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:

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.

Rationale:

A. Administer oxygen: The client is experiencing labored respirations and increasing distress. Although their oxygen saturation is currently within normal range, supplemental oxygen is a priority to support oxygenation during this acute episode, especially with signs of anxiety and shortness of breath.

B. Obtain prescription for amiodarone: Amiodarone is used for certain ventricular arrhythmias. The client’s heart rhythm is described as regular, though tachycardic, not indicating a need for amiodarone. This is not an immediate priority without evidence of a specific arrhythmia like ventricular tachycardia.

C. Place client in semi-Fowler's position: Elevating the head of the bed helps reduce the work of breathing and improves lung expansion. This position supports respiratory function, especially when the client is experiencing shortness of breath.

D. Monitor blood pressure every 30 minutes: Blood pressure monitoring is important, but this action is not immediate in the face of worsening symptoms. The client needs more urgent interventions first, including respiratory and cardiac stabilization.

E. Obtain prescription for a beta blocker: The client’s heart rate increased significantly to 170/min and they have a history of poorly controlled hypertension. A beta blocker may be needed to reduce sympathetic overactivity and heart rate, helping to lower blood pressure and myocardial oxygen demand.

F. Monitor for neurologic complications: With a blood pressure of 185/100 mmHg and a worsening severe headache, the client is at risk for neurologic complications such as hypertensive encephalopathy or stroke. Close neurologic monitoring is essential to detect early signs of deterioration.