A nurse is preparing the discharge paperwork for a client newly diagnosed with a new onset of hearing loss. The nurse understands that the most appropriate intervention for this client would be?

Choice A reason: Shallow breathing may indicate respiratory depression, a concern with opioids, but assessing pain intensity is the priority to determine the need for medication need. Pain level guides safe dosing, ensuring appropriate relief without overmedicating, making this a secondary assessment in acute pain.

Choice B reason: Blood pressure may rise with pain but is less specific than pain intensity for guiding medication administration. Pain level directly informs the need for and dose of analgesia, while blood pressure changes can have multiple causes, making this less critical.

Choice C reason

d): Assessing pain intensity level is the priority, as it quantifies the client’s subjective experience using a scale (e.g., 0-10 scale)), determining the need for and dose of pain medication. This ensures effective, patient-centered pain management, making it the most critical assessment before administering medication.

Choice D reason: Heart rate may increase with pain, but it is not the priority compared to pain intensity, which directly drives medication decisions. Heart rate changes are less specific and can result from other factors (e.g., anxiety), making this a secondary assessment in acute pain management.

Choice A reason: pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L are normal values, indicating no acidosis. Metabolic acidosis involves low pH and low bicarbonate, which this does not show, making it incorrect.

Choice B reason: pH 7.4 is normal, and HCO3- 35 mEq/L suggests metabolic alkalosis, not acidosis. Renal failure and diabetes typically cause acidosis due to acid accumulation, making this inconsistent with metabolic acidosis.

Choice C reason: pH 7.3 (low) and HCO3- 19 mEq/L (low) with normal PaCO2 indicate metabolic acidosis, common in renal failure due to impaired acid excretion and diabetic ketoacidosis, making this the correct choice.

Choice D reason: pH 7.45 and HCO3- 30 mEq/L suggest metabolic alkalosis, not acidosis. Elevated bicarbonate is opposite to the low levels expected in metabolic acidosis, making this incorrect for the patient’s condition.