NCLEX Question of the Day – Sunday, March 08, 2026

NCLEX Question of the Day – Sunday, March 08, 2026. Today’s question targets safe medication management and prioritization in Pharmacology. Nurses catch drug interactions first because we see the patient, the meds, and the labs at the same time. Knowing what to hold, what to report, and what to monitor prevents harm.

Clinical Scenario

A 76-year-old resident in a skilled nursing facility has a history of atrial fibrillation managed with warfarin 5 mg daily, hypertension, and mild heart failure. Yesterday, the provider started trimethoprim-sulfamethoxazole (TMP-SMX) for a urinary tract infection. This morning, the nurse notes new petechiae on both forearms, the resident reports bleeding gums while brushing teeth, and a dark, tarry stool overnight. Vital signs: BP 110/64, HR 102, RR 16, SpO2 98% on room air. The INR resulted at 4.6.

The Question

Which action is the nurse’s priority?

Answer Choices

1. Hold the next dose of warfarin and notify the provider about the findings and current medications.
2. Administer acetaminophen for discomfort and recheck the INR tomorrow morning.
3. Encourage increased oral fluids to flush the antibiotic and continue all medications as prescribed.
4. Teach the resident to avoid leafy green vegetables until the antibiotic course is complete.

Correct Answer

A. Hold the next dose of warfarin and notify the provider about the findings and current medications.

Detailed Rationale

This resident shows signs of over-anticoagulation: petechiae, bleeding gums, and melena suggest active bleeding. An INR of 4.6 is supratherapeutic. TMP-SMX is a high-risk interaction with warfarin. It inhibits warfarin metabolism and displaces it from protein-binding sites, which increases the anticoagulant effect. The combination explains the sudden rise in INR and bleeding.

The nurse’s priority is to stop anything that can worsen bleeding and alert the provider with a focused report. Holding the next dose of warfarin prevents further anticoagulation while the situation is evaluated. Notifying the provider ensures timely orders for reversal or adjustments.

What to assess now:

• Focused bleeding assessment: oral cavity, urine, stool color, skin, injection sites, and any new bruising.
• Neurologic check: headache, confusion, vision changes, weakness (screen for intracranial bleeding).
• Hemodynamics: trending BP and HR for occult blood loss; orthostatic vitals if safe.

What to do next (anticipate orders):

• Stat repeat INR and CBC (Hgb/Hct, platelets).
• Administer vitamin K if ordered; severe bleeding may require reversal agents and higher-level care.
• Stool guaiac testing and possible GI evaluation based on symptoms.
• Antibiotic review: consider an alternative with lower interaction risk; adjust warfarin dosing as needed.

What to monitor:

• Bleeding progression or new sites of bleeding.
• Trends in vital signs and mental status.
• Follow-up INR after any interventions or medication changes.

Why the Other Options Are Wrong

• B. Administer acetaminophen for discomfort and recheck the INR tomorrow morning. This delays action on an unsafe INR and active bleeding. Waiting until tomorrow risks worsening hemorrhage. Pain control does not address the cause and can mask symptoms.
• C. Encourage increased oral fluids to flush the antibiotic and continue all medications as prescribed. Hydration will not reverse a pharmacokinetic interaction. Continuing both drugs without adjustment invites more bleeding. This option ignores the current clinical evidence of harm.
• D. Teach the resident to avoid leafy green vegetables until the antibiotic course is complete. Diet counseling is not the priority during active bleeding. Also, abruptly avoiding vitamin K foods can further increase INR. Consistency in vitamin K intake is the goal, not elimination—especially when the INR is already high.

Key Takeaways

• Warfarin has many clinically significant interactions. TMP-SMX can sharply increase INR and bleeding risk.
• Active bleeding signs with a supratherapeutic INR require immediate action: hold warfarin and notify the provider.
• Assess bleeding, neuro status, and hemodynamics; prepare for labs and possible reversal.
• Diet changes are not first-line in acute over-anticoagulation; stabilize first, then educate.

• On-shift mini-checklist:
  • Hold warfarin now.
  • Perform focused bleed and neuro assessments; get vitals.
  • Review all meds for interactions (especially new antibiotics).
  • Call provider with SBAR: symptoms, vitals, INR, current meds, timing.
  • Anticipate orders: repeat INR/CBC, vitamin K, medication changes, monitoring plan.
  • Reassess and document response and patient education.

Quick Practice Extension

• A patient on warfarin starts metronidazole and reports new nosebleeds. Which assessment findings would make you escalate care immediately, and what information must you include when calling the provider?
• A post-op patient on a heparin infusion shows oozing at the IV site and an aPTT above therapeutic range. What is your first nursing action, and what labs do you anticipate repeating?

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