A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.
The client becomes agitated and combative when the nurse approaches him.
Which of the following actions should the nurse plan to take?

Choice A rationale:

Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.

Choice B rationale:

Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.

Choice C rationale:

Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.

Choice D rationale:

Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue first.

Choice A rationale:

"Obtain a prescription for pramipexole." Rationale: This statement is not appropriate for a pregnant client experiencing trouble sleeping. Pramipexole is a medication used to treat restless legs syndrome and Parkinson's disease. It is not typically prescribed for sleep disturbances during pregnancy.

Choice B rationale:

"Lie on your left side with your top leg forward." Rationale: This is the correct instruction. The recommended sleeping position during pregnancy is lying on the left side with the top leg forward. This position can help improve blood flow to the uterus and relieve pressure on major blood vessels, promoting better sleep.

Choice C rationale:

"Use a transcutaneous electrical nerve stimulator." Rationale: Using a transcutaneous electrical nerve stimulator (TENS) is not a standard intervention for pregnancy-related sleep problems. TENS units are typically used for pain management and are not indicated for sleep disturbances.

Choice D rationale:

"Soak in a bathtub of hot water each night." Rationale: This recommendation is not appropriate during pregnancy. Soaking in hot water for extended periods can raise the body's core temperature, which is not recommended during pregnancy as it may pose a risk to the developing fetus. Pregnant individuals should avoid hot tubs, saunas, and prolonged exposure to hot water.