A nurse is about to take a client’s oral temperature, but the client has just consumed some ice chips. What should the nurse do next?

Choice A rationale
Skim milk is not acceptable for a client on a clear liquid diet. Clear liquid diets only include liquids that you can see through, and milk is not a clear liquid.
Choice B rationale

Carrot juice is not acceptable for a client on a clear liquid diet. While it is a liquid, it is not clear, and therefore does not meet the criteria for a clear liquid diet.
Choice C rationale
Grape juice is acceptable for a client on a clear liquid diet, as long as it is without pulp. Clear fruit juices are typically included in a clear liquid diet.
Choice D rationale
Chicken broth is acceptable for a client on a clear liquid diet. Broths are clear liquids and are often included in a clear liquid diet to provide some savory flavor.

Choice A rationale

While involving the family in the care of an older adult client is important, calling the family to make arrangements for someone to sit with the client is not the immediate action the nurse should take. The nurse’s first responsibility is to ensure the client’s safety and well-being.
Choice B rationale
Obtaining a prescription for medication to sedate the client is not the immediate action the nurse should take. Sedating the client does not address the immediate concern of potential injury.
Choice C rationale
The nurse should first check the client for injuries. This is the immediate action because the client may have sustained injuries from the fall. The nurse should perform a thorough assessment to determine the extent of any injuries and provide appropriate care.
Choice D rationale
Assisting the client back into bed and applying restraints is not the immediate action the nurse should take. Restraints should be used as a last resort and only if less restrictive measures have been ineffective. Furthermore, restraints require a physician’s order.