Difficulty: Medium
Average Score: 67%
Simulated
The client underwent a lumbar laminectomy with spinal fusion 12 hours earlier. Which nursing assessment finding indicates that the client has a leakage of CSF?
Correct answer
C
Rationale
Unrelieved back pain may be associated with another complication, not CSF leakage. A severe headache, rather than back pain, may be associated with CSF leakage. 50 mL of serosanguineous fluid in the bulb drain is a normal finding. Clear drainage on the surgical dressing is indicative of a CSF leak. The temperature elevation could indicate an infection.