# A client receiving an IV unfractionated heparin infusion has oozing from the venipuncture site and an aPTT above the therapeutic range. Which action should the nurse take?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397309&lang=en  
> language: en  
> subject: Blood/Blood Products  
> category: PPT

## Question

A client receiving an IV unfractionated heparin infusion has oozing from the venipuncture site and an aPTT above the therapeutic range. Which action should the nurse take?

## Option

1. Increase the infusion because clotting risk remains high.
2. Massage the venipuncture site until the oozing stops.
3. Administer aspirin to improve anticoagulation control.
4. Hold the infusion according to protocol and notify the provider. **✔ Correct answer**

**Correct answer: 4**

## Explanation

Bleeding with an elevated aPTT indicates excessive anticoagulation. The nurse should follow the heparin protocol, hold or adjust the infusion as directed, and notify the provider. Increasing heparin, massaging the site, or adding aspirin increases bleeding risk.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Heparin over-anticoagulation.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Heparin over-anticoagulation, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Heparin** — An anticoagulant that requires monitoring for bleeding and therapeutic effect.
- **aPTT** — A laboratory test used to monitor unfractionated heparin effect.
- **Bleeding Precautions** — Safety measures used to reduce injury when bleeding risk is increased.

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