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.