A nurse is caring for a client who has acute kidney injury and a potassium level of 6.5 mEq/L (3.5 to 5 mEq/L). Which of the following electrocardiogram (ECG) changes should the nurse expect?

Rationale:

• Peripheral pulse: Strong and symmetric peripheral pulses in this client indicate that circulation through the femoral artery (the common catheter insertion site for PCI) is intact. This suggests no vascular complications like thrombus or hematoma, which are post-PCI risks.
• Pain level: The client initially reported chest pain rated 8/10 with radiation to the left arm and dyspnea. A decreased pain level after PCI reflects reduced myocardial oxygen demand and ischemia, indicating that the intervention was successful.
• Blood pressure: The client presented with elevated blood pressure (158/92 mm Hg), likely due to cardiac stress and pain. A return to a more stable range post-intervention indicates reduced sympathetic activation and improved hemodynamic status.
• Heart rate: The client had a heart rate of 116/min earlier, likely secondary to chest pain and cardiac stress. A drop toward normal levels post-PCI reflects improved cardiac function and relief of ischemia.
• Oxygen saturation: Earlier, the client showed dyspnea and shallow, labored respirations, with an SpO₂ of 96% on room air. An improved or sustained oxygen saturation level after PCI indicates better oxygen delivery and respiratory status, confirming reduced cardiac workload and improved perfusion.

Rationale:

Stop transfusion: The client is showing signs of a serious transfusion reaction such as fever, chills, back pain, and hypotension. Immediately stopping the transfusion prevents further infusion of incompatible blood, which could worsen hemolysis and lead to shock or kidney failure.

Flush blood transfusion tubing: Flushing the existing blood tubing with saline could push more incompatible blood cells into the circulation. This can intensify the reaction and increase the risk of complications. Instead, new IV tubing with normal saline should be used if further IV access is needed.

Notify blood bank: The blood bank must be informed to initiate an investigation, verify blood compatibility, and conduct testing to determine the cause of the reaction. This helps prevent further occurrences and ensures patient safety.

Notify primary physician: The physician needs to be informed promptly to provide additional orders, such as fluid resuscitation, lab tests, or medications to stabilize the client. Immediate collaboration is essential to manage the adverse event effectively.

Return blood and tubing to blood bank: Returning the blood product and used tubing allows the blood bank to analyze the unit for errors or contamination. This is necessary for confirming the transfusion reaction and documenting the incident.

Administer IV diphenhydramine: Diphenhydramine may be used to reduce symptoms such as itching or chills if an allergic component is suspected. It is often part of the initial response while further evaluation and treatment are underway.

Administer oxygen: The client’s oxygen saturation has dropped, and respirations are rapid and labored. Administering oxygen supports tissue oxygenation and addresses hypoxia during this acute reaction, which may compromise respiratory function.