A nurse is providing discharge teaching for a client who will be receiving oxygen therapy at home. Which of the following instructions should the nurse include in the teaching?

A. Urine output 25 mL/hr: Urine output less than 30 mL/hr is considered inadequate, especially after surgery. This could indicate possible renal insufficiency or hypovolemia, requiring immediate attention.

B. Heart rate 68/min: A heart rate of 68/min falls within the normal adult range (60-100 beats per minute). This finding is generally considered stable and does not typically indicate an immediate complication requiring urgent reporting to the provider in a postoperative client.

C. Hypoactive bowel sounds: Hypoactive bowel sounds are common in the immediate postoperative period, especially after abdominal surgery. This occurs due to the effects of anesthesia and bowel manipulation.

D. Serosanguineous drainage on surgical dressing: Serosanguineous drainage is typical in the early postoperative period and usually decreases over time. It’s not abnormal unless the amount increases significantly or the drainage becomes purulent.

B. Don clean gloves: The nurse should first don clean gloves to ensure proper hygiene and to reduce the risk of infection during the procedure. This protects both the client and the nurse from any potential contamination.

E. Attach the syringe to the balloon injection port: After gloves are on, the next step is to attach the syringe to the balloon injection port of the catheter. This is the part where sterile fluid (usually saline) was used to inflate the balloon that keeps the catheter in place.

C. Withdraw the solution from the balloon: Once the syringe is attached, the nurse slowly withdraws the fluid from the balloon. This is necessary to deflate the balloon, which allows the catheter to be removed easily and without causing injury to the urethral canal.

A. Slowly pull the catheter out of urethral canal: After the balloon is deflated, the nurse gently and slowly pulls the catheter out of the urethral canal. This should be done carefully to avoid causing trauma to the urethra and surrounding tissues. The catheter should be removed in a smooth, controlled motion.

D. Dry the perineal area: After the catheter is removed, the nurse should clean and dry the perineal area to ensure hygiene. This step helps prevent skin irritation and infection after the catheter removal, ensuring that the area is properly cared for and free of moisture.