# A nurse is caring for a client who underwent a radical cystectomy with ureterostomy 2 days ago. Which nursing intervention is most important for preventing complications in this client?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541524  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a client who underwent a radical cystectomy with ureterostomy 2 days ago. Which nursing intervention is most important for preventing complications in this client?

## 보기

1. Encourage the client to drink 3-4 liters of fluid daily to maintain adequate hydration
2. Monitor urine output and assess stoma appearance every 2 hours for signs of complications **✔ 정답**
3. Assist the client with deep breathing exercises and ambulation to prevent pneumonia
4. Administer prescribed pain medications on a scheduled basis to maintain comfort

**정답: 2**

## 해설

Monitoring urine output and stoma appearance every 2 hours is critical to detect early complications like obstruction, infection, or necrosis in ureterostomy patients. Other options are important but less urgent for immediate complication prevention.

## 심화 해설

Understanding the Postoperative Context

A radical cystectomy with ureterostomy is a major surgical procedure that involves the removal of the urinary bladder and the creation of a new pathway for urine elimination through a stoma on the abdominal wall. In the immediate postoperative period, the most critical priority is ensuring the viability and function of the newly created urinary diversion. The stoma, constructed from a segment of the ileum, is particularly vulnerable to ischemia and necrosis due to potential edema or compromised blood flow. Simultaneously, the ureteroileal anastomosis is at risk for obstruction or leakage, which can lead to life-threatening complications such as urinary ascites, infection, and acute kidney injury.

Prioritizing the Most Important Intervention

While all listed interventions are components of comprehensive postoperative care, the most important action to prevent complications is to monitor urine output and assess stoma appearance every 2 hours. This intervention directly targets the most time-sensitive and high-risk complications specific to this surgery. A sudden decrease in urine output is the earliest and most objective sign of a potentially reversible obstruction, a leak, or prerenal failure due to hypovolemia. The evidence supporting enhanced recovery pathways for radical cystectomy emphasizes that structured, protocol-driven monitoring is fundamental to reducing complication rates by enabling early detection and intervention . Without vigilant monitoring, a mechanical or vascular complication could progress silently, leading to irreversible tissue damage or severe metabolic disturbances before systemic signs become apparent.

Clinical Rationale and Evidence-Based Practice

The assessment of the stoma must include its color, moisture, and turgor. A healthy, well-perfused stoma should appear rosy and moist. A stoma that becomes dusky, cyanotic, or black indicates critical ischemia, a surgical emergency requiring immediate notification of the surgeon. This frequent monitoring is a cornerstone of specialized nursing-led interventions for bladder cancer management, which have been shown to significantly impact clinical outcomes through systematic and proactive assessment . Furthermore, the meticulous observation of the peristomal skin is crucial. The development of peristomal skin complications (PSCs) is a significant source of patient distress and morbidity, and early identification of symptoms like erythema, erosion, or maceration can prevent severe breakdown that compromises the pouching system and leads to urine leakage . While promoting fluid intake of 3-4 liters daily is essential for maintaining urine flow and preventing infection, it is a secondary, longer-term goal. In the first 48 hours, fluid status is managed primarily through intravenous therapy, and the priority is verifying that the urine is flowing freely through the newly created system. Similarly, deep breathing exercises and scheduled pain management are vital for preventing pneumonia and promoting comfort, but they do not take precedence over the assessment that directly detects failure of the primary surgical reconstruction. A key focus of evidence-based care bundles for these patients is the recovery of gastrointestinal function, which is a parallel but distinct concern from the immediate patency of the urinary diversion . The nurse’s ability to interpret the significance of hourly urine output and subtle changes in stoma viability is the most critical factor in preventing a cascade of severe, potentially fatal, postoperative complications.

## 임상 시나리오

Post-Ureterostomy Stoma & Output MonitoringEarly Detection of Ischemia and Obstruction
Assess the stoma every 2 hours for color, moisture, and edema. A healthy stoma is budding, moist, and pink to red. Any dusky, cyanotic, or black appearance indicates ischemia and requires immediate reporting.

Monitor urine output hourly. A sudden decrease or cessation is the earliest sign of a mechanical obstruction, anastomotic leak, or acute kidney injury. Notify the surgeon immediately for output less than 30 mL/hour.

CautionNever catheterize a ureterostomy stoma without a specific order, as this can disrupt the delicate ureteroileal anastomosis and cause a leak or perforation.

## 핵심 개념

- **Radical Cystectomy** — Surgical removal of the urinary bladder, often performed for invasive bladder cancer.
- **Ureterostomy** — A surgical procedure that creates a stoma on the abdominal wall to divert urine flow directly from the ureters to the outside of the body.
- **Stomal Ischemia** — Inadequate blood supply to the stoma, an early postoperative complication that can lead to tissue necrosis if not promptly identified.
- **Ureteroileal Anastomosis** — The surgical connection between the ureters and a segment of the ileum used to create a conduit for urine in a urinary diversion.

## 같은 주제 문제

- [A nurse is assessing a 55-year-old female client who has been diagnosed with bladder cance…](https://mymerci.kr/pages/nclex_q.php?qn_id=540752)
- [A nurse is assessing a 68-year-old male client who has been diagnosed with bladder cancer.…](https://mymerci.kr/pages/nclex_q.php?qn_id=540753)
- [A nurse is caring for a client who underwent a radical cystectomy with urinary diversion 2…](https://mymerci.kr/pages/nclex_q.php?qn_id=540754)
- [A nurse is caring for a client who underwent a radical cystectomy with urinary diversion 2…](https://mymerci.kr/pages/nclex_q.php?qn_id=540755)
- [A 55-year-old female client presents to the clinic with symptoms suggestive of bladder can…](https://mymerci.kr/pages/nclex_q.php?qn_id=541519)
- [A nurse is assessing a 68-year-old male client who has been diagnosed with bladder cancer.…](https://mymerci.kr/pages/nclex_q.php?qn_id=541520)
- [A nurse is assessing a 55-year-old male client who has been diagnosed with bladder cancer.…](https://mymerci.kr/pages/nclex_q.php?qn_id=541521)
- [A nurse is caring for a client who underwent a radical cystectomy with ileal conduit creat…](https://mymerci.kr/pages/nclex_q.php?qn_id=541522)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._