A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

The correct answer is B. Placement of a central venous catheter.

Rationale: The nurse should identify that informed consent is required for the placement of a central venous catheter, as this is an invasive procedure that carries significant risks and benefits that need to be explained to the client before obtaining consent. Informed consent is not required for irrigation of a wound with antibiotic solution, as this is a routine nursing intervention that does not involve significant risks or benefits.

Informed consent is not required for the insertion of a nasogastric tube, as this is a common nursing procedure that does not involve significant risks or benefits. Informed consent is not required for the administration of an iron injection using the Z-track technique, as this is a standard medication administration technique that does not involve significant risks or benefits.

A. Keep the finger in a dependent position:

• Keeping the finger in a dependent position (lower than the heart) helps promote blood flow to the fingertips, making it easier to obtain a blood sample. This position can facilitate the formation of a blood drop, improving the chances of obtaining an adequate sample for testing.

B. Wear sterile gloves:

• Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. Clean, non-sterile gloves are generally sufficient for this procedure. However, the nurse should perform proper hand hygiene to minimize the risk of contamination.

C. Select the central tip of a finger:

• The central tip of the finger is more sensitive, and choosing this area may cause greater discomfort for the client. The sides of the fingertips are often preferred for capillary blood glucose testing as they have a good blood supply and are less sensitive.

D. Test the first drop of blood that forms after the puncture:

• The initial drop may contain tissue fluid or contaminants from the puncture site, so it is important to use the first drop to obtain a representative blood sample. This step contributes to the accuracy of the blood glucose measurement.