# A 68-year-old client with atrial fibrillation on warfarin was started on trimethoprim-sulfamethoxazole for a urinary tract infection 4 days ago. The client reports new bruising on the arms and legs. The nurse reviews the electronic health record. What should the nurse do first?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505807&lang=en  
> language: en  
> subject: Pharmacological and Parenteral Therapies  
> category: PPT

## Question

A 68-year-old client with atrial fibrillation on warfarin was started on trimethoprim-sulfamethoxazole for a urinary tract infection 4 days ago. The client reports new bruising on the arms and legs. The nurse reviews the electronic health record. What should the nurse do first?

History

Vitals

Labs

Orders

Notes

Atrial fibrillation on warfarin 5 mg daily; started trimethoprim-sulfamethoxazole for UTI 4 days ago; reports new bruising on arms and legs.

BP 128/78 mmHg, HR 88 bpm, RR 18/min, Temp 98.6°F (37.0°C)

INR 5.8 (therapeutic range 2.0-3.0), Hgb 12.1 g/dL, Platelets 210,000/mm³

Warfarin 5 mg PO daily; Trimethoprim-sulfamethoxazole DS 1 tablet PO BID for 7 days; PT/INR today

Client alert, oriented; multiple ecchymoses on bilateral upper and lower extremities; no active bleeding.

1

Hold the next dose of warfarin and notify the healthcare provider.

✕

2

Administer vitamin K 2.5 mg orally as prescribed.

✕

3

Obtain a urine specimen for culture and sensitivity.

✕

4

Apply ice to the bruised areas and elevate the extremities.

✕

## Explanation

The client's INR is 5.8, which is supratherapeutic and places them at high risk for bleeding, as evidenced by new bruising. The priority action is to hold the next warfarin dose to prevent further anticoagulation and immediately notify the healthcare provider for further orders, such as vitamin K administration or closer monitoring. Administering vitamin K without a provider's order is not within the nurse's scope of practice. Obtaining a urine specimen and applying ice are lower-priority actions that do not address the immediate risk of bleeding.

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