The nurse determines that preoperative instruction regarding leg exercises has been effective when what is assessed?
1. Lower extremity swollen and hot to touch.
2. Vein feels hard.
3. No cramping or pain with ambulation.
4. Pain in calf with dorsiflexion.
Correct Answer: 3
Rationale 1: Lower extremity swelling and heat would indicate the presence of thrombophlebitis.
Rationale 2: A hard vein would indicate the presence of thrombophlebitis, and that leg exercises were not effective.
Rationale 3: The absence of cramping or pain with ambulation indicates that leg exercises instructed prior to surgery were effective to prevent the onset of thrombophlebitis.
Rationale 4: Pain in the calf with dorsiflexion would indicate the presence of thrombophlebitis, and that leg exercises were not effective.
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