The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective?
1. The lower extremity is swollen and hot to touch.
2. The vein feels hard.
3. There is no cramping or pain with ambulation.
4. There is pain in the 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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