# A 59-year-old with cirrhosis and previously documented large esophageal varices develops hematemesis without preceding retching. After initial blood-product resuscitation, the client is awake, protects the airway, and has BP 104/66 mm Hg and pulse 106/min. Two large-bore IVs are patent. There is no current confusion or tense ascites. Urgent endoscopy is being arranged; the medication orders below are available for the nurse to clarify or implement. Select the most likely bleeding source, TWO pharmacologic actions before endoscopy, and TWO bedside parameters that best track restored perfusion over the next 2 hours.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=569388&lang=en  
> language: en  
> subject: Illness Management  
> category: PA

## Question

A 59-year-old with cirrhosis and previously documented large esophageal varices develops hematemesis without preceding retching. After initial blood-product resuscitation, the client is awake, protects the airway, and has BP 104/66 mm Hg and pulse 106/min. Two large-bore IVs are patent. There is no current confusion or tense ascites. Urgent endoscopy is being arranged; the medication orders below are available for the nurse to clarify or implement. Select the most likely bleeding source, TWO pharmacologic actions before endoscopy, and TWO bedside parameters that best track restored perfusion over the next 2 hours.

Condition

Select 1
Portal-hypertensive esophageal variceal hemorrhage
Stress-related gastric ulcer bleeding after illness
Mucosal tear following repeated forceful vomiting
Portal-hypertensive gastropathy with chronic oozing

Actions to take

Select 2
Start oral propranolol during the active bleeding episode
Begin prescribed IV octreotide before endoscopy
Give oral lactulose to prevent future confusion
Begin prescribed IV ceftriaxone before endoscopy
Give IV furosemide to reduce portal venous pressure

Parameters to monitor

Select 2
Blood pressure and pulse trend at the bedside
Serum ammonia concentration after admission
Abdominal girth compared with the prior clinic visit
Hourly urine output after initial resuscitation
Longitudinal serum albumin response to nutrition

## Explanation

Choose esophageal variceal hemorrhage; begin prescribed octreotide and ceftriaxone. Monitor blood pressure/pulse trends and hourly urine output. Known large varices and acute hematemesis make variceal bleeding the leading working diagnosis, although endoscopy establishes the source. Vasoactive treatment and antibiotic prophylaxis are indicated before endoscopy in suspected acute variceal hemorrhage. Bedside hemodynamics and urine output provide complementary perfusion information.

## In-depth explanation

Correct answer
Choose esophageal variceal hemorrhage; begin prescribed octreotide and ceftriaxone. Monitor blood pressure/pulse trends and hourly urine output.

Why this is correct
Known large varices and acute hematemesis make variceal bleeding the leading working diagnosis, although endoscopy establishes the source. Vasoactive treatment and antibiotic prophylaxis are indicated before endoscopy in suspected acute variceal hemorrhage. Bedside hemodynamics and urine output provide complementary perfusion information.

Clinical picture
Successful initial resuscitation is a transition to continued surveillance, not proof that bleeding has stopped. Recurrent hematemesis, falling pressure, worsening tachycardia, or declining urine output requires prompt reassessment and escalation.

Memory hook
Stabilize circulation, reduce portal inflow, prevent infection, and obtain definitive hemostasis. These are complementary tasks, not a universal minute-by-minute ordering rule.

NCLEX decision rule
Distinguish active-bleeding management from secondary prevention and from treatment of other cirrhosis complications. Do not postpone indicated vasoactive therapy or antibiotic prophylaxis until the endoscopic diagnosis.

Why the alternatives are wrong
Ulcer bleeding remains a possible differential but the known large varices favor the selected source. A mucosal tear is less supported without forceful retching. Chronic gastropathy oozing is less consistent with this acute presentation. Propranolol belongs to prevention after stabilization and can worsen hypotension during active bleeding. Lactulose addresses encephalopathy, absent here, and does not achieve hemostasis. Furosemide is not acute variceal-bleeding therapy and may impair perfusion. Ammonia, abdominal girth and albumin address other disease dimensions rather than immediate resuscitation response. Hemoglobin is clinically important but is not among these bedside options and cannot replace perfusion assessment.

Sources
AASLD variceal bleeding

## Clinical scenario

Practice transfer: Successful initial resuscitation is a transition to continued surveillance, not proof that bleeding has stopped. Recurrent hematemesis, falling pressure, worsening tachycardia, or declining urine output requires prompt reassessment and escalation.

## Key concepts

- **Portal hypertension** — Elevated pressure in the portal venous system.
- **Vasoactive therapy** — Medication that changes vascular tone or regional blood flow.
- **Perfusion** — Delivery of blood to tissues sufficient to support their function.

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