What is the priority action the nurse should take when a client with DVT is mistakenly given heparin along with warfarin?

In the scenario where a client with deep vein thrombosis (DVT) has received both heparin and warfarin mistakenly, the priority action is to monitor for signs of bleeding. This is crucial because both heparin and warfarin are anticoagulants that can significantly increase the risk of hemorrhage when administered simultaneously.

Monitoring for signs of bleeding allows the nurse to quickly identify any adverse effects resulting from the interaction of these medications. Signs such as unusual bruising, prolonged bleeding from cuts, blood in urine or stool, or changes in mental status can indicate serious complications that require prompt intervention.

While notifying the healthcare provider is also important, the immediate focus should be on the client's safety and the recognition of any bleeding complications that could emerge from this medication error. Establishing an intravenous line for fluids might be necessary later depending on the situation, but it does not address the immediate hazard of potential bleeding. Checking vital signs every hour is routine but does not specifically account for the critical need to monitor bleeding risks in this context. Prioritizing the assessment of bleeding aligns with the most pressing need for patient safety when faced with the risks associated with anticoagulation therapy.