NCLEX Question of the Day – Saturday, March 21, 2026

Today’s question targets early recognition of medication-related complications and the nurse’s next best action. That skill matters because small assessment details often show up before a patient has a full crisis. In real nursing, catching the pattern early can prevent bleeding, respiratory failure, falls, or a rapid response call.

Clinical Scenario

A 72-year-old patient is on a medical-surgical unit after being admitted 2 days ago for a left lower-extremity deep vein thrombosis. The patient has a history of hypertension, chronic kidney disease stage 3, and osteoarthritis. The provider prescribed enoxaparin 80 mg subcutaneously every 12 hours as a bridge to warfarin therapy. During morning assessment, the nurse notes new, large bruises across the abdomen and both arms. The patient says, “My gums bled when I brushed my teeth, and my urine looked a little pink earlier.” The patient is alert and oriented, blood pressure is 108/64 mm Hg, heart rate is 96/min, respirations are 18/min, and oxygen saturation is 97% on room air. The morning lab report shows platelet count decreased from 228,000/mm3 on admission to 86,000/mm3 today.

The Question

Which action should the nurse take first?

Answer Choices

1. A. Administer the scheduled dose of enoxaparin and recheck the platelet count in 4 hours
2. B. Hold the enoxaparin, notify the provider, and prepare to implement bleeding precautions
3. C. Encourage the patient to increase oral fluids to reduce hematuria and continue monitoring
4. D. Place the patient in Trendelenburg position and give oxygen at 2 L/min by nasal cannula

Correct Answer

B. Hold the enoxaparin, notify the provider, and prepare to implement bleeding precautions

Detailed Rationale

This patient has several red flags for a serious anticoagulation-related problem. The key findings are new bruising, bleeding gums, pink urine, and a major platelet drop from 228,000/mm3 to 86,000/mm3. That is not a minor change. It suggests a high risk for bleeding and raises concern for heparin-induced thrombocytopenia, also called HIT, because enoxaparin is a low-molecular-weight heparin.

The nurse’s first priority is safety. The scheduled anticoagulant should be held. Giving another dose could worsen bleeding or increase the severity of the reaction. After holding the medication, the nurse should notify the provider promptly because the patient may need a change in anticoagulation therapy and additional testing. The nurse should also prepare to implement bleeding precautions right away. That includes avoiding unnecessary sticks, using a soft toothbrush, monitoring urine and stool for blood, checking vital signs for signs of hemodynamic instability, and watching for worsening bruising or occult bleeding.

The platelet drop matters because HIT is not just “low platelets.” It is an immune-mediated reaction that can paradoxically increase the risk of thrombosis while platelets are falling. In other words, the patient is at risk for both bleeding signs and dangerous clot formation. That is why this finding requires urgent action, not routine observation.

What should the nurse assess next? Start with a focused bleeding and clotting assessment. Look for petechiae, oozing at injection sites, melena, worsening hematuria, epistaxis, headache, abdominal pain, unilateral swelling, chest pain, or shortness of breath. Review recent medication timing, lab trends, and renal function because reduced kidney function can increase the effect of enoxaparin. Monitor blood pressure and heart rate closely because falling pressure and rising heart rate may be early signs of significant blood loss.

What should the nurse do after notifying the provider? Be ready for orders such as discontinuing all heparin products, obtaining repeat labs, and possibly starting a non-heparin anticoagulant if HIT is suspected. The exact replacement drug depends on the provider’s order and the clinical picture, but the nurse’s role is to recognize the danger early and stop exposure to the likely cause.

The priority logic here is simple: this patient has evidence of active bleeding plus a major platelet decrease while receiving a heparin-based drug. That combination makes continuing the medication unsafe.

Why the Other Options Are Wrong

A. Administer the scheduled dose of enoxaparin and recheck the platelet count in 4 hours

This is unsafe. The patient already has signs of bleeding and thrombocytopenia. Waiting 4 hours delays action and exposes the patient to more harm. The right move is to stop the likely cause first, then escalate.

C. Encourage the patient to increase oral fluids to reduce hematuria and continue monitoring

Pink urine in a patient on anticoagulants is not just a hydration issue. It may be blood. Fluids do not fix medication-induced bleeding or HIT. This option ignores the most urgent problem.

D. Place the patient in Trendelenburg position and give oxygen at 2 L/min by nasal cannula

This patient is not showing signs of shock or respiratory distress. Blood pressure is low-normal but not crashing, oxygen saturation is normal, and respirations are stable. Trendelenburg is not the first-line response here and does not address the cause of the problem.

Key Takeaways

• New bruising, mucosal bleeding, hematuria, and a sharp platelet drop in a patient on enoxaparin are urgent findings.
• Low platelets with heparin exposure can point to HIT, which increases clot risk even while bleeding signs may appear.
• The nurse should hold the anticoagulant first, then notify the provider and apply bleeding precautions.
• Trend the platelet count, assess for occult bleeding, and monitor for new thrombosis.
• Chronic kidney disease can increase enoxaparin effect because the drug is cleared through the kidneys.

• On-shift mini-checklist:
• Stop and verify the next anticoagulant dose before giving it.
• Check platelet trend, urine, stool, gums, skin, and injection sites.
• Monitor vital signs for hidden blood loss.
• Use bleeding precautions and avoid unnecessary invasive procedures.
• Report the findings clearly: drug, dose, timing, symptoms, platelet drop, and current vital signs.

Quick Practice Extension

1. If this same patient suddenly reports shortness of breath and chest pain, what complication should the nurse suspect first, and what assessment would become the priority?

2. If the provider discontinues enoxaparin and orders a different anticoagulant, what teaching points should the nurse give about monitoring for bleeding at home?

Category today: Pharmacology

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