymph node removal 14 months ago and has an IV in the left hand. What should the phlebotomist do?

• a.Draw from the right antecubital area since the surgery was over a year ago
• b.Draw above the IV in the left arm
• c.Use a fingerstick on the right hand without asking anyone
• d.Consult the patient's provider for guidance before selecting a site✓

Lymph node dissection impairs lymph drainage indefinitely, so the affected side is avoided because of infection and lymphedema risk, and there is no automatic time limit that makes it safe. With the only other arm carrying an IV, the correct step is to obtain provider direction rather than choose unilaterally. Drawing above an IV dilutes the sample, and a fingerstick on the affected side carries the same restriction as a venipuncture.CLSI GP41

Why is the basilic vein the last antecubital choice for venipuncture?

• a.The brachial artery and median nerve lie close beneath it✓
• b.It collapses under vacuum more easily than other veins
• c.It contains more valves than any other arm vein
• d.It is too small to accommodate a 21 gauge needle

The basilic vein sits on the medial side of the antecubital fossa directly over the brachial artery and near the median nerve, so puncture there carries the highest risk of arterial nicking and nerve injury. Size, collapse tendency and valve count are not the deciding factors. When the basilic vein must be used, the needle is anchored carefully and the patient is monitored for shooting pain.CLSI GP41

A light blue tube is filled only two thirds of the way because the vein collapsed. What should the phlebotomist do?

• a.Pour the contents into a second light blue tube to reach the fill line
• b.Send it and note 'short draw' on the requisition
• c.Discard the tube and recollect a properly filled citrate tube✓
• d.Add saline to the tube to reach the fill line

A short-filled citrate tube violates the required 9:1 ratio and produces falsely prolonged PT and aPTT results, so it must be recollected rather than reported with a comment. Combining two partially filled tubes doubles the anticoagulant relative to blood and makes the error worse. Adding any diluent to an evacuated tube is never acceptable because it alters both the ratio and the analyte concentration.CLSI GP41

How should an EDTA tube be mixed immediately after collection?

• a.Shake vigorously five times
• b.Invert once and place upright in the rack
• c.Invert gently 8 to 10 times✓
• d.Do not mix; the additive dissolves on its own

EDTA tubes require roughly 8 to 10 gentle inversions so the anticoagulant coats all the blood and microclots do not form. Vigorous shaking introduces mechanical trauma and hemolysis, which invalidates many tests. A single inversion or no mixing at all leaves clotted or clumped specimens that the laboratory must reject.CLSI GP41

A phlebotomist collects an aerobic and anaerobic blood culture set, then a green heparin tube, then a light blue citrate tube. What is the main problem?

• a.The citrate tube was drawn after heparin, so heparin carryover can prolong clotting times✓
• b.Heparin and citrate tubes cannot be drawn during the same venipuncture
• c.Blood cultures should never be drawn first
• d.There is no problem; the sequence is correct

The citrate tube must immediately follow the blood cultures and precede all serum and heparin tubes. Because heparin inhibits thrombin, carryover into the citrate tube can falsely prolong the aPTT. Blood cultures are correctly drawn first, and both tubes may be collected in one venipuncture as long as the sequence is respected.CLSI GP41

A phlebotomist has just filled a light blue citrate tube. According to the standard order of draw, which tube is collected next?

• a.Lavender EDTA tube
• b.Gray sodium fluoride tube
• c.Green heparin tube
• d.Gold serum separator tube✓

After the citrate tube, serum tubes with or without a gel separator are collected, followed by heparin, then EDTA, then the fluoride tube. Placing EDTA or fluoride earlier risks carrying potassium-containing or oxalate additives into chemistry tubes. Heparin also follows, not precedes, the serum tube in the standard sequence.CLSI GP41

A patient is told to pump the fist repeatedly while the tourniquet is on. Which result is most affected?

• a.Hemoglobin, which may be falsely decreased
• b.Potassium, which may be falsely elevated✓
• c.Sodium, which may be falsely decreased
• d.Platelet count, which may be falsely elevated

Vigorous fist pumping causes muscle cells to release potassium into the local circulation, so the measured potassium can be falsely high. Patients may make a fist once to help the vein, but repeated pumping is discouraged. Hemoglobin, sodium and platelet counts are not meaningfully changed by this mechanism.CLSI GP41

A coagulation specimen is the only tube ordered and a winged blood collection set will be used. What should be done first?

• a.Draw and discard a tube first to prime the tubing air space✓
• b.Fill the citrate tube directly, since the tubing volume is negligible
• c.Remove the tourniquet before attaching the citrate tube
• d.Use a 25 gauge needle to slow the fill rate

The air in a winged set's tubing displaces blood from the first tube, so a discard tube is drawn first to prime the line and preserve the 9:1 fill ratio. Filling the citrate tube directly would underfill it and falsely prolong clotting times. The tourniquet stays on until blood flow is established, and a 25 gauge needle is too small and would cause hemolysis.CLSI GP41

The last tube is filling. In what order should the phlebotomist complete the venipuncture?

• a.Remove the needle, release the tourniquet, then remove the last tube
• b.Apply pressure to the site, then remove the needle and tourniquet together
• c.Remove the last tube, release the tourniquet, then withdraw the needle and apply pressure✓
• d.Release the tourniquet, remove the needle, then remove the last tube

The tube is removed from the holder first so no vacuum pulls on the vein, the tourniquet is released next to lower venous pressure, and only then is the needle withdrawn and pressure applied. Pulling the needle out with the tourniquet still tight forces blood into the tissue and causes a hematoma. Removing a tube after the needle is out is impossible, and pressure cannot be applied while the needle is still in the vein.CLSI GP41

A 4-year-old needs a CBC and a basic metabolic panel. Which approach best matches pediatric practice?

• a.Use an 18 gauge needle to finish quickly
• b.Use a 23 gauge winged set with small-volume tubes and secure, gentle immobilization✓
• c.Draw from a foot vein without provider approval
• d.Apply the tourniquet for three minutes to enlarge the vein

Children have small, mobile veins and a limited total blood volume, so a 23 gauge winged set with pediatric-volume tubes reduces trauma and blood loss. A large 18 gauge needle is unnecessarily traumatic, prolonged tourniquet time causes hemoconcentration, and lower-extremity draws require provider authorization. Comforting and safely holding the child also improves success on the first attempt.CLSI GP41

An 88-year-old patient has thin skin, fragile veins and takes warfarin. Which modification is most appropriate?

• a.Use a 16 gauge needle so the draw finishes faster
• b.Slap the arm firmly to raise the vein
• c.Apply the tourniquet as tightly as possible
• d.Anchor the vein without dragging the skin, use a 23 gauge winged set, and hold pressure longer after the draw✓

Older skin tears easily and anticoagulated patients bleed longer, so gentle anchoring, a smaller winged needle and extended pressure after needle removal are appropriate. Slapping the arm and overtightening the tourniquet bruise fragile tissue and can rupture the vein. A large bore needle increases trauma without any benefit for a routine draw.CLSI GP41

A requisition lists the patient name and tests but has no ordering provider and no collection priority. What should the phlebotomist do?

• a.Collect the specimens and write in a provider name from the chart
• b.Collect only the tests the phlebotomist recognizes
• c.Collect the specimens and let the laboratory sort it out
• d.Stop and have the incomplete requisition corrected before collecting✓

Laboratory testing must be performed on an authorized, complete order, so an incomplete requisition is clarified with the ordering source before any blood is drawn. Writing in information the phlebotomist did not receive from the provider falsifies the record. Collecting first and deferring the problem risks an unauthorized draw and a redraw for the patient.CLIA

How should the needle be positioned as it enters the skin during venipuncture?

• a.Bevel down and against the direction of blood flow
• b.Bevel up and in line with the vein, pointing toward the heart✓
• c.Bevel sideways at 90 degrees to the vein
• d.Bevel up but angled across the vein at 45 degrees

The bevel faces up and follows the long axis of the vein so the sharpest point enters first and the opening sits inside the lumen. Bevel-down entry can occlude the opening against the vein wall and stop flow. Crossing the vein at a steep or perpendicular angle increases the chance of going through the far wall and causing a hematoma.CLSI GP41

A phlebotomist has attempted venipuncture twice on the same patient without obtaining blood. What is the correct next step?

• a.Attempt a third and fourth time on the same arm
• b.Probe laterally with the needle already in place until blood appears
• c.Stop and ask another qualified phlebotomist to attempt the draw✓
• d.Send the patient home and cancel the tests

Standard practice limits a phlebotomist to two attempts before handing the patient to another qualified collector, which protects the patient from repeated trauma. Blind lateral probing risks nerve damage and arterial puncture and is never acceptable. Canceling ordered tests without escalation deprives the provider of needed results.CLSI GP41

Blood flow stops shortly after a good flash is seen. Which corrective action is appropriate?

• a.Rotate the needle slightly or advance it a small amount, and confirm the tube is fully seated✓
• b.Pull the needle nearly out and reinsert it at a new angle
• c.Move the needle rapidly side to side to find the vein
• d.Ask the patient to pump the fist continuously for one minute

Loss of flow is often caused by the bevel resting against a vein wall, a partially seated tube or a collapsed vein, so gentle rotation, slight advancement or reseating the tube usually restores flow. Withdrawing and reinserting or moving the needle laterally can lacerate the vein and injure nerves. Continuous fist pumping falsely elevates potassium and does not solve a positional problem.CLSI GP41

Which fingerstick technique is correct for an adult capillary glucose?

• a.Puncture the center of the fingertip parallel to the fingerprint lines
• b.Puncture the side of the fleshy pad of the third or fourth finger, across the fingerprint lines✓
• c.Puncture the tip of the fifth finger
• d.Puncture the thumb because it has the best blood supply

The side of the fleshy pad of the middle or ring finger is used, and the puncture crosses the fingerprint lines so the drop forms rather than running along a groove. The very center of the fingertip is the most nerve-dense and painful area. The fifth finger has little tissue over bone and the thumb has a pulse and thicker calluses, so both are avoided.CLSI GP42

A legal blood alcohol specimen is ordered. Which site preparation is required?

• a.70% isopropyl alcohol allowed to dry for one minute
• b.Alcohol followed by chlorhexidine
• c.No cleaning at all, to avoid contaminating the sample
• d.A non-alcohol antiseptic such as povidone-iodine or soap and water✓

Alcohol-based antiseptics can contaminate the specimen and cast doubt on a legally defensible result, so a non-alcohol antiseptic is used. Chlorhexidine preparations frequently contain alcohol, so combining them does not solve the problem. Skipping antisepsis entirely violates infection control and would itself invalidate the collection.CLSI GP41

An order requires a lavender EDTA tube and a gray fluoride tube only. Which sequence is correct and why?

• a.Lavender first, because EDTA precedes the glycolytic inhibitor tube in the order of draw✓
• b.Gray first, because it is the smallest tube
• c.Either order, because neither additive affects the other
• d.Gray first, because the fluoride preserves glucose better when drawn early

In the standard sequence the EDTA tube always precedes the sodium fluoride and potassium oxalate tube, which is drawn last. Potassium oxalate carried backward into an EDTA tube can distort cell morphology and hematology results. Tube size and how early the fluoride is drawn have no bearing on the required order.CLSI GP41

A newly hired phlebotomist asks about the hepatitis B vaccine. Under the Bloodborne Pathogens Standard, what must the employer do?

• a.Provide it only after the employee has a documented exposure
• b.Require the employee to pay half the cost of the series
• c.Offer the vaccination series at no cost within 10 working days of assignment to at-risk duties✓
• d.Provide it only if the employee has worked there for one year

The standard requires employers to offer the hepatitis B vaccination series free of charge within 10 working days of initial assignment to duties with occupational exposure. Employees may decline, but they must sign a declination form and may request the vaccine later at no cost. Charging the employee, waiting for an exposure or imposing a service requirement all violate the rule.OSHA 29 CFR 1910.1030

Which description matches a compliant sharps container?

• a.A clear plastic bag labeled with a biohazard symbol
• b.A cardboard box lined with a red bag
• c.A rigid, puncture-resistant, leak-proof container that is closable and labeled with the biohazard symbol✓
• d.Any lidded container kept in a locked cabinet

Sharps containers must be closable, puncture resistant, leak proof on sides and bottom, and labeled or color coded as biohazardous. Bags and cardboard cannot resist punctures and allow injuries and leakage. Storing an ordinary container in a locked cabinet does not meet the construction or labeling requirements, and containers must also be replaced before they are overfilled.OSHA 29 CFR 1910.1030

After a successful draw, what is the correct handling of the used needle?

• a.Activate the safety device immediately and drop the whole assembly into the sharps container✓
• b.Bend it so it cannot be reused, then discard it
• c.Recap it with two hands and then discard it
• d.Carry it to the laboratory and discard it there

Contaminated needles must not be recapped, bent, sheared or removed by hand, and the engineered safety feature is activated immediately at the point of use. The intact needle and holder are discarded together in the nearest sharps container. Recapping with two hands is the classic cause of needlesticks, and transporting an unprotected sharp exposes everyone along the route.OSHA 29 CFR 1910.1030

A phlebotomist sustains a needlestick from a used needle. What is the correct first action?

• a.Squeeze the site hard to force out blood
• b.Apply a caustic agent such as bleach to the wound
• c.Finish the shift and report the injury at the end of the day
• d.Wash the site immediately with soap and running water, then report the exposure✓

Immediate washing with soap and running water is the recommended first step, followed by prompt reporting so post-exposure evaluation, source testing and prophylaxis can begin within the effective window. Squeezing the wound damages tissue and has no proven benefit. Applying bleach or other caustics injures tissue, and delaying the report can push treatment past the point where it works best.OSHA 29 CFR 1910.1030

A phlebotomist finishes drawing a patient on contact precautions for Clostridioides difficile. Which hand hygiene is required?

• a.Use an alcohol-based hand rub only
• b.Wash with soap and running water✓
• c.Use an alcohol rub twice in a row
• d.Change gloves without performing hand hygiene

Alcohol-based rubs do not kill C. difficile spores, so hands must be washed with soap and running water, which physically removes them. Soap and water are also required whenever hands are visibly soiled. Repeating an alcohol rub does not add sporicidal activity, and changing gloves alone does not decontaminate the hands underneath.CDC Guideline for Hand Hygiene in Healthcare Settings

Which removal sequence for personal protective equipment best limits self-contamination?

• a.Gloves, goggles or face shield, gown, mask✓
• b.Mask, gown, gloves, goggles
• c.Gown, gloves, mask, goggles
• d.Goggles, mask, gloves, gown

Gloves are the most contaminated item and come off first, followed by eye protection, then the gown, and finally the mask, which is removed last and outside the patient room. Removing the mask early exposes the face while the hands are still contaminated. Hand hygiene is performed after glove removal and again after all PPE is off.CDC Guideline for Isolation Precautions

A phlebotomist is sent to draw a patient in airborne precautions for suspected tuberculosis. What is required?

• a.A surgical mask and gloves
• b.A gown and face shield only
• c.A fit-tested N95 or higher respirator, with the room door kept closed✓
• d.No additional protection if the draw takes under five minutes

Airborne precautions require a fit-tested N95 or higher-level respirator and an airborne infection isolation room with the door closed. A surgical mask does not filter droplet nuclei that stay suspended in air. Gowns and face shields address contact and splash risks, and short exposure time does not remove the inhalation hazard.CDC Guideline for Isolation Precautions

A patient is on contact precautions for MRSA. What PPE does the phlebotomist wear to enter and draw blood?

• a.N95 respirator and goggles
• b.Gown and gloves, donned before entering the room✓
• c.Gloves only, since the skin is intact
• d.Surgical mask only

Contact precautions require a gown and gloves put on before room entry and removed before exit, because transmission occurs through direct and indirect surface contact. An N95 is reserved for airborne precautions and a surgical mask for droplet precautions. Gloves alone leave the uniform free to pick up organisms from bedding and equipment.CDC Guideline for Isolation Precautions

Droplet precautions are ordered for a patient with suspected pertussis. What does the phlebotomist do?

• a.Wear no PPE because droplets fall quickly to the ground
• b.Wear a fit-tested N95 and place the patient in negative pressure
• c.Wear a gown but no facial protection
• d.Wear a surgical mask when working within about three to six feet of the patient✓

Droplet precautions call for a surgical mask on close approach, since respiratory droplets travel only a short distance before settling. Negative pressure rooms and N95 respirators are used for airborne organisms, not droplet spread. A gown alone leaves mucous membranes unprotected, and the fact that droplets settle is exactly why close-range protection is needed.CDC Guideline for Isolation Precautions

Two phlebotomists discuss a patient's positive test result by name in a crowded elevator. Which principle is violated?

• a.Chain of custody
• b.Informed consent
• c.Quality control documentation
• d.Protection of patient health information and the minimum necessary rule✓

Identifiable health information may be disclosed only to those with a legitimate need to know, and a public elevator conversation exposes it to people with no treatment relationship. Chain of custody concerns forensic specimen tracking, quality control concerns test accuracy, and informed consent concerns permission for a procedure. None of those cover casual disclosure of results.HIPAA

A pre-employment drug screen requires chain of custody. What does this documentation establish?

• a.That the specimen was collected while the donor was fasting
• b.Every person who handled the specimen and every transfer from collection to reporting✓
• c.That the correct tube additive was used
• d.That the laboratory participates in proficiency testing

Chain of custody is a legal record documenting identity, handling and transfer of a specimen at every step so its integrity can be defended in court. It typically includes a tamper-evident seal, dated signatures at each transfer and secure storage. Fasting status, additive selection and proficiency testing are quality issues but are not what a chain of custody form proves.

Which statement about CLIA-waived testing is accurate?

• a.Waived tests do not require any manufacturer instructions to be followed
• b.Waived status means the facility needs no CLIA certificate at all
• c.Waived tests are simple, low-risk methods that must still be run exactly per the manufacturer instructions✓
• d.Waived tests may be reported without patient identification

CLIA-waived tests, such as many point-of-care glucose meters, are considered simple with a low risk of error, but the facility still needs a Certificate of Waiver and must follow the manufacturer instructions exactly. Deviating from the instructions voids waived status. Patient identification and result documentation requirements apply to waived testing just as they do to all laboratory testing.CLIA

A point-of-care glucose meter's control result falls outside the acceptable range. What should be done?

• a.Stop patient testing, troubleshoot and repeat the control, and document the action before reporting results✓
• b.Report the patient results and repeat the control at the end of the shift
• c.Average the failed control with the previous passing control
• d.Ignore the failure if the patient result looks clinically reasonable

An out-of-range control indicates the system cannot be trusted, so patient testing stops until the cause is corrected and an acceptable control is obtained, with all steps documented. Reporting results from an unverified instrument risks patient harm. Averaging controls or judging results by clinical appearance defeats the purpose of objective quality control.CLIA

How often must an employer review and update the written Exposure Control Plan?

• a.Only when a new employee is hired
• b.At least annually, and whenever new tasks or procedures affect exposure✓
• c.Every five years
• d.Only after a documented exposure incident

The Exposure Control Plan must be reviewed and updated at least annually and whenever new or modified tasks and procedures change occupational exposure, including when safer devices become available. A five-year cycle is far too long and hiring alone is not the trigger. Waiting for an exposure incident is reactive and does not satisfy the standard.OSHA 29 CFR 1910.1030

A phlebotomist has just drawn an outpatient and the next patient is waiting. What is correct glove practice?

• a.Keep the same gloves and disinfect them with alcohol between patients
• b.Keep the same gloves if they are not visibly soiled
• c.Wear two pairs and peel off the outer pair between patients
• d.Remove and discard gloves after each patient, perform hand hygiene, and put on a new pair✓

Gloves are single-use items that must be removed and discarded after each patient, followed by hand hygiene and a fresh pair. Alcohol degrades glove material and does not reliably decontaminate it. Absence of visible soiling does not mean absence of contamination, and double gloving is not an approved substitute for changing gloves.OSHA 29 CFR 1910.1030

Which labeling is required on a container used to transport blood specimens off the collection floor?

• a.A biohazard symbol or red color coding identifying the contents as infectious✓
• b.The phlebotomist's name only
• c.No labeling is required if the lid is closed
• d.A handwritten note that says fragile

Containers holding blood or other potentially infectious material must carry the biohazard label or be red color coded so anyone handling them knows the risk. A fragile note or a staff name conveys nothing about infectious hazard. A closed lid contains the specimen but does not warn the next handler.OSHA 29 CFR 1910.1030

Which item is an example of an engineering control rather than a work practice control?

• a.Washing hands after glove removal
• b.Not recapping used needles
• c.A needle with a retractable safety shield✓
• d.Prohibiting eating in the specimen processing area

Engineering controls are devices that isolate or remove the hazard, such as self-sheathing needles, sharps containers and splash guards. Work practice controls change how a task is performed, which is what not recapping, hand washing and food restrictions do. Both categories are required, but only the device itself is an engineering control.OSHA 29 CFR 1910.1030

Which statement best describes standard precautions?

• a.They apply only to patients with a known bloodborne infection
• b.They replace the need for transmission-based precautions
• c.They apply to every patient because infection status may be unknown✓
• d.They apply only in the emergency department

Standard precautions treat blood and body fluids from every patient as potentially infectious, because many infections are undiagnosed at the time of care. Transmission-based precautions such as contact, droplet and airborne are added on top of standard precautions, not substituted for them. The approach applies in every care setting, not just high-acuity areas.CDC Guideline for Isolation Precautions

A tube of blood breaks on the floor. What is the correct decontamination sequence?

• a.Put on gloves, cover and absorb the spill, then apply an appropriate disinfectant such as 1:10 bleach and allow the required contact time✓
• b.Spray disinfectant and wipe it up right away with a paper towel
• c.Mop the area immediately with plain water
• d.Leave it for housekeeping and mark the area with a chair

The spill is contained and absorbed while wearing appropriate PPE, then treated with an EPA-registered disinfectant or a freshly prepared 1:10 bleach solution left in place for the required contact time before final cleanup, with any glass picked up mechanically. Water does not disinfect and wiping immediately gives no contact time. Abandoning a biohazard spill leaves others exposed.OSHA 29 CFR 1910.1030

Which activity is prohibited in an area where blood specimens are handled?

• a.Wearing a buttoned lab coat
• b.Storing labeled specimens in a designated refrigerator
• c.Documenting collection times in the log
• d.Applying lip balm or eating a snack at the bench✓

Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses are prohibited where there is a reasonable likelihood of occupational exposure, because they create a hand-to-mucous-membrane route. Wearing appropriate protective clothing and documenting collections are expected practices. Specimens may be stored in a refrigerator designated for that purpose, but food may never be stored there.OSHA 29 CFR 1910.1030

After a reported needlestick, what must the employer provide?

• a.A written warning documenting the employee's technique error
• b.A confidential medical evaluation, source testing when permitted by law, and follow-up at no cost to the employee✓
• c.A requirement that the employee use personal insurance for follow-up
• d.Reassignment away from patient care for six months

The standard requires a confidential post-exposure medical evaluation and follow-up at no cost, including source individual testing where legally permitted, prophylaxis when indicated and counseling. Disciplining the employee discourages reporting and is not a required response. Shifting cost to the employee or automatically removing them from duty is not part of the requirement.OSHA 29 CFR 1910.1030

A patient's adult daughter asks the phlebotomist for her mother's lab results. What is the appropriate response?

• a.Explain that results are released by the ordering provider and refer her to the care team✓
• b.Read the results aloud since she is immediate family
• c.Print the results and hand them over if the patient is in the room
• d.Give a general summary without naming specific values

Phlebotomists do not release results, and protected health information may not be disclosed to family members without proper authorization. Referring the request to the ordering provider respects both privacy rules and scope of practice. Being related, being present in the room or softening the disclosure into a summary does not create authorization.HIPAA

Which set of elements must appear on a blood specimen label?

• a.Patient room number and diagnosis
• b.Patient last name and the test name only
• c.Patient full name, a second unique identifier, date and time of collection, and the collector's identification✓
• d.Ordering provider and insurance number

A compliant label carries the patient's full name plus a second unique identifier such as the medical record number or date of birth, the date and time of collection and the identity of the person who collected it. Room numbers and diagnoses change and are not unique identifiers. Test names and billing information belong on the requisition, not in place of patient identification.CLIA

When and where should blood tubes be labeled?

• a.In the laboratory after delivery, using the requisition
• b.At the patient's side immediately after collection, before leaving the patient✓
• c.At the nurses' station after all patients on the floor are collected
• d.Before the draw, so the tubes are ready

Tubes are labeled at the bedside immediately after collection and before leaving the patient, which is the only point at which identity can still be verified against the patient. Pre-labeling risks putting the wrong patient's blood in an already labeled tube. Labeling later in the laboratory or at a workstation makes mislabeling likely and is a leading cause of transfusion and diagnostic errors.CLIA

Which specimen must be transported chilled in an ice slurry?

• a.Complete blood count
• b.Bilirubin
• c.Cold agglutinins
• d.Ammonia✓

Ammonia rises rapidly at room temperature as cells continue to metabolize, so the tube is chilled in an ice and water slurry and delivered immediately. Bilirubin is protected from light rather than chilled, and cold agglutinins must be kept at body temperature because cooling causes the antibody to bind red cells. A CBC is transported at room temperature.CLSI GP44

A neonatal bilirubin is collected. How must the specimen be handled during transport?

• a.Frozen immediately at minus 20 degrees Celsius
• b.Left uncovered at room temperature to allow clotting
• c.Kept in an ice slurry for at least 30 minutes
• d.Protected from light, for example with an amber tube or foil wrap✓

Bilirubin is photosensitive and degrades within minutes of light exposure, so an amber microtube or foil wrapping is used. Vitamin B12, folate, carotene and vitamin A require the same protection. Freezing whole blood hemolyzes it, chilling is not the required protection here, and leaving the tube exposed causes falsely low results.CLSI GP44

A cryofibrinogen test is ordered. What handling is required?

• a.Transport on ice
• b.Keep the specimen at 37 degrees Celsius until processed✓
• c.Freeze the whole blood immediately
• d.Refrigerate at 4 degrees Celsius for one hour before centrifuging

Cryofibrinogen, cryoglobulins and cold agglutinins precipitate or bind when cooled, so the specimen is kept warm at body temperature from collection through processing, often using a prewarmed tube and a 37 degree carrier. Icing or refrigerating causes the target protein to drop out of solution and gives falsely low results. Freezing whole blood destroys the cells entirely.CLSI GP44

Within what time should serum or plasma be separated from cells for routine chemistry testing?

• a.Within 8 hours of collection
• b.Within 24 hours if refrigerated
• c.Within 2 hours of collection✓
• d.Only after the specimen has been refrigerated overnight

Serum or plasma should be physically separated from the cells within two hours of collection, because continued cellular metabolism lowers glucose and raises potassium, LDH and phosphorus. Holding the tube for 8 or 24 hours before separation produces clinically misleading results. Refrigerating an unseparated tube actually accelerates potassium leakage from red cells.CLSI GP44

Which collection practice is most likely to hemolyze a specimen?

• a.Forcing blood from a syringe through the needle into an evacuated tube✓
• b.Inverting an EDTA tube gently eight times
• c.Using a 21 gauge needle on a good antecubital vein
• d.Letting the alcohol dry fully before puncture

Pushing blood through a narrow needle under pressure shears red cells and is a classic cause of hemolysis, which is why a transfer device is used instead. Gentle inversion, an appropriately sized needle and fully dried alcohol all reduce hemolysis. Hemolysis falsely raises potassium, LDH, AST and magnesium and often forces a redraw.CLSI GP41

A chemistry specimen arrives visibly hemolyzed. Which result is most likely to be falsely elevated?

• a.Sodium
• b.Potassium✓
• c.Albumin
• d.Chloride

Potassium is far more concentrated inside red cells than in plasma, so cell rupture releases it and drives the measured value up sharply. LDH, AST and magnesium rise for the same reason. Sodium and chloride are higher outside the cells, and albumin is a plasma protein unaffected by red cell lysis.CLSI GP44

A lavender tube submitted for a CBC contains visible small clots. What should happen?

• a.Run the CBC and add a comment about clots
• b.Filter the specimen and then run it
• c.Add extra EDTA and mix again
• d.Reject the specimen and recollect, because clotting invalidates cell counts✓

Clots consume platelets and trap white and red cells, so counts are falsely low and the specimen must be rejected and recollected with prompt, adequate mixing. Commenting on a clotted CBC still reports unreliable numbers. Filtering removes cells that should be counted, and adding anticoagulant after the fact cannot reverse clot formation.CLIA

An unlabeled tube arrives in the laboratory with a completed requisition attached. What is the correct action?

• a.Reject the specimen and request recollection✓
• b.Ask the phlebotomist who drew it to label it now
• c.Process it and hold the result until labeling is confirmed
• d.Label it from the requisition and process it

An unlabeled specimen cannot be positively linked to a patient, so it is rejected and recollected, and the event is documented. Labeling after the fact from a requisition or from memory is exactly how patients receive another patient's results. Only irreplaceable specimens such as cerebrospinal fluid have a special resolution process, and whole blood is not in that category.CLIA

An EDTA specimen is collected for a CBC with a manual differential. What time limit applies to making the blood smear?

• a.Smears must be made after refrigerating the tube overnight
• b.Smears may be made up to 24 hours later at room temperature
• c.Smears should be prepared within about one hour of collection✓
• d.Timing does not matter because EDTA preserves morphology indefinitely

EDTA preserves cells for automated counting for roughly 24 hours, but white cell and platelet morphology begins to distort within a few hours, so smears are made within about one hour. Waiting a day produces artifacts that mimic disease. Refrigeration does not restore morphology, and no anticoagulant preserves cell shape indefinitely.CLSI GP44

A gel serum separator tube has already been centrifuged and the serum is above the gel. A repeat test is requested. What should be done?

• a.Recentrifuge the original tube to obtain more serum
• b.Shake the tube to remix the serum with the cells
• c.Test from the serum already above the gel, or aliquot it into a labeled tube✓
• d.Freeze the whole tube and thaw it before testing

Once the gel barrier has formed, the serum above it is stable and can be tested or aliquotted into a properly labeled tube. Recentrifuging a gel tube can force cellular contents into the serum and falsely raise potassium. Remixing serum with cells or freezing the tube with cells still present destroys specimen integrity.CLSI GP44

Which specimen requirement applies to an erythrocyte sedimentation rate?

• a.It should be tested within about four hours at room temperature✓
• b.It must be protected from light
• c.It must be frozen if not tested within one hour
• d.It requires a serum separator tube

An ESR is performed on a well-mixed EDTA specimen and should be set up within about four hours at room temperature, because red cells lose their normal shape over time and settle differently. Freezing destroys the cells, and light does not affect sedimentation. A serum tube is unusable because the test requires anticoagulated whole blood.CLSI GP44

Unless a test specifies otherwise, at what temperature are routine blood specimens transported?

• a.Frozen at minus 20 degrees Celsius
• b.Refrigerated at 2 to 8 degrees Celsius
• c.Warmed to 37 degrees Celsius
• d.At ambient room temperature, roughly 15 to 30 degrees Celsius✓

Most routine specimens travel at ambient room temperature unless the test specifically calls for chilling, freezing or warming. Routine refrigeration of unseparated blood raises potassium as it leaks from red cells. Freezing whole blood causes hemolysis, and warming is reserved for cold-sensitive analytes such as cryoglobulins.CLSI GP44

A tube is submitted with far less blood than the test requires. How is this documented as a rejection reason?

• a.Chain of custody break
• b.Quantity not sufficient✓
• c.Improper additive
• d.Delayed transport

An underfilled specimen that cannot support the ordered testing is reported as quantity not sufficient, and the laboratory requests recollection. A chain of custody break involves lost documentation of handling, an improper additive means the wrong tube was used, and delayed transport refers to exceeding time limits. Each of these is a distinct rejection category with a different corrective action.CLIA

A routine urinalysis cannot be tested for 90 minutes. What is the correct interim handling?

• a.Refrigerate the specimen or use a chemical preservative tube✓
• b.Leave it at room temperature and test when convenient
• c.Freeze the specimen
• d.Add a small amount of bleach to prevent bacterial growth

Urine should be tested within about two hours or refrigerated, because bacteria multiply and cells and casts break down at room temperature. A preservative transport tube is an accepted alternative. Freezing destroys formed elements, and adding a disinfectant contaminates the specimen and invalidates chemical testing.CLSI GP44

Serum is transferred into a secondary aliquot tube for send-out testing. What must be done?

• a.Leave it unlabeled because the parent tube is labeled
• b.Write only the accession number on the cap
• c.Label the aliquot with the same patient identifiers as the original tube✓
• d.Combine aliquots from the same patient collected on different days

Every aliquot is an independent specimen and must carry the same patient identifiers as the parent tube so identity is never lost. Relying on the parent tube or writing an identifier only on a removable cap breaks the chain of identification. Pooling specimens collected at different times mixes results from different clinical moments and is never acceptable.CLIA

A phlebotomist notices the expiration date on a box of lavender tubes passed last month. What is the concern?

• a.The tube color will fade and cause misidentification
• b.Vacuum and additive reactivity decline, so fill volume and results become unreliable✓
• c.Nothing, since expiration applies only to reagents
• d.The stopper will not fit the holder correctly

Evacuated tubes lose vacuum and additive effectiveness over time, so an expired tube may underfill or fail to anticoagulate properly, producing unreliable results. Expired tubes are removed from stock and not used. Color coding and stopper fit are not the reason for the date, and expiration dating applies to collection devices as well as reagents.CLIA

Why must additive tubes be mixed by gentle inversion rather than shaking?

• a.Shaking increases the vacuum inside the tube
• b.Shaking dissolves the stopper lubricant into the specimen
• c.Gentle inversion is required only for serum tubes
• d.Shaking causes mechanical hemolysis and foaming that invalidate many tests✓

Vigorous shaking shears red cells and creates foam, producing hemolysis that falsely raises potassium, LDH and AST and can prevent testing altogether. Gentle inversion distributes the additive without damaging cells and is required for every additive tube, not just serum tubes. Shaking has no effect on stopper lubricant or on the residual vacuum.CLSI GP41

A serum tube is centrifuged five minutes after collection and fibrin strands appear in the serum. What went wrong?

• a.The tube was centrifuged at too low a speed
• b.The serum was exposed to light
• c.The tube contained too much clot activator
• d.The specimen was spun before the clot had fully formed✓

A plain or gel serum tube needs roughly 30 minutes at room temperature to clot completely before centrifugation, and spinning early leaves fibrin that clogs analyzers and skews results. Speed affects separation quality but does not create fibrin. Clot activator quantity is fixed by the manufacturer, and light exposure affects photosensitive analytes rather than clot formation.CLSI GP44

How should an outpatient be identified before venipuncture?

• a.Ask, Are you Mr. Johnson, and proceed if the patient says yes
• b.Ask the patient to state full name and date of birth, then match both to the requisition✓
• c.Confirm the name on the sign-in sheet
• d.Match the room number and the last four digits of the record number

Two independent identifiers must be actively stated by the patient and matched against the requisition, most commonly full name and date of birth. Asking a yes-or-no question invites a confused or hard-of-hearing patient to agree incorrectly. A sign-in sheet is not a verified identifier and outpatients have no room number, which is never an acceptable identifier in any setting.CLIA

An inpatient scheduled for a type and screen has no identification wristband. What should the phlebotomist do?

• a.Draw the specimen and note the missing band on the label
• b.Ask the roommate to confirm the patient's identity
• c.Ask the nurse to verify identity and apply a new wristband before collecting✓
• d.Use the name on the door and the chart at the bedside

An inpatient must wear an attached identification band, and blood bank specimens have the strictest identification requirements because a mismatch can cause a fatal transfusion reaction. The nurse verifies identity and applies a new band before collection proceeds. Roommates, door signs and bedside charts are not verified patient identifiers and can be wrong after a room change.CLIA

A patient scheduled for a fasting lipid panel reports drinking black coffee two hours ago. What should the phlebotomist do?

• a.Notify the laboratory or provider and document the non-fasting status before collecting or rescheduling✓
• b.Draw the specimen and say nothing since coffee has no calories
• c.Send the patient home for a full 24 hour fast
• d.Collect the specimen and label it as fasting anyway

A fasting specimen typically requires 9 to 12 hours with only water, and coffee stimulates metabolism and can alter results, so the deviation must be reported and documented. Recording a non-fasting sample as fasting falsifies the record and misleads interpretation. Fasting longer than about 12 hours can itself distort results, so a 24 hour fast is not appropriate.

During a 3-hour glucose tolerance test the patient vomits 20 minutes after drinking the glucose solution. What is the correct action?

• a.Give a second glucose drink and restart the timing
• b.Notify the provider or laboratory immediately, since the test usually must be discontinued and rescheduled✓
• c.Continue the collections and note the vomiting on the last tube
• d.Shorten the test to one hour

Vomiting means the glucose load was not absorbed, so the remaining timed results are meaningless and the provider or laboratory decides whether to stop and reschedule. Repeating the drink is not the phlebotomist's decision and doubles the dose risk. Continuing the draws or arbitrarily shortening the protocol produces uninterpretable data.

A 9-year-old is brought for a blood draw by an adult neighbor with no documented authorization. What should the phlebotomist do?

• a.Proceed because the child agrees to the draw
• b.Proceed because any adult present may consent
• c.Ask the child to sign the consent form
• d.Verify legal authorization from a parent or guardian before collecting✓

A minor cannot give legal consent for a procedure, so authorization must come from a parent, legal guardian or a documented designee. A neighbor without documented authority cannot supply it, and a child's agreement is assent rather than consent. Having the child sign a form creates a record with no legal standing.

A competent adult inpatient refuses the ordered blood draw. What is the correct response?

• a.Respect the refusal, notify the nurse or provider, and document it✓
• b.Tell the patient that refusing will delay discharge
• c.Have a family member hold the arm still
• d.Draw anyway because a provider ordered it

A competent adult has the right to refuse any procedure, and proceeding without consent may constitute battery. The correct steps are to stop, explain the purpose of the test respectfully, notify the nurse or ordering provider and document the refusal. Coercing the patient or restraining an arm is never acceptable regardless of the order.

Midway through a draw an outpatient becomes pale, sweaty and says the room is spinning. What is the first action?

• a.Hold an ammonia inhalant under the patient's nose
• b.Continue the draw quickly before the patient faints
• c.Release the tourniquet, remove the needle, and lower the patient's head while keeping the patient seated or supine✓
• d.Leave the patient to get help from the front desk

Presyncope is managed by immediately stopping the draw and removing the needle so an unconscious patient is not injured, then lowering the head or laying the patient flat to restore cerebral perfusion. Continuing the collection risks a fall with the needle in place. Ammonia inhalants are discouraged because they can trigger bronchospasm, and the patient must never be left alone.

A swelling appears rapidly at the site while the tube is filling. What should the phlebotomist do?

• a.Tighten the tourniquet to slow the swelling
• b.Continue until the tube is full, then apply a bandage
• c.Release the tourniquet, remove the needle, and apply firm direct pressure for several minutes✓
• d.Massage the area to disperse the blood

Rapid swelling indicates a hematoma from blood leaking into tissue, so the draw is stopped and firm direct pressure is applied for several minutes, longer if the patient takes anticoagulants. Tightening the tourniquet increases venous pressure and worsens the leak. Continuing the draw enlarges the hematoma, and massaging spreads blood through the tissue and increases bruising.

On needle insertion the patient reports sudden shooting, electric pain radiating to the hand. What should be done?

• a.Discontinue immediately, remove the needle, and report the event✓
• b.Redirect the needle deeper to find the vein
• c.Reassure the patient and finish the draw quickly
• d.Loosen the tourniquet and continue

Shooting, electric or radiating pain and tingling suggest nerve involvement, and the needle must be removed at once to prevent lasting injury, with the event reported and documented. Continuing or redirecting the needle deepens the contact and increases the risk of permanent damage. Loosening the tourniquet does nothing about the nerve contact itself.

Small red pinpoint spots appear on the arm under the tourniquet. What do they indicate?

• a.An allergic reaction to the tourniquet latex
• b.The beginning of a hematoma
• c.Contamination of the site
• d.Petechiae, suggesting capillary fragility or a platelet problem, and a tendency to bleed at the site✓

Petechiae are tiny non-raised red spots from capillary leakage and often warn that the patient may bleed longer after the draw. They are not an allergic reaction, which appears as raised itchy welts, and not a hematoma, which is a diffuse swelling and bruise. They do not indicate contamination, but they do mean pressure should be held longer after needle removal.

During a draw the blood is bright red and pulses into the tube, filling it very quickly. What should the phlebotomist do?

• a.Continue since fast filling means a good draw
• b.Suspect arterial puncture, remove the needle at once, and apply firm pressure for at least five minutes✓
• c.Apply a bandage without pressure and send the patient on
• d.Reposition the needle and collect the remaining tubes

Bright red blood that pulsates and fills rapidly suggests an artery was entered, so the needle is withdrawn immediately and firm pressure is held at least five minutes, with the patient observed and the event reported and noted for the laboratory. Continuing or repositioning risks significant bleeding. A bandage without sustained pressure will not control arterial bleeding.

A frightened 6-year-old is scheduled for a venipuncture. Which approach is most appropriate?

• a.Explain the steps in simple honest words, offer a comfort position with the caregiver, and work efficiently✓
• b.Promise the child that it will not hurt at all
• c.Tell the child that the draw will be canceled if the crying continues
• d.Show the child the needle in detail so there are no surprises

Honest, simple explanations paired with a caregiver comfort hold reduce anxiety and improve first-attempt success, and working efficiently shortens the stressful period. Promising no pain destroys trust as soon as the needle enters. Threats increase distress, and displaying the needle usually escalates fear rather than reducing it.

Before beginning a draw, what should the phlebotomist explain to the patient?

• a.The likely diagnosis based on the tests ordered
• b.The cost of each test and the insurance coverage
• c.Who the phlebotomist is, that blood will be collected, and roughly what will happen✓
• d.The reference ranges the results will be compared against

Introducing oneself, stating that a blood specimen will be collected and briefly describing the procedure supports implied consent and reduces anxiety. Interpreting test results or offering a diagnosis is outside the phlebotomist's scope of practice. Billing questions belong to the business office, and reference ranges are part of the physician's interpretation.HIPAA

Which description of antecubital vein anatomy is correct?

• a.The basilic vein lies on the lateral or thumb side of the arm
• b.The cephalic vein lies laterally and the basilic vein medially, with the median cubital between them✓
• c.The median cubital vein lies deep to the brachial artery
• d.The cephalic vein lies on the medial or little finger side

In the antecubital fossa the cephalic vein runs along the lateral thumb side, the basilic vein along the medial little finger side, and the median cubital connects them across the middle. The median cubital is superficial and lies above, not beneath, the brachial artery. Reversing the cephalic and basilic positions would put the phlebotomist next to the artery and nerve without realizing it.

Which statement about arterial, venous and capillary blood is correct?

• a.Arterial blood is collected routinely for a CBC
• b.Venous blood is bright red because it carries nutrients
• c.Capillary blood is identical in composition to venous blood
• d.Arterial blood is bright red and oxygen rich, venous blood is darker, and capillary blood is a mixture of both plus interstitial fluid✓

Oxygenated arterial blood appears bright red, deoxygenated venous blood appears darker, and capillary blood collected by dermal puncture mixes arterial and venous blood with interstitial and intracellular fluid. Because of that mixture, capillary glucose tends to run higher and capillary potassium and total protein lower than venous values. Routine hematology and chemistry use venous blood; arterial puncture is reserved for blood gases and is outside the entry-level phlebotomy scope.

What distinguishes plasma from serum?

• a.Serum contains fibrinogen and plasma does not
• b.Plasma is obtained only from a serum separator tube
• c.Serum contains red cells and plasma does not
• d.Plasma contains fibrinogen and clotting factors, while serum is the fluid left after clotting✓

Plasma comes from an anticoagulated tube and still contains fibrinogen and the clotting factors, while serum is what remains after the blood has clotted and consumed fibrinogen. Neither fraction contains red cells once the specimen is centrifuged. Plasma requires an anticoagulant tube such as heparin or EDTA, not a serum separator tube.

After an EDTA tube is centrifuged, what is the thin layer between the plasma and the packed red cells?

• a.Fibrin clot
• b.Buffy coat, containing white blood cells and platelets✓
• c.Separator gel
• d.Hemolyzed plasma

The buffy coat is the pale layer of leukocytes and platelets that settles between the denser red cells and the lighter plasma. A fibrin clot forms only in a tube without anticoagulant, and separator gel exists only in gel tubes, not in a standard lavender tube. Hemolyzed plasma appears as pink or red discoloration throughout the plasma rather than as a discrete layer.

Which structural feature of veins is most relevant to venipuncture technique?

• a.Veins have thicker muscular walls than arteries
• b.Veins carry blood away from the heart
• c.Veins have one-way valves and thinner walls, so they collapse easily under strong vacuum✓
• d.Veins pulsate under the fingertip

Veins have thin walls and one-way valves that keep blood moving toward the heart, which is why a large vacuum tube or aggressive suction can collapse them and why needles are inserted pointing toward the heart away from valves. Arteries, not veins, have thick muscular walls and a palpable pulse. Arteries carry blood away from the heart while veins return it.

Which blood component makes up roughly 55 percent of whole blood volume?

• a.Plasma✓
• b.Erythrocytes
• c.Leukocytes
• d.Platelets

Plasma accounts for approximately 55 percent of whole blood and is about 90 percent water carrying proteins, electrolytes and waste products. Red cells make up most of the remaining 45 percent, which corresponds to the hematocrit. White cells and platelets together form only a small fraction, visible as the thin buffy coat after centrifugation.

A requisition is marked NPO. What does this abbreviation mean?

• a.The specimen is needed post-operatively
• b.Nothing by mouth✓
• c.No preservative ordered
• d.Notify provider only

NPO comes from the Latin nil per os and means the patient is to take nothing by mouth, a status the phlebotomist must respect by not offering food or fluids. It is distinct from a fasting order, though the two often overlap. Postoperative status, preservative choice and notification instructions are all conveyed by different notations.

In medical terminology, what does the suffix -emia indicate?

• a.Inflammation of a structure
• b.Surgical removal
• c.Excessive discharge or flow
• d.A condition of the blood✓

The suffix -emia refers to a blood condition, as in anemia, bacteremia and hyperkalemia. Inflammation is indicated by -itis, surgical removal by -ectomy, and excessive flow by -rrhea or -rrhage. Recognizing these roots helps a phlebotomist interpret test names and requisitions accurately.

A specimen is marked STAT. What does this require of the phlebotomist?

• a.Collect and deliver it immediately, ahead of routine work✓
• b.Collect it only after all fasting patients are done
• c.Collect it at the end of the shift and label the time
• d.Collect it with the next scheduled sweep

STAT means immediately, and these draws take priority over routine and timed collections so critical results reach the provider quickly. Deferring a STAT to a scheduled sweep or to the end of a shift defeats the purpose and can delay urgent treatment. Fasting patients are a scheduling convenience, not a higher priority than a STAT order.

Which tube and test pairing is correct?

• a.Lavender tube for a prothrombin time
• b.Light blue tube for a complete blood count
• c.Royal blue tube for trace element studies such as lead and zinc✓
• d.Gray tube for a type and crossmatch

Royal blue tubes are manufactured with low background metal contamination for trace element and toxicology testing. A CBC requires the lavender EDTA tube and a prothrombin time requires the light blue citrate tube, so those two pairings are reversed. Type and crossmatch is performed on a pink or red blood bank tube, never on a gray fluoride tube.