NCLEX Question of the Day – Tuesday, February 24, 2026

Today’s question targets safe anticoagulant management: reading a critical lab, spotting bleeding risk, and choosing the first action. These decisions prevent hemorrhage at the bedside. You will use this skill whenever a patient receives high-risk medications like heparin.

Clinical Scenario

A 68-year-old man on a telemetry unit is receiving a weight-based unfractionated heparin infusion for a pulmonary embolism started 12 hours ago. History includes hypertension and stage 3 chronic kidney disease. He reports a mild headache and “bloody taste” in his mouth. The nurse notes oozing at his peripheral IV site and a small spontaneous nosebleed. Vital signs: BP 118/68, HR 96 and irregular, RR 18, SpO2 96% on room air. Labs just resulted: aPTT 122 seconds (baseline 31 seconds; facility therapeutic target 60–80 seconds).

The Question

Which action should the nurse take first?

Answer Choices

1. Stop the heparin infusion and notify the provider; prepare to administer protamine sulfate if ordered.
2. Reduce the heparin infusion rate by 50% and recheck the aPTT in 1 hour.
3. Continue the heparin infusion and apply firm pressure to the nose and IV site.
4. Administer vitamin K as an antidote for heparin and continue to monitor.

Correct Answer

A. Stop the heparin infusion and notify the provider; prepare to administer protamine sulfate if ordered.

Detailed Rationale

This patient has a critically elevated aPTT (122 seconds) and signs of active bleeding (epistaxis, gum/IV oozing). Unfractionated heparin increases bleeding risk as a dose- and time-dependent effect. When the aPTT is far above the target and bleeding is present, the priority is to immediately stop the source of anticoagulation. This action limits further anticoagulant effect while you reassess and escalate care.

Next, notify the provider using concise SBAR: current aPTT, bleeding signs, vital signs, and infusion details (concentration, rate, start time, weight). Anticipate orders for reversal with protamine sulfate, the specific antidote for heparin. Protamine binds heparin, neutralizing its effect. Expect repeat coagulation labs after reversal and close monitoring for recurrent bleeding.

While awaiting orders, perform focused assessments and safety measures:

• Reassess bleeding sites (gums, nose, IV, urine, stool). Check for bruising, hematuria, melena, or new back/abdominal pain that could signal internal bleeding.
• Trend vital signs for early hypovolemia (tachycardia, hypotension) and monitor mental status for signs of intracranial bleed.
• Maintain IV access; avoid new invasive procedures (IM injections, arterial sticks) unless emergent.
• Have type and screen current; gather supplies for protamine and repeat labs.
• Educate the patient to report new bleeding, dizziness, severe headache, or weakness.

Stopping the infusion first is a high-priority safety intervention because it directly removes the immediate cause of harm. Supportive measures (pressure to the nose) help, but they do not fix the pharmacologic problem. Rate adjustments are too slow and unsafe in the context of active bleeding with a critically high aPTT.

Why the Other Options Are Wrong

• B. Reduce the heparin infusion rate by 50% and recheck the aPTT in 1 hour. Inadequate and unsafe. With active bleeding and a very high aPTT, simply reducing the rate allows continued anticoagulation and ongoing risk. The correct first step is to stop the infusion.
• C. Continue the heparin infusion and apply firm pressure to the nose and IV site. This treats a symptom but ignores the cause. Local pressure may slow bleeding, but maintaining the infusion increases the chance of serious hemorrhage (GI, intracranial). Not the priority.
• D. Administer vitamin K as an antidote for heparin and continue to monitor. Vitamin K reverses warfarin, not heparin. The antidote for heparin is protamine sulfate. Giving vitamin K will not correct heparin-induced anticoagulation.

Key Takeaways

• Unfractionated heparin is monitored with aPTT; target is typically 1.5–2.5 times baseline (often 60–80 seconds, facility-specific).
• Active bleeding with a critically high aPTT requires immediate cessation of the heparin infusion.
• Protamine sulfate reverses heparin; vitamin K reverses warfarin.
• Assess for overt and occult bleeding and trend vitals for hemorrhagic instability.
• Avoid new invasive procedures until anticoagulation is corrected.

On-shift mini-checklist (heparin infusion):

• Verify weight-based dose, concentration, and pump settings with a second nurse per policy.
• Check baseline and scheduled aPTT, CBC (Hgb/Hct), and platelets.
• Assess for bleeding each round: gums, nose, IV sites, urine, stool, bruising.
• If aPTT is critically high or bleeding occurs: stop infusion, notify provider, prepare protamine, repeat labs, maintain IV access, and implement bleeding precautions.

Quick Practice Extension

1. A patient on a heparin infusion has a new platelet count drop from 220,000 to 95,000 in 24 hours without obvious bleeding. What is your priority concern and first action?
2. After administering protamine sulfate for heparin reversal, which labs and timing would you anticipate to evaluate effectiveness and guide next steps?

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com