Safety and Compliance
26%of exam
OSHA BloodbornePPE and SharpsInfection ControlHIPAA PrivacyQuality Assurance
Patient Preparation
20%of exam
Patient IDAntecubital AnatomySite SelectionFasting RulesEquipment Setup
Routine Blood Collections
28%of exam
Special Collections
12%of exam
Blood CulturesGTT and BACDrug MonitoringNeonatal HeelstickTemperature Tests
Processing
14%of exam
Labeling RulesCentrifugationSpecimen StabilityTransport ConditionsRejection Criteria
Quick Facts
- Exam
- NHA CPT
- Credential
- Phlebotomy Technician
- Items
- 120 (100 scored)
- Time
- 2 hours
- Pass
- 390 scaled (200-500)
- Fee
- $125
- Validity
- 2 yr, 10 CE
- Delivery
- PSI or online proctor
PPE Donning
Gown, Mask, Eyes, Gloves on last
Gown firstMask nextEyes thirdGloves cover cuffs
OSHA Bloodborne Rules
- Standard
- 29 CFR 1910.1030
- HBV vaccine
- Offer within 10 days
- Needlestick first
- Wash soap, water
- Sharps container
- Rigid, puncture-resistant, red
- Exposure plan
- Report then evaluate
- OPIM
- Body fluids, not saliva
Domain Weights
Routine 28, Safety 26, Prep 20, Process 14, Special 12
Routine: 28%Safety: 26%Prep: 20%Process: 14%Special: 12%
PPE and Infection Control
- Don order
- Gown, mask, eyes, gloves
- Doff order
- Reverse of donning
- Glove change
- Every patient, when soiled
- Hand hygiene
- Most effective measure
- Standard precautions
- All patients infectious
- Airborne
- N95, negative pressure
- Blood spill
- Absorb, 1:10 bleach
Compliance and Privacy
- PHI
- Identifier plus health data
- Minimum necessary
- Need-to-know only
- Breach
- Unencrypted wrong recipient
- CLIA agency
- CMS regulates testing
- SDS required
- Every hazardous chemical
- Incident report
- Prompt, non-punitive
Vein Choice
Median first, Cephalic next, Basilic last
Median: anchoredCephalic: lateralBasilic: risky
Antecubital Veins
- Median cubital
- First choice, anchored
- Cephalic
- Lateral, thumb side
- Basilic
- Medial, last choice
- H-pattern
- Median connects both
- Basilic risk
- Near nerve, artery
- Insertion angle
- 15-30 degrees, bevel up
Site Selection Rules
- Mastectomy side
- Avoid, lymphedema risk
- IV arm
- Use opposite arm
- Same arm IV
- Below site, pause 2 min
- Hematoma
- Avoid, contaminated sample
- AV fistula
- Never draw from
- Scarred site
- Avoid, hard access
Order of Draw
Cultures, Light blue, Red, Green, Lavender, Gray
Culture: sterileLight blue: citrateRed: serumGreen: heparinLavender: EDTAGray: glucose
EDTA Heparin Citrate
EDTA
- Chelates calcium
- CBC hematology
- Lavender top
Heparin/Citrate
- Heparin: STAT chem
- Citrate: coagulation
- 9:1 fill
Match additive to test
Which Tube
- CBC or ESR→Lavender(EDTA)
- PT / INR / aPTT→Light blue(Citrate)
- STAT chemistry→Light green(PST heparin)
- Serum chemistry→Gold SST(Clot + gel)
- Glucose / lactate→Gray(Fluoride)
- Blood culture→SPS bottles(Drawn first)
- Crossmatch→Pink EDTA(Blood bank)
Order of Draw
- 1 Blood culture
- Sterile, firstSPS
- 2 Light blue
- Sodium citrate
- 3 Red / SST
- Serum, clot activator
- 4 Green
- Heparin tube
- 5 Lavender
- EDTA tube
- 6 Gray
- Glycolytic inhibitor
- Source
- CLSI GP41 sequence
Syncope vs Seizure
Syncope
- Faints, pale
- Lower head
- Quick recovery
Seizure
- Convulsions
- Protect from injury
- Do not restrain
Faint vs convulse
If Complication
- Shooting forearm pain→Remove needle(Nerve)
- Pale, diaphoretic→Lower head(Syncope)
- Swelling forms→Release, pressure(Hematoma)
- Short draw coagulation→Recollect(Bad ratio)
- Two failed sticks→Call assistance
- Visible hemolysis→Recollect(Falsely high K)
Tube Additive and Use
- Light blue
- 3.2% citrate, coagulation
- Red plain
- No additive, serum
- Gold SST
- Clot activator + gel
- Green
- Heparin, STAT chemistry
- Light green PST
- Lithium heparin + gel
- Lavender
- EDTA, CBC and ESR
- Gray
- Fluoride/oxalate, glucose
- Citrate ratio
- 9:1 blood-to-additive
Hematoma vs Hemoconc.
Hematoma
- Blood leaks tissue
- Swelling, bruise
- Vessel injury
Hemoconcentration
- Plasma shifts out
- Long tourniquet
- Falsely elevated
Leak vs concentrate
Tube Inversions
- Red plain
- 0 inversions
- SST gel
- 5 inversions
- Light blue
- 3-4 inversions
- Green heparin
- 8-10 inversions
- Lavender EDTA
- 8-10 inversions
- Gray
- 8-10 inversions
- Mix method
- Gentle, never shake
Venous vs Capillary
Venous
- Order: blue first
- Larger volume
- Standard values
Capillary
- EDTA first
- Wipe first drop
- Higher glucose
Reversed fill order
Tourniquet Rules
- Max time
- 1 minute
- Placement
- 3-4 inches above
- Too long
- Hemoconcentration, petechiae
- Pressure check
- Pulse stays palpable
- Affected analytes
- Protein, calcium, potassium
- Reapply
- Only if needed
Complications and Response
- Shooting pain
- Remove needle now
- Syncope
- Lower head, raise legs
- Hematoma
- Release, apply pressure
- Hemolysis
- Recollect, no shaking
- Post-draw pressure
- 1-2 min, longer anticoagulated
- Failed sticks
- Two attempts, get help
Capillary Puncture
- Adult site
- Lateral middle or ring
- First drop
- Wipe away
- Neonatal site
- Medial/lateral plantar heel
- Heel danger
- Avoid calcaneus bone
- Capillary fill
- EDTA before serum
- Child over 1
- Finger stick allowed
Which Antiseptic
- Routine venipuncture→70% alcohol
- Blood culture→Chlorhexidine(30 sec contact)
- Blood alcohol level→Benzalkonium(Alcohol-free)
- Legal BAC alternate→Povidone-iodine(No alcohol)
- Re-palpate after prep→Re-cleanse site
Antiseptic By Test
- Routine draw
- 70% isopropyl alcohol
- Blood culture
- Chlorhexidine gluconate
- Blood alcohol
- Non-alcohol, benzalkonium
- BAC alternate
- Povidone-iodine, alcohol-free
- Technique
- Concentric circles outward
- Dry time
- Air dry fully
Special Collections Timing
- Culture fill (set)
- Aerobic before anaerobic
- GTT first
- Fasting baseline draw
- Peak drug
- 1-2 hr post-dose
- Trough drug
- Before next dose
- Blood smear
- Within 1 hour EDTA
- Donor needle
- 16-18 gauge, CPDA-1
Temperature and Light
- Cold agglutinin
- Keep at 37 C
- Cryoglobulin
- 37 C until separated
- Lactic acid
- Transport on ice
- Bilirubin
- Protect from light
- Light list
- B12, folate, porphyrins
- Newborn screen
- Fill circle one side
Serum vs Plasma
Serum
- No anticoagulant
- Clotted first
- Red or SST
Plasma
- Anticoagulated
- Has fibrinogen
- Green or lavender
Clotted vs anticoagulated
Processing and Centrifuge
- Clot time
- 30-60 min serum
- Centrifuge balance
- Equal weight, opposite
- SST result
- Gel between serum, cells
- aPTT window
- Within 4 hours
- Delayed factors
- Separate, freeze -20 C
- Aliquot volume
- Test plus dead volume
Hemolysis vs Lipemia
Hemolysis
- Red cells rupture
- High potassium
- Rough handling
Lipemia
- Milky lipids
- Non-fasting
- Turbid serum
Burst cells vs fat
Specimen Rejection
- Unlabeled
- Most common rejection
- Name only
- Missing second identifier
- Clotted CBC
- Absolute rejection, recollect
- Hemolyzed
- Falsely high potassium
- QNS
- Quantity not sufficient
- Label timing
- Bedside, before leaving
Common Traps
EDTA vs coagulation
EDTA is CBC ≠ Citrate is PT/INR
Gauge vs bore
Smaller number ≠ Larger bore
Culture antiseptic
Alcohol routine ≠ Chlorhexidine cultures
BAC antiseptic
Never alcohol prep ≠ Use benzalkonium
Capillary order
Venous: blue first ≠ Capillary: EDTA first
Tourniquet limit
One minute max ≠ Longer concentrates
Last Minute
- 1.Top weights: Routine 28, Safety 26
- 2.Order: blue, red, green, lavender, gray
- 3.Light blue = citrate, 9:1 fill
- 4.Lavender = EDTA = CBC
- 5.EDTA inverts 8-10 times, never shake
- 6.Median cubital = first vein choice
- 7.Tourniquet = 1 minute max
- 8.Blood culture = chlorhexidine, not alcohol
- 9.BAC = non-alcohol antiseptic only
- 10.Capillary fill = EDTA before serum
- 11.Unlabeled = top rejection cause
- 12.Hemolysis = falsely high potassium
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