A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL How many mL should the nurse administer per dose?

(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Inspection:This is the first step because it allows the nurse to gather information through observation without causing any discomfort to the child. It involves looking at the child's abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.

Auscultation:After inspection, the nurse listens to the bowel sounds using a stethoscope. This helps assess peristalsis (movement of food through the intestines) and identify potential problems like bowel obstruction or decreased motility.

Superficial Palpation:This gentle palpation helps assess muscle tone, tenderness, and masses. It's performed after auscultation to avoid altering bowel sounds. Since children are often apprehensive about abdominal exams, starting with a gentler touch can help them feel more comfortable.

Deep Palpation (if necessary):Deep palpation is reserved for last as it can be more uncomfortable for the child. It's used to assess for organomegaly (enlarged organs) or masses that may not be palpable with superficial palpation. It's only performed if there are indications from the first three steps.

Here's a breakdown of why this order is important:

Minimize Discomfort:Starting with non-invasive methods like inspection and auscultation helps establish trust and reduces anxiety in the child, making the overall assessment more cooperative.

Maintain Baseline Bowel Sounds:Palpation can alter bowel sounds, so it's important to listen to them first to get an accurate baseline.

Gradual Progression:Moving from gentle to deeper palpation allows the child to adjust to the sensation and helps the nurse identify potential areas of tenderness before applying deeper pressure.

A. "The oral medication you will take after this IV will dissolve the clot": This statement is incorrect. While anticoagulants like warfarin or direct oral anticoagulants (DOACs) may be prescribed to prevent the formation of new clots or to treat existing clots, heparin, whether administered intravenously or subcutaneously, is not typically used to dissolve existing clots.
B. "A pharmacist is the person to answer that question": This response deflects the client's question and does not provide useful information. While pharmacists are knowledgeable about medications, nurses are responsible for educating clients about their treatments and should be able to provide accurate information regarding heparin therapy.
C. "Heparin does not dissolve clots. It stops new clots from forming": This is the correct response. Heparin is an anticoagulant medication that works by inhibiting the formation of new clots rather than dissolving existing ones. It does so by inhibiting the activity of clotting factors in the blood, thus preventing the clot from enlarging or new clots from forming.
D. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level": While this statement provides information about the time required for heparin to achieve a therapeutic effect, it does not address the client's specific question about clot dissolution. Heparin's anticoagulant effects occur rapidly, but its primary action is prevention rather than dissolution of existing clots.