Patient Assessment & Documentation Flashcards
7 cards from real MLS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Documentation flashcards as text
A patient refuses to provide a blood specimen. What is the FIRST action the MLS should take?
Answer: Document the refusal and notify the nursing staff or ordering provider
Competent adult patients have the right to refuse procedures; the refusal must be documented and the clinical team notified so patient care decisions can be made.
Which element on a laboratory requisition form is MOST critical for routing a specimen to the correct testing department?
Answer: Test(s) ordered and specimen type
The test ordered and specimen type determine which department receives and processes the specimen, making them the most operationally critical elements.
An elderly patient is confused and unable to state their name. What is the BEST approach to verify identity?
Answer: Check the wristband and cross-reference with the medical record using two identifiers
For confused or non-verbal patients, the wristband cross-referenced against the medical record provides the required two-identifier verification.
A laboratory receives a blood culture specimen drawn from a peripheral IV catheter rather than a fresh venipuncture. The best course of action is to:
Answer: Reject the specimen and request a recollection via venipuncture
Blood cultures drawn through IV catheters have significantly higher contamination rates and should be rejected in favor of a fresh venipuncture.
Which of the following best describes the purpose of an ABN (Advance Beneficiary Notice) in laboratory documentation?
Answer: It notifies Medicare patients that a test may not be covered and they may be billed
An ABN informs Medicare beneficiaries that a specific test may not be covered and that they will be personally responsible for the cost if Medicare denies the claim.
When assessing a patient's arm prior to venipuncture, the MLS notices edema in the antecubital area. What is the primary concern?
Answer: Edema fluid dilutes the blood sample, potentially causing falsely low results
Edematous tissue contains excess interstitial fluid that can dilute the blood specimen, leading to falsely decreased analyte concentrations.
A specimen is received with no patient name but with a medical record number and date of birth. Per most laboratory policies, this specimen should be:
Answer: Processed, as two acceptable identifiers are present
Medical record number and date of birth each qualify as acceptable patient identifiers; two valid identifiers are present so the specimen can be processed.