The nurse cares for the client the day after insertion of the external ventricular drain (EVD). Click to highlight the assessment information that is most concerning to the nurse. Select one option. 0800 Client stabilized after EVD insertion and remained stable through night. Client was extubated with a stable respiratory assessment on oxygen 4L/NC. Client lethargic, arouses to voice and falls asleep after responding to questions. Purposeful movement in response to pain. Client has an opioid PCA for pain control. Blood glucose this morning 122 mg/dL. Client remains NPO with IV fluids with dextrose infusing. Minimal CSF output from EVD. Level assessed and appropriate, tubing patent. CSF appears cloudy. Oral care performed. Indwelling urinary catheter emptied for 360 mL clear, light amber urine. Peripheral pulses present. Toes pink and warm with cap refill <3 seconds.

Postoperative assessment after placement of an external ventricular drain (EVD), which is used to monitor intracranial pressure and drain cerebrospinal fluid (CSF), in a stable post-EVD patient, CSF should appear clear and colorless. Changes in CSF appearance can indicate serious complications such as infection (ventriculitis or meningitis), which is a high-priority concern due to the direct access of the device into the central nervous system. Early recognition of infection is critical to prevent rapid neurological deterioration and sepsis. Rationale for correct choice: CSF appears cloudy: Cloudy cerebrospinal fluid is an abnormal finding and strongly suggests infection, such as ventriculitis or meningitis, especially in a patient with an indwelling EVD. The EVD provides a direct pathway into the central nervous system, increasing the risk of pathogen entry. Normal CSF should be clear and colorless; any cloudiness indicates the presence of white blood cells, bacteria, or protein. This is a priority finding requiring immediate provider notification and possible culture and antibiotic therapy. Rationale for incorrect findings: Client lethargic, arouses to voice and falls asleep after responding to questions: Although a decreased level of consciousness is always important to monitor, the client has just undergone major surgery, was recently extubated, and is currently using an opioid PCA. Post-operative somnolence is an expected finding under these circumstances, provided the client remains arousable to voice. Purposeful movement in response to pain: This is a localized response and is actually a positive sign compared to the previous assessment (0220), where the client was only withdrawing or muttering sounds. It indicates that the client is not deteriorating further into non-purposeful or absent movement. Client has an opioid PCA for pain control: This is a standard treatment for a client with multiple traumatic fractures (femur, tibia, ulnar) and recent spinal surgery. While it requires monitoring for respiratory depression, the presence of the pump itself is not a "concerning assessment finding." Blood glucose this morning 122 mg/dL: For a client with type 2 diabetes undergoing major physiological stress (trauma and surgery), a glucose of 122 mg/dL is considered well-controlled. Most critical care protocols target a range of 140–180 mg/dL to prevent both hypoglycemia and severe hyperglycemia. Client remains NPO with IV fluids with dextrose infusing: This is expected postoperatively for a client who was recently extubated and is at risk for aspiration or may require further procedures. The dextrose provides necessary calories to prevent ketosis while NPO. Minimal CSF output from EVD: EVD output depends entirely on the level at which the drain is set and the client’s intracranial pressure (ICP). If the client’s ICP is within normal limits and the drain is leveled correctly, output should be minimal. The note confirms the level is appropriate and the tubing is patent (not blocked). Indwelling urinary catheter emptied for 360 mL clear, light amber urine: This indicates adequate renal perfusion and fluid balance. A volume of 360 mL over several hours is a normal finding (well above the minimum requirement of 30 mL/hr).