Which nursing action is most important after administering nitroglycerin sublingually?

This is the appropriate action because it prevents the spread of infection and maintains a clean environment.

The nurse should also wear gloves and dispose of the bag properly.

Choice A is wrong because saturating the dressing with saline before removing it can cause maceration of the skin and increase the risk of infection. The dressing should be removed gently and carefully, and if it is adhered to the wound, small amounts of sterile saline can be used to loosen it.

Choice C is wrong because using the old dressing to debride any tissue that is adhered to the wound can cause trauma, bleeding, and pain. The nurse should use sterile forceps or cotton- tipped applicators to gently press moistened gauze into the wound surfaces.

Choice D is wrong because reinserting the drain if removed with the dressing can cause injury and infection. The nurse should notify the surgeon immediately if the drain is accidentally removed.

I give the client his medications when the wife is grocery shopping. This statement would require the nurse to re-evaluate and correct the plan of care because home health aides are not allowed to administer medications in most states. Home health aides can only provide medication reminders, help put the medication into the hands of the user, or assist with self-administration of certain forms of medications.

Giving medications to the client without supervision or delegation by a registered nurse or physician is a violation of the scope of practice and could harm the client.

Choice A is wrong because removing throw rugs from the client’s walking path is a safety measure that can prevent falls and injuries for a client with Alzheimer’s disease.

Choice B is wrong because documenting activities with the client before leaving for the day is a professional responsibility that ensures continuity of care and accountability.

Choice C is wrong because contacting the nurse if there are any questions about the plan of care is a sign of good communication and collaboration that can enhance the quality of care for the client.