A nurse is preparing to administer a blood transfusion to an anemic patient. Which of the following interventions are necessary before starting the transfusion?

Document the blood product and verification in the patient''s medical record.
Instruct the patient to report swelling, lower back and flank pain, itching, or difficulty breathing.
Obtain vital signs before the transfusion.
The nurse and another approved healthcare provider check the patient identifiers and blood band ID with the blood product and then begin the infusion.

Explanation

•Baseline vitals are taken before transfusion to provide a means of identifying changes during the transfusion that would indicate a reaction.

•The patient should be instructed to report signs or symptoms of a transfusion reaction.

•Documenting the blood product to be administered as well as the two-person verification is important.

•Baseline vitals are taken before transfusion to provide a means of identifying changes during the transfusion that would indicate a reaction. Also, if a patient has a fever, the blood transfusion may need to be postponed until the patient is afebrile.

•The RN cannot verify a blood product alone. The RN will verify with another RN or approved healthcare provider that the patient and blood product are compatible by comparing the patient identifiers and the blood product form. The form is signed and dated by both providers and kept with the blood until the transfusion is complete.  This needs to be done prior to starting the transfusion to avoid administering the wrong blood product to the patient.

•The nurse should assess the patient's vital signs at least once during the transfusion, and it should be done in accordance with hospital or facility policy.

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