NCLEX Question of the Day – Monday, April 06, 2026

Today’s question targets early recognition of medication-related bleeding and the nurse’s first priority action. This matters in real nursing because anticoagulants prevent dangerous clots, but they can also cause rapid harm if bleeding is missed. Nurses often catch the first signs at the bedside, before a crisis develops.

Clinical Scenario

A 68-year-old man is on a medical-surgical unit after being admitted with a left lower-extremity deep vein thrombosis. He started a continuous heparin infusion 18 hours ago. His history includes hypertension, type 2 diabetes, and chronic kidney disease stage 3. During morning rounds, the nurse notes that he is more restless than earlier, reports new lower back pain, and has fresh bleeding at his IV site. His urine in the collection container appears pink. Vital signs are temperature 37 C (98.6 F), heart rate 108/min, blood pressure 96/58 mm Hg, respirations 20/min, and oxygen saturation 97% on room air. The latest aPTT result is 118 seconds.

The Question

Which action should the nurse take first?

Answer Choices

1. A. Slow the heparin infusion rate and recheck the aPTT in 1 hour
2. B. Stop the heparin infusion and notify the provider immediately
3. C. Administer the prescribed PRN acetaminophen for back pain and continue close observation
4. D. Encourage increased oral fluids to reduce hematuria and reassess in 30 minutes

Correct Answer

B. Stop the heparin infusion and notify the provider immediately

Detailed Rationale

This patient is showing multiple signs of possible heparin-associated bleeding: oozing at the IV site, pink urine, hypotension, tachycardia, and a markedly elevated aPTT. The new lower back pain is especially concerning because it can point to internal bleeding, including retroperitoneal bleeding. That type of bleeding may not be obvious at first, so the nurse has to connect the symptom with the patient’s anticoagulant therapy.

The first nursing action is to stop the source of harm. In this case, that means stopping the heparin infusion right away. Waiting, slowing the rate, or watching longer would allow anticoagulation to continue while the patient is already showing evidence of bleeding. Once the infusion is stopped, the nurse should notify the provider immediately and be ready for additional orders, such as repeat coagulation studies, a CBC to check hemoglobin and hematocrit, and possible administration of protamine sulfate if the bleeding is clinically significant.

The nurse should also assess systematically. Check for visible bleeding at gums, IV sites, urine, stool, and skin. Ask about headache, abdominal pain, flank pain, dizziness, or weakness, because these can point to internal bleeding. Reassess vital signs closely for worsening shock. Review the medication record for anything else that raises bleeding risk, such as aspirin, NSAIDs, or other anticoagulants.

Monitoring matters just as much as the initial action. After stopping heparin, the nurse should watch blood pressure, heart rate, urine output, mental status, and oxygenation. A falling blood pressure with rising heart rate can mean ongoing blood loss. Decreased urine output can suggest poor perfusion. Mental status changes can be an early sign of decreased cerebral perfusion or intracranial bleeding.

In practice, this is a priority framework question. The patient has signs of an actual complication, not just a risk. Using ABCs and safety priorities, ongoing anticoagulation in a bleeding patient is the immediate threat. The nurse acts first to prevent further harm, then escalates care.

Why the Other Options Are Wrong

A. Slow the heparin infusion rate and recheck the aPTT in 1 hour

This is not enough. The patient already has evidence of bleeding and hemodynamic change. Slowing the infusion still exposes him to more anticoagulant effect. Rechecking labs later delays treatment when the bedside findings already show a serious problem.

C. Administer the prescribed PRN acetaminophen for back pain and continue close observation

The back pain is not the main problem. In a patient on heparin, new back pain can be a red flag for internal bleeding. Treating the symptom without addressing the cause could hide deterioration and delay urgent intervention.

D. Encourage increased oral fluids to reduce hematuria and reassess in 30 minutes

Hematuria in this setting is not likely due to dehydration. It is a possible sign of anticoagulant-related bleeding. Fluids do not fix the cause, and delaying action for 30 minutes could put the patient at greater risk.

Key Takeaways

• Heparin plus bleeding signs plus elevated aPTT means think complication first, not routine adjustment.
• New back, flank, or abdominal pain in an anticoagulated patient can signal internal bleeding.
• The first action is to stop the heparin infusion when active bleeding is suspected.
• Then notify the provider and prepare for labs, reversal, and closer monitoring.
• Do not focus only on the lab value. The bedside assessment tells you how urgent the problem is.

• On-shift mini-checklist:
• Stop the heparin infusion.
• Reassess vital signs and bleeding sites immediately.
• Check mental status, urine output, and pain location.
• Notify the provider with clear data: symptoms, vital signs, aPTT, and current infusion details.
• Prepare for stat CBC, coagulation studies, and possible protamine sulfate.
• Document findings, actions taken, and the patient’s response.

Quick Practice Extension

1. A patient receiving heparin develops sudden severe headache and vomiting. What complication should the nurse suspect first, and what assessment data would make it more urgent?
2. A patient on warfarin has black, tarry stools and an INR above the therapeutic range. What nursing actions should be prioritized before the provider calls back?

Category used today: Pharmacology

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