# A 60-year-old client diagnosed with a new deep vein thrombosis is started on enoxaparin therapeutic dose AND warfarin 5 mg orally on the same day. The provider plans transition to oral warfarin only. Which transition criterion should the nurse expect to apply?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375007&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 60-year-old client diagnosed with a new deep vein thrombosis is started on enoxaparin therapeutic dose AND warfarin 5 mg orally on the same day. The provider plans transition to oral warfarin only. Which transition criterion should the nurse expect to apply?

## Option

1. Continue enoxaparin and warfarin together (overlap) for at least 5 days AND until the INR has been within the therapeutic range (typically 2.0-3.0) for at least 24 hours, then discontinue enoxaparin. **✔ Correct answer**
2. Initiate warfarin therapy following a 5-day course of enoxaparin, because providing low-molecular-weight heparin alone before warfarin reduces the risk of paradoxical clotting in the initial phase of oral anticoagulation.
3. Stop warfarin and continue enoxaparin monotherapy, because low-molecular-weight heparin provides more reliable anticoagulation for DVT than warfarin, which is no longer indicated for long-term prevention.
4. Discontinue enoxaparin after 2 days of concurrent therapy, since warfarin reaches its full anticoagulant effect by the second day and the INR will be in the therapeutic range without further overlap.

**Correct answer: 1**

## Explanation

Warfarin transition rule
Warfarin inhibits the synthesis of new vitamin-K-dependent clotting factors (II, VII, IX, X) and proteins C, S. Existing factors must clear before INR rises into therapeutic range — this typically takes 5-7 days. During the warm-up period, the patient is paradoxically pro-thrombotic because protein C (anticoagulant) drops faster than factor II.

Standard transition (CHEST/ACC guideline):
• Start warfarin and parenteral anticoagulant (UFH, LMWH, or fondaparinux) on day 1 simultaneously when feasible.
• Overlap for at least 5 days AND until INR ≥2.0 for at least 24 hours.
• Then stop the parenteral agent and continue warfarin.
• Mechanical valves, large clot burden, malignancy may require longer parenteral therapy.

Option 4 (stop tomorrow) leaves the patient unprotected. Option 3 (stop warfarin) defeats the long-term oral plan. Option 2 (delay warfarin) is wrong — warfarin and parenteral start together to overlap.

## In-depth explanation

Clinical reasoning summary
Warfarin transition rule
Warfarin inhibits the synthesis of new vitamin-K-dependent clotting factors (II, VII, IX, X) and proteins C, S. Existing factors must clear before INR rises into therapeutic range — this typically takes 5-7 days. During the warm-up period, the patient is paradoxically pro-thrombotic because protein C (anticoagulant) drops faster than factor II.

Standard transition (CHEST/ACC guideline):
• Start warfarin and parenteral anticoagulant (UFH, LMWH, or fondaparinux) on day 1 simultaneously when feasible.
• Overlap for at least 5 days AND until INR ≥2.0 for at least 24 hours.
• Then stop the parenteral agent and continue warfarin.
• Mechanical valves, large clot burden, malignancy may require longer parenteral therapy.

Option 1 (stop tomorrow) leaves the patient unprotected. Option 3 (stop warfarin) defeats the long-term oral plan. Option 4 (delay warfarin) is wrong — warfarin and parenteral start together to overlap.

## Related questions

- [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en)
- [A 68-year-old client with COPD is admitted with shortness of breath and SpO2 86% on room a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362940&lang=en)
- [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en)
- [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en)
- [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en)
- [A 76-year-old female with chronic heart failure and atrial fibrillation receives digoxin 0…](https://mymerci.kr/pages/nclex_q.php?qn_id=374883&lang=en)
- [A 70-year-old client on long-term digoxin therapy reports new yellow-green halos around li…](https://mymerci.kr/pages/nclex_q.php?qn_id=374884&lang=en)
- [A 58-year-old client with type 2 diabetes mellitus and migraine prophylaxis is taking prop…](https://mymerci.kr/pages/nclex_q.php?qn_id=374893&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=375007&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=375007&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=375007&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=375007&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=375007&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._