Multiple Choice Identify the
choice that best completes the statement or answers the question.
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1.
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A client was transferred to the nursing unit from
the coronary care unit after experiencing a myocardial infarction (MI). When reviewing the
client’s serum creatinine phosphokinase (CPK) levels recorded in the chart, the nurse knows
that an elevation of which of the following was due to the MI?
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2.
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A client with history of seizure disorder is having
a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes
that the client’s blood level of the medication is within the normal range if the value
reported is:
a. | 15 mcg/mL | b. | 6 mcg/mL | c. | 28
mcg/mL | d. | 35 mcg/mL |
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3.
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A long-term-care nurse about to give a daily dose
of digoxin (Lanoxin) is told that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL.
The nurse should take which of the following actions first?
a. | Gather data from the client related to signs of
toxicity. | b. | Report the finding to the health care
provider. | c. | Record the normal value on the intershift report
sheet. | d. | Administer the daily dose of the
medication. |
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4.
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A licensed practical nurse (LPN) is assisting in
the care of a client receiving a continuous intravenous (IV) infusion of heparin sodium for deep vein
thrombosis (DVT). The LPN notes that the result of a newly drawn activated partial thromboplastin
time (aPTT) level is 90 seconds. The client’s baseline before the initiation of therapy was 30
seconds. The LPN should take which of the following actions?
a. | Leave the report for the registered nurse (RN) to review
later in the day. | b. | Ask the client
about worsening pain from the DVT. | c. | Notify the RN
about the value immediately. | d. | Check to see if
additional heparin is available on the unit. |
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5.
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A client is receiving oral anticoagulant therapy
with warfarin (Coumadin). The result of a newly drawn prothrombin time (PT) is 28 seconds. The nurse
anticipates carrying out an order to:
a. | Hold the next dose of
warfarin. | b. | Stop the warfarin and administer
heparin. | c. | Administer the next dose of
warfarin. | d. | Increase the next dose of
warfarin. |
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6.
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An adult client has had serum electrolytes drawn.
The nurse receiving the results by telephone from the laboratory would be most concerned with which
of the following results?
a. | Chloride 103 mEq/L | b. | Bicarbonate 24 mEq/L | c. | Sodium 142
mEq/L | d. | Potassium 5.4
mEq/L |
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7.
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A nurse is providing directions to a client about
how to test a stool for occult blood. The nurse cautions that which of the following could cause a
false-negative result?
a. | Iodine | b. | Acetylsalicylic acid | c. | Ascorbic
acid | d. | Colchicine |
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8.
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An older client has been treated for dehydration
and pneumonia. The nurse evaluates that the client’s dehydration has been successfully treated
if the blood urea nitrogen (BUN) level drops to:
a. | 19 mg/dL | b. | 5 mg/dL | c. | 46
mg/dL | d. | 32 mg/dL |
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9.
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A nurse is reading a computer printout of the
results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar
puncture. The nurse knows that a reported value of 0 is normal for which of the following substances
in CSF?
a. | Protein | b. | Glucose | c. | White blood
cells | d. | Red blood cells |
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10.
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A nurse has provided dietary instructions to a
client with renal calculi who must learn to eat an alkaline-ash diet. The nurse determines that the
client has properly understood the information presented if the client chooses which of the following
selections from a diet menu?
a. | Chicken, potatoes, and
cranberries | b. | Peanut butter
sandwich, milk, and prunes | c. | A spinach salad,
milk, and a banana | d. | Linguini with
shrimp, tossed salad, and a plum |
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11.
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A client with hypertension has been prescribed a
low-sodium diet. The nurse teaching this client about foods that are allowed would include which of
the following in a list provided to the client?
a. | Tomato soup | b. | Summer squash | c. | Instant
oatmeal | d. | Boiled shrimp |
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12.
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A client with a history of hypertension has been
prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of
this medication on the diet if the client states to avoid which of the following
fruits?
a. | Apples | b. | Pears | c. | Bananas | d. | Cranberries |
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13.
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A client with a history of gastrointestinal upset
has been diagnosed with acute diverticulitis. The nurse gives the client suggestions for foods to aid
in symptom management that are on which of the following diets?
a. | A high-carbohydrate diet | b. | A low-fat diet | c. | A high-fat
diet | d. | A low-fiber diet |
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14.
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A client is recovering from abdominal surgery and
has a large abdominal wound. The nurse encourages the client to eat which of the following foods that
are naturally high in vitamin C to promote wound healing?
a. | Chicken | b. | Bananas | c. | Oranges | d. | Milk |
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15.
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A client with a brain attack (stroke) is
experiencing residual dysphagia. The nurse would remove which of the following food items that
arrived on the client’s meal tray from the dietary department?
a. | Mashed potatoes | b. | Peas | c. | Cheese
casserole | d. | Scrambled eggs |
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16.
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A client is resuming a diet after hemigastrectomy.
To minimize complications, the nurse would tell the client to avoid doing which of the
following?
a. | Eating six small meals per
day | b. | Excluding concentrated sweets in the
diet | c. | Lying down after eating | d. | Drinking liquids with meals |
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17.
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A client who has developed atrial fibrillation that
is not responding to medication therapy has begun taking warfarin (Coumadin). The nurse is doing
discharge dietary teaching with the client. The nurse would plan to teach the client to avoid which
of the following foods while taking this medication?
a. | Cherries | b. | Potatoes | c. | Spaghetti | d. | Broccoli |
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18.
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A nurse is instructing a pregnant client in her
first trimester about nutrition. The nurse would correct which of the following misunderstandings on
the part of the client about nutrition during pregnancy?
a. | Calcium intake should be increased for the duration of
the pregnancy. | b. | Iron supplements
should be taken throughout pregnancy. | c. | The maternal diet
significantly influences fetal growth and development. | d. | Pregnancy greatly increases the risk of malnourishment for the
mother. |
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19.
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A client with liver cancer who is receiving
chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to
limit which of the following foods that is most likely to have this taste for the
client?
a. | Beef | b. | Potatoes | c. | Custard | d. | Cantaloupe |
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20.
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A nurse has been assigned to the care of four adult
clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work
assignment for the shift makes a notation to check the IV sites of these clients every:
a. | 1 hour | b. | 2 hours | c. | 3
hours | d. | 4 hours |
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21.
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A licensed practical nurse (LPN) is asked to
prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer’s at 80 mL/hour
to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00.
After making hourly marks on the time-tape, the LPN notes that the completion time for the bag
is:
a. | 15:30 | b. | 17:30 | c. | 19:30 | d. | 21:30 |
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22.
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A client is scheduled for insertion of a
peripherally inserted central catheter (PICC), and the nurse explains the advantages of this
catheter. Which statement by the client indicates a lack of understanding about this type of
catheter?
a. | There is less pain and
discomfort. | b. | This type of
catheter is very reliable. | c. | It is reasonable
in cost. | d. | It is specifically designed for short-term
use. |
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23.
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A client rings the call bell and complains of pain
at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and
determines that the client has developed phlebitis. The LPN would plan to avoid which of the
following actions in the care of this client?
a. | Prepare to apply warm moist packs to the
site. | b. | Prepare to start a new line in a proximal portion of the
same vein. | c. | Prepare to
discontinue the IV catheter at that site. | d. | Notify the
registered nurse (RN). |
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24.
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A client had a 1000-mL bag of 5% dextrose in 0.9%
sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds that the client is
complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased
pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the
following actions first?
a. | Sit the client up in bed. | b. | Place the client in Trendelenburg’s position. | c. | Shut off the infusion. | d. | Discontinue the
angiocatheter and IV. |
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25.
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A nurse is preparing a continuous intravenous (IV)
infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a
needleless device, the tubing drops and hits the top of the medication cart. Which of the following
is the appropriate action by the nurse?
a. | Wipe the tubing port with
povidone-iodine. | b. | Scrub the
needleless device with an alcohol swab. | c. | Attach a new
needleless device. | d. | Change the IV
tubing. |
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26.
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A nurse enters a client’s room to check the
client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and
dyspneic. The nurse listens to the client’s lung sounds and notes the presence of crackles in
the lung bases. The client states that she was just going to ring the call bell for the nurse. The
nurse determines that this client is most likely experiencing which of the following complications of
blood transfusion therapy?
a. | Hypovolemic shock | b. | Transfusion reaction | c. | Fluid
overload | d. | Bacteremia |
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27.
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A nurse is assisting in monitoring a client who is
receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the
client that it is most important to immediately report which of the following signs if they
occur?
a. | Fatigue | b. | Nausea | c. | Headache | d. | Backache |
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28.
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A client with methicillin-resistant
Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed
practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which
action by the new LPN would indicate the need to review the procedure for contact
precautions?
a. | Wears gloves, gown, and goggles when changing the
client’s colostomy bag | b. | Wears a gown when
caring for the client and removes the gown immediately after leaving the client’s
room | c. | Places the client in a semiprivate room with another
client who has active infection with the same microorganism but who has no other
infection | d. | Places the client in a private
room |
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29.
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A nurse is caring for a client who is on airborne
precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI)
test. Which of the following nursing actions would be most appropriate in preparing the client for
the test?
a. | Ask that the MRI department be called to tell the
technician that the test will have to be delayed until the airborne precautions are
discontinued. | b. | Plan to have the
MRI performed at the bedside. | c. | Ask that the MRI
department be called to tell technicians in the department to wear masks. | d. | Place a surgical mask on the client for transport and for contact with other
individuals. |
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30.
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A nurse employed in the ambulatory care department
hears a client in the waiting room call out, “Help, fire!” The nurse rushes to the
waiting room and finds the wastebasket on fire. The nurse immediately:
a. | Removes the clients from the waiting
room | b. | Activates the fire alarm | c. | Confines the fire | d. | Extinguishes the
fire |
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31.
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A nurse is instructing a group of nursing
assistants in the principles of body mechanics. The nurse determines that a student is using the
principles appropriately if the nurse observes the nursing assistant:
a. | Positioning a box that is to be lifted between the
knees | b. | Turning the back to change position while moving a
client | c. | Helping a client requiring total care into a chair
without additional assistance | d. | Leaning forward
when turning a client in bed |
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32.
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A nurse is working in a long-term care facility and
is observing a new nursing assistant caring for a client who requires a security device (wrist
restraints). The nurse determines that the nursing assistant is providing safe care if the nurse
observes the nursing assistant assessing skin integrity by completely removing the client’s
wrist restraints:
a. | Every 2 hours | b. | Every 3 hours | c. | Every 4
hours | d. | Every 6 hours |
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33.
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A nurse is assisting in developing a plan of care
for an older client to prevent a fall. Which of the following actions would be least likely to
prevent a fall?
a. | Placing the bed in the lowest
position | b. | Placing the call light within the client’s
reach | c. | Keeping the bathroom light off at
nighttime | d. | Keeping the side rails up while the client is in
bed |
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34.
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A physician writes an order to apply a heating pad
to a client’s back. The nurse implements the prescribed order and avoids which of the
following?
a. | Setting the heating pad on a low
setting | b. | Placing the heating pad under the
client | c. | Assessing the heating pad periodically for proper
electrical function | d. | Assessing the skin
integrity frequently for signs of burns |
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35.
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A nurse is providing instructions to a client
regarding the use of ice packs to treat an eye injury. The nurse instructs the client
to:
a. | Keep the ice pack on the eye continuously for 24
hours. | b. | Place the ice pack directly on the
eye. | c. | Avoid the use of commercially prepared ice
bags. | d. | Wrap a plastic bag filled with ice with a pillowcase and
place it on the eye. |
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36.
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A nurse is preparing to clean up a blood spill on
the client’s bedside table. The spill occurred when a blood tube containing the client’s
blood specimen broke. The nurse avoids doing which of the following when cleaning up the blood
spill?
a. | Wearing gloves for the cleanup
procedure | b. | Using tongs to collect any broken
glass | c. | Blotting up the spill with a face cloth or cloth
towel | d. | Disinfecting the area of the blood spill with a dilute
bleach solution |
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37.
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A physician orders 1000 mL of 0.9% normal saline
(NS) to run over 8 hours. The drop (gt) factor is 10 drops (gtt) per 1 mL. The nurse adjusts the flow
rate to run at how many gtt per minute?
a. | 15 gtt/minute | b. | 17 gtt/minute | c. | 21
gtt/minute | d. | 23
gtt/minute |
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38.
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A physician prescribes meperidine hydrochloride
(Demerol), 40 mg intramuscularly stat, for a postoperative client in pain. The medication label
states meperidine hydrochloride, 50 mg/mL. How many mL will the nurse prepare to administer to the
client?
a. | 0.5 mL | b. | 0.6 mL | c. | 0.8
mL | d. | 1 mL |
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39.
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A physician prescribes atenolol (Tenormin) 0.05 g
by mouth daily. The label on the medication bottle states atenolol 25-mg tablets. How many tablets
will the nurse administer to the client?
a. | 0.5 tablet | b. | 1 tablet | c. | 2
tablets | d. | 3 tablets |
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40.
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A client is to receive 1000 mL of 5% dextrose in
water (D5W) at a rate of 100 mL/hour. The drop (gt) factor is 10 drops (gtt) per mL. The
nurse adjusts the flow rate to deliver how many gtt per minute?
a. | 10 gtt | b. | 13 gtt | c. | 17
gtt | d. | 20 gtt |
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41.
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A physician orders an intramuscular (IM) dose of
250,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the
pharmacy reads penicillin G benzathine 300,000 units/mL. How much medication will the nurse prepare
to administer the correct dose?
a. | 0.25 mL | b. | 0.8 mL | c. | 1.5
mL | d. | 8 mL |
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42.
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A physician orders a bolus of 500 mL of 0.9% normal
saline (NS) to run over 4 hours. The drop (gt) factor is 10 drops (gtt) per 1 mL. The nurse plans to
adjust the flow rate at how many gtt per minute?
a. | 15 gtt | b. | 17 gtt | c. | 19
gtt | d. | 21 gtt |
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Completion Complete each
statement.
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43.
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A physician prescribes digoxin (Lanoxin), 0.25 mg
by mouth (PO) daily, for a client with congestive heart failure. The medication label states 0.125 mg
per tablet. How many tablet(s) will the nurse administer to the client?
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44.
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Ampicillin sodium (Omnipen) 250 mg in 50 mL of
normal saline (NS) is being administered over a period of 30 minutes. The drop (gt) factor is 10
drops (gtt) per mL. The nurse is asked to check the flow rate of the infusion. The nurse determines
that the infusion is running at the prescribed rate if the infusion is delivering how many gtt per
minute? (Round answer to the nearest whole number.)
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45.
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A physician prescribes 1000 mL of normal saline
(NS) to be infused over a period of 10 hours. The drop (gt) factor is 15 drops (gtt) per mL. The
nurse adjusts the flow rate at how many gtt per minute?
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46.
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A physician orders 3000 mL of 5% dextrose in water
(D5W) to run over a 24-hour period. The drop (gt) factor is 15 drops (gtt) per 1 mL. The
nurse adjusts the flow rate to run at how many gtt per minute? (Round answer to the nearest whole
number.)
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