You return to the room later in the shift to check on Z.O. Which of these assessment findings would cause concern? Select all that apply.
a. Blood pressure 90/55 mm Hg
b. Increased clear drainage on dressing
c. Decreased responsiveness
d. Facial edema
e. Heart rate 120 beats/min
Ans:
b. Increased clear drainage on dressing
c. Decreased responsiveness
Any clear drainage and decreased LOC should be brought to the surgeon's attention immediately
because there could be a cerebrospinal fluid (CSF) leak and decline in neurologic function.
Neurologic function should be gradually improving, not decreasing. Z.O.'s BP and HR are within
normal limits. Facial edema is not unusual after this surgery.
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