The nurse is providing discharge instruction to a client who is going home after a knee replacement. Which information regarding symptoms of deep vein thrombosis (DVT) should the nurse include?
1. "If you develop a DVT, you will know it."
2. "Watch for paleness or coolness in your toes."
3. "Report any swelling in your knee."
4. "Look for increased tenderness in your lower legs."
Correct Answer: 4
Rationale 1: Some DVTs produce no symptoms.
Rationale 2: Pale toes would indicate arterial insufficiency.
Rationale 3: Because this client just had a knee replacement, swelling is likely to be present and is an expected finding.
Rationale 4: Tenderness, warmth, or swelling in the lower legs may indicate DVT.
Global Rationale: Tenderness, warmth, or swelling in the lower legs may indicate DVT. Some DVTs produce no symptoms. Pale toes would indicate arterial insufficiency. Because this client just had a knee replacement, swelling is likely to be present and is an expected finding.
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