A nurse is preparing to administer an injection to a client. Which of the following actions should the nurse plan to take after administering the Injection?

Choice A reason:
"New dressing applied as prescribed; no drainage on old dressing. “This entry provides clear and concise information about the action taken (applying a new dressing as prescribed) and the assessment of the old dressing (no drainage present). It accurately reflects the dressing change process and the status of the wound.
Choice B reason:
"Client premedicated with MSO, sub-prior to dressing change." This entry is incorrect because it provides information about the client being premedicated, but it doesn't specifically address the dressing change or the pressure injury.
Choice C reason:
"The wound seems clean and does not appear to be infected." While this entry provides an assessment of the wound's cleanliness and potential infection, it lacks specific details about the dressing change itself.
Choice D reason:
"No changes noted to the wound from previous nursing notes." This entry focuses on comparing the wound to previous notes but doesn't provide information about the current dressing change or assessment.

Choice A reason:
Performing percussion over the lower back: While percussion is part of the postural drainage technique, the specific areas to be percussed depend on the client's individualized care plan, which is based on the location of lung segments affected by cystic fibrosis. The nurse should follow the care plan and target the appropriate lung segments for percussion.
Choice B reason:
Covering the area of percussion with a towel is correct. When performing postural drainage with percussion and vibration for a client with cystic fibrosis, it is important to cover the area of percussion with a towel. This helps protect the client's skin and prevent discomfort or injury during the procedure. The towel acts as a barrier between the nurse's hand and the client's skin, allowing for effective percussion while minimizing friction and pressure

Choice Creason:
Scheduling postural drainage after meals: Postural drainage is ideally performed before meals or at least 1-2 hours after meals to avoid potential discomfort or vomiting due to the positioning and movement during the procedure.
Choice Dreason:
Instructing the client to exhale quickly during vibration: Vibration is typically performed during the client's exhalation phase, but the instruction should focus on slow, controlled exhalation rather than quick exhalation.