A client with chronic kidney disease (CKD) is prescribed a low-potassium diet. Which food choice indicates to the nurse that the client understands the dietary restrictions?

Choice A reason: Connecting to suction is inappropriate, as “coffee ground” drainage indicates upper GI bleeding, likely from an ulcer. Suction could worsen bleeding by traumatizing the site. Clamping and notifying the provider ensure assessment, preventing further hemorrhage or complications like perforation in this critical scenario.

Choice B reason: “Coffee ground” drainage suggests oxidized blood from upper GI bleeding (e.g., gastritis). Clamping prevents irritation or bleeding exacerbation, and contacting the provider ensures urgent evaluation, possibly via endoscopy or proton pump inhibitors, addressing the bleeding source to stabilize the client and prevent shock.

Choice C reason: Removing and reinserting the tube risks further trauma to the bleeding site, as “coffee ground” drainage indicates active hemorrhage. Repeated insertion may dislodge clots, worsening bleeding. Clamping and notifying the provider prioritize safety, allowing diagnostic and therapeutic interventions for the underlying cause.

Choice D reason: High continuous suction is contraindicated, as “coffee ground” drainage signals GI bleeding, and aggressive suction could dislodge clots, increasing hemorrhage. Clamping and contacting the provider ensure controlled management, preventing complications like hypovolemic shock, making this action harmful and inappropriate.

Choice A reason: Placing the chair by the bed is preparatory but not immediate after sitting up. Prolonged bedrest risks orthostatic hypotension from reduced plasma volume and baroreceptor sensitivity. Assessing the client’s response ensures stability before transfer, preventing falls, making this less urgent than evaluating for dizziness or hypotension.

Choice B reason: Supporting the client when rising is premature before assessing their response to sitting. Bedrest causes deconditioning, increasing orthostatic hypotension risk, leading to dizziness or syncope. Determining how the client feels confirms cardiovascular stability, preventing falls during transfer due to blood pressure drops.

Choice C reason: Determining how the client feels assesses for orthostatic hypotension, common post-bedrest due to reduced venous return and baroreceptor dysfunction. Dizziness or lightheadedness signals syncope risk during transfer. This ensures cardiovascular stability, prioritizing safety before physical support, addressing physiological changes from prolonged immobility.

Choice D reason: Offering non-skid socks prevents falls during ambulation but is secondary to assessing sitting response. Bedrest heightens hypotension risk, and ensuring the client is not dizzy takes precedence to avoid syncope. Socks are a later safety measure, making this less immediate than evaluating physiological stability.