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NCCT Phlebotomy Certification Examination Review

Case (5)
Here is a partial list of equipment on your drawing tray:
21 gauge needles (for syringes and multisample adapters)
23 gauge needles (for syringes and multisample adapters)
Microsampling lancets
Adult size red and speckled tops, lavender top, light blue top, and green top tubes
Pedi-red and Pedi-lavender top tubes
Assorted Microtainer tubes
What woud you consider using to draw a CBC order on a 5-year old?
23 gauge needle and the pedi-lavender top tube; maybe the syringe if needed (** the higher the gauge number, the smaller the needle bore)
What would you consider using to draw a Creatinine on a 45-year old male with huge veins?
21 gauge needle and an adult speckled top tube
What would you consider using to draw blood from an infant heel?
Lancet, less than 2.0 mm tip and microtainers
What are the medical terms for the smallest veins and arteries?
Venules and Arterioles
What happens if you use a drawing device with excessive vacuum on a pt with a very thin and fragile vein?
The vessel may collapse under the pressure; might consider a syringe draw to control the amount of vacuum exerted
If you had to draw both the red and lavender tops on a single pt, which do you draw first? What is the order for all tube top colors?
Draw red first, then lavender (since it has an additive). The tube order recommended by CLSI* is blood culture tubes/bottles; coagulation tube (light blue); serum tube with or without clot activator (red, gold, or red/black); herapin with or without gel plasma separator (green); EDTA (lavender or pink); and glycolytic inhibitor (gray); yellow top (A or B) ACD tubes; all others.
*Clinical and Laboratory Standards Institute
What additives are in which tubes?
Red top=nothing; speckled (gray and red) polymer barrier
Lavender top=EDTA
Light Blue top=Sodium Citrate
Gray=Potassium Oxalate +/or Sodium Fluoride
Case (6)
After drawing a blood sample on Mrs. Baxter in the hospital, you discard your needle in an approved sharp's container on your tray and finish up your paperwork. As you are about to leave the room, you notice a capped needle on the floor next to Mrs. Baxter's bed, some obviously "used" gloves (turned inside out) close by, and some liquid spilled on the floor. It looks like water but you aren't sure.
What might be your course of action?
Depending upon the location of the items on the floor to your own location, you would address the needs that should be addressed first. If the needle is close, you might very carefully pick it up and dispose of it in your own sharps container.
Next, you would assess the spill danger. You would want to make sure that no one would slip on the spilled liquid, including yourself; the pt, and any visitors-while awaiting cleanup. You must assume the liquid is hazardous since you do not know its origin, and whoever cleans the spill must use universal precausions.
Finally, with gloved hands, you could pick up the used gloves and dispose of them as you would your own.
Conatiners that are used to dispose of sharps should have what characteristics?
The must be spill-proof, tamper proof , and puncture resistant.
If you accidentially stick yourself with the needle as you pick it up, how would you clean your wound?
You could bleed the wound slightly and then clean it with soap and water or an alcohol swab.
Can you name at least three laws or regulations that govern safe practices for phlebotomy? What do they address?
OSHA (universal precautions, etc); Right to Know Law (MSDS sheets); JCAHO regulations for patient and employee safety.
As you leave, you notice that your tube adapter has been visibly contaminated with pt's blood. Where should you dispose of it?
Try the nearest biohazard waste container
Case (7)
You are asked to speak to a class of biology students about your career in phlebotomy. The teacher wants you to address the following key points in your presentation: Your risk of catching diseases from your pts Your risk of spreading diseases from pt to pt *Your pt's risk of catching diease from you
How do you address the key points?
Key points
*Some risk, but kept low because of the use of universal precautions and isolation procedures as needed. One of the greatest risks for laboratory workers is hepatitis B, although people hear more in the news about the risk of AIDS.
*The spread of disease from pt to pt is very possible unless universal precautions are used. The single most important thing that will work to prevent such transfer is handwashing between wach pt, followed by the use of gloves.
*Working while fighting an illness (any communicable disease or illness) is never advised for any health care worker. Respiratory or skin diseases would be among the most easily spread. Because of that, there is very little risk of the pt catching anything from the phlebotomist who responsibly stays home while ill.
If a pt acquires an infection while hospitalized that s/he did not have prior to hospital admision, what do you call it?
Nosocomial infection
What preventative measure can decrease the chance of acquiring Hepatitis B from contaminated serum or blood products?
Hepatitis B Vaccination
Case (8)
Mrs. Bledsoe enters the hospital with orders for Prothrombin Time and Partial Thromboplastin Time tests. As the blue top tube is filling with blood, the physician enters the room and asks also that you draw a CBC, DIFF, and Type and Crossmatch.
What tube or tubes were you originally drawing for the PT and PTT?
Blue top(s)
What tubes would be needed for the new requests?
Lavender top for the CBC; an additional red for the Crossmatch (and some people might want another lavender for typing); several glass slides for the DIFF.
Can they be added to the end of the first draw without hurting results?
Obviously, it would have been better to have drawn any tube without an addititive first, to avoid cross contamination. The phlebotomist could draw a very small amount of blood into a discard tube in between the first and second tubes to decrease the risk of contamination from the sodium citrate in the blue top tube.
How is DIFF prepared?
Using two glass slides, one at a 30-degree angle to the other, spread a drop of the pt's unclotted blood along one slide until a film approximately 1 cell in thickness is produced. A nice feathered edge is helpful, and a smear that covers about 2/3 of the slide surface makes it easier for the cells to be counted under the microscope.
Why would a Type and Crossmatch be ordered?
The pt may need surgery or may require a blood transfusion.
Can you explain why a pt's blood does not normally clot as it is flowing through the pt's bloodstream?
Blood flows freely in the bloodstream unless the coagulation mechanism is activated for some reason.
Can you explain how a "cut" heals itself?
When skin is "cut", "tissue factors" activate the extrinsic clotting system that is measurd by the Prothrombin Time (Pro Time) test. The coagulation factors interact in a sequence that is known and predictable. At the same time, platelets form a plug to shore up the vessel break until the body can do more permanent repairs. This also activates the "intrinsic" coagulation pathway, and sets yet another series of coagulation factors to work activating one another in sequence that can be tested by an APTT. Together, the intrinsic and extrinsic pathways of coagulation combine to activate a common pathway, which eventually leads to the coversion of Prothrombin to Thrombin. Thrombin then activates Fibrinogen to form Fibrin-which is the framework for the formation of a permanent plug-which remains until tissue repair is complete. Calcium is needed for this to occur, which is why blood does not clot in the presence of EDTA, as it binds up all the calcium.
There is also a natural body system for getting rid of products of clotting or coagulation. This is called the fibrin-lysis of fibrinolytic system.
Case (9)
You find some urine and blood samples that have obviously gone unnoticed for quite a long while. A check of the sample collection time shows:
A routine urinalysis sample that is 2 days old
A blood sample with orders for Infectious Mono testing that is 8 hours old
A blood sample with orders for a CBC that has been sitting for about 3 weeks.
What should be your next step?
You can call the laboratory Clinical Laboratory Scientists or Medical Technologists for advice, or look in a service directory, to determine specimen collection requirements for the three tests ordered. They may perform the Mono test, but ask for recollection for the others. Make sure the draw time is easily noted in any case.
A test is only as good as the sample upon which it is performed. If the sample is too old, it won't give the same results as a fresh one and the pt might get the wrong treatment or diagnosis.
Does anyone need to track the cause? Why?
YES. This is just good Quality practice. Controlling the quality of each step in the collection and performance of laboratory tests is crucial. Obviously, this process has a flaw-these samples were somehow overlooked for days or weeks. The process must be fixed so that it won't happen again. We wouldn't investigate to place blame, but to make the process work better.
Case (10)
For each of these pts, explain anything "different' you would want to consider before drawing a blood sample.
What special consideration do you think about when drawing blood from a pt who--
--had a right side mastectomy yesterday?
Not drawing from the right side.
--with a brand new hematoma (courtesy of your draw)?
Applying steady pressure on the hematoma until it is no longer swelling, and then using the other arm
--is an outpatient without an identification bracelet?
What other numeric identifier you will get to insure you have the right pt, with no attention to all names (first, middle, last, and initials) as well; birthdate and Social Security Numbers would help.
--has an IV in her left hand?
Not drawing anywhere above the IV in her left arm
--needs a fingerstick and whose hands are freezing cold?
Using a pre-warming technique
--weighs 432 pounds?
Asking the pt where people have had the most success if no vein can be palpated, or considering a finger stick if no veins are palpable.
--is 5 years of age and is supposed to have Dilantin levels drawn?
Asking the nurse when the pt last had Dilantin, and use soothing and reassuring styles of communication to lessen the child's fear and to insure that s/he will cooperate as much as possible. You will also note bed rail postitions and put them back.
--needs a Lipid Profile drawn?
Has he been fasting 8-12 hours?
--refuses to let you touch her?
Nothing. You can try to talk her into it, but she ultimately has the right to refuse tretment.
--has no good arm/hand veins, but one in the left ankle?
Check with the doctor to see that he is not a heart pt, for whom leg draws are not usually advised. They are also not advised in pts with diabetes or coagulation disorders. Always seek physician approval beforehand.
Case (11)
Mr. Simpson is a 45-year-old male pt weighing 200 pounds who has come to the Outpatient Drawing Station for blood work. As you bring him back to have a blood sample drawn, he tells you that he "never really minds having blood drawn", but that sometimes he tends to "faint" afterward. He really doesn't look like the type to faint.
How would you react to the news?
Take it seriously. It doesn't matter whether you believe he will faint. The safest thing to do is place him in a reclining position for the draw.
Suppose you ignored the warning, left him in a chair for venipuncture, and then Mr. Simpson faints anyway. What do you do now?
Protect the pt from harm. Try to keep him from falling and injuring himself further. Make sure to remove the tourniquet and needle as safely as possible. Help to move him into a position to get blood circulating to his head as quickly as possible. A cold compress will help. Get medical assistance as needed.
Suppose he suddenly develops clammy skin, very shallow breathing, and a very rapid pulse. What might concern you?
Those are some of the symptoms of shock. You would seek medical help as quickly as possible.
Case (12)
You have test orders for blood work on a pt who is coming in later that afternoon. She will need about eight tubes of blood drawn. You decide to pre-label the tubes to save time. You put her name, the date of collection, and your initials on all the tubes and line them up in a test tube rack to be ready to go.
Is pre-labeling tubes considered good practice?
Are these tubes labeleld correctly?
No; they also need a numeric identifier (#) and the time of collection as well.
Why is pre-labeling NOT a good idea?
What if the pt doesn't show up? What if they are accidentally picked up and used on another pt? What if you go home and someone else draws the blood? If no one used them, you's waste them or have to try to remove the old labels.
Who is legally responsible for labeling the pt sample correctly?
The phlebotomist who draws the sample, and whose initials are on the paperwork.
Why is it crucial to have the right pt with the right orders with the right labels for the right tests?
The pt's diagnosis and/or treatment may depend upon it.