# Situation: A 62-year-old woman has cirrhosis caused by chronic hepatitis B. Endoscopy shows large esophageal varices that have never bled. She has moderate ascites and takes spironolactone, furosemide, and lactulose. Carvedilol has just been started. Her discharge plan states: take carvedilol twice daily; hold the dose and call the clinic if the pulse is below 55/min or the systolic blood pressure is below 90 mmHg; do not stop the drug or change the dose on her own. The nurse asks her what she would do with different home readings. Which statement shows correct understanding?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630394  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 62-year-old woman has cirrhosis caused by chronic hepatitis B. Endoscopy shows large esophageal varices that have never bled. She has moderate ascites and takes spironolactone, furosemide, and lactulose. Carvedilol has just been started.

Her discharge plan states: take carvedilol twice daily; hold the dose and call the clinic if the pulse is below 55/min or the systolic blood pressure is below 90 mmHg; do not stop the drug or change the dose on her own. The nurse asks her what she would do with different home readings. Which statement shows correct understanding?

## 보기

1. "My pulse is 54 and my top pressure 110, so I'll take half a tablet."
2. "My pulse is 62 and my top pressure 88, so I'll hold it and call." **✔ 정답**
3. "My pulse is 56 but I feel dizzy, so I'll stop it until my next visit."
4. "My pulse is 58 and my top pressure 94, so I'll skip today's dose."

**정답: 2**

## 해설

Carvedilol lowers portal pressure to prevent a first variceal bleed but can cause bradycardia and hypotension, so her plan sets two hold limits, and either one alone is enough. A systolic pressure of 88 mmHg is below 90 even though the pulse of 62/min is acceptable, so she holds the dose and calls. She does not skip, halve, or stop the drug on her own.

## 심화 해설

The statement that shows correct understanding
Her plan sets two separate hold limits for carvedilol: hold the dose and call the clinic if the pulse is below 55/min or the systolic blood pressure is below 90 mmHg. Either limit alone is enough to hold the dose. A pulse of 62/min with a systolic pressure of 88 mmHg meets the blood pressure limit, so she holds the dose and calls. This is the statement that shows correct understanding.

Why carvedilol is used and why it needs limits
Carvedilol is a nonselective beta blocker with additional alpha-blocking action. In cirrhosis with large varices that have never bled, it lowers portal pressure and reduces the risk of a first variceal bleed. The same actions can cause bradycardia and hypotension, which is why the plan includes hold limits. She must not skip, halve, or stop the drug on her own, because inconsistent dosing weakens protection against bleeding, and abrupt stopping of a beta blocker is avoided.

| Reading | Pulse below 55? | Systolic below 90? | Action |
| --- | --- | --- | --- |
| Pulse 54, systolic 110 | Yes | No | Hold and call; do not halve |
| Pulse 62, systolic 88 | No | Yes | Hold and call |
| Pulse 56, dizzy | No | Not stated | Report dizziness; do not stop on her own |
| Pulse 58, systolic 94 | No | No | Dose is due; take it |

Why the other statements are wrong
With a pulse of 54, she meets the hold limit, but taking half a tablet is a dose change made on her own; the plan says hold and call. Feeling dizzy with a pulse of 56 should be reported, but stopping the drug until the next visit is exactly what the plan forbids. With a pulse of 58 and systolic 94, both readings are above the limits, so skipping the dose leaves her unprotected without reason.

Teaching approach
Asking the client to apply the rules to sample readings is an effective way to check understanding. The nurse teaches her to check pulse and blood pressure before each dose, to record the readings, to treat the two limits as independent triggers, and to report dizziness, fainting, or black stools.

Exam takeaway
Watch out When a plan lists two hold limits joined by "or," one abnormal value is enough. Answers that modify the dose without contacting the prescriber are always unsafe.

## 임상 시나리오

Carvedilol Hold Limits at HomeApplying two independent rules
Carvedilol lowers portal pressure to prevent a first variceal bleed but can cause bradycardia and hypotension. Her plan holds the dose if pulse is below 55/min or systolic pressure is below 90 mmHg.

Either limit alone is enough. A systolic pressure of 88 mmHg with a pulse of 62/min means hold the dose and call the clinic.

CautionShe must not halve, skip, or stop the drug on her own. Abrupt stopping is avoided, and missed doses weaken protection against bleeding.

## 핵심 개념

- **Carvedilol** — A nonselective beta blocker with alpha-blocking action, used to lower portal pressure in cirrhosis.
- **Esophageal varices** — Dilated veins in the lower esophagus caused by portal hypertension, which can bleed massively.
- **Primary prophylaxis** — Treatment to prevent a first event, such as a first variceal bleed.
- **Hold parameter** — A preset vital sign limit at which a dose is withheld and the prescriber is contacted.

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