A nurse is teaching a client about the safety risks in their home. Which of the following statements should the nurse include?

Rationale for correct choices

• Sepsis: The client presents with fever, hypotension, tachycardia, tachypnea, confusion, and a positive urinalysis for infection; all classic signs of a urinary tract infection progressing toward urosepsis. Older adults often present with altered mental status rather than localized pain. Early recognition and treatment of sepsis are critical to prevent multi-organ failure and mortality.

• Acute kidney injury: Laboratory results show elevated BUN (22 mg/dL) and creatinine (2 mg/dL), indicating impaired renal function. The hypotension and possible infection-related renal hypoperfusion place the client at high risk for acute kidney injury. Prompt fluid resuscitation and monitoring of renal function are essential to prevent further kidney damage.

Rationale for incorrect choices

• Seizures: While severe infection or metabolic disturbances can precipitate seizures, there is no current evidence of seizure activity in this client. Seizures are not the most immediate risk given the presenting signs. The priority risks are systemic infection and renal impairment.

• Urolithiasis: Although the client has urinary symptoms, there is no evidence of kidney stones or obstruction. The urine is cloudy due to infection rather than calculi. Urolithiasis is not the most urgent concern.

• Hemorrhage: There is no indication of bleeding or coagulopathy in the assessment or labs. Hemorrhage is not a likely complication in this context and does not require immediate attention compared with sepsis and acute kidney injury.

A. Document the fetal heart rate: While monitoring fetal well-being is important, the immediate priority is the safety of the mother. In the presence of severe hypertension (188/112 mm Hg) and neurological symptoms, maternal stabilization takes precedence because maternal compromise can directly impact fetal oxygenation and survival.

B. Check urine for protein: Proteinuria is a diagnostic criterion for preeclampsia, but testing urine is not the first priority. The nurse must first address immediate risks to prevent life-threatening complications such as eclampsia.

C. Administer IV beta blocker medication: Administering antihypertensive medication is necessary to lower dangerously high blood pressure, but interventions to prevent seizures (e.g., magnesium sulfate and seizure precautions) take precedence because seizures can occur rapidly and pose an immediate threat to maternal and fetal life.

D. Implement seizure precautions: The first action is to implement seizure precautions because the client’s blood pressure and severe headache indicate severe preeclampsia with high risk for eclampsia. Ensuring safety (e.g., padding side rails, maintaining airway readiness, having suction and emergency equipment available) is critical to prevent injury if a seizure occurs.