A nurse is caring for a client who has COPD.
The following are the client’s vital signs: Temperature 38.6C (101.5° F), BP 114/86 mm Hg, Heart rate 99/min, Respiratory rate 32/min, Oxygen saturation 85% on room air.
Which three findings require follow-up?

Choice A rationale

A lesion with uniform pigmentation is not typically a sign of skin malignancy. Most benign moles are uniform in color, including shades of tan, brown, and black.

Choice B rationale

The new appearance of petechiae, or small, pinpoint hemorrhages under the skin, is not typically associated with skin cancer. Petechiae can be a sign of a number of conditions, including certain infections, low platelet count, or certain medications.

Choice C rationale

A mole with an asymmetrical appearance is a potential indication of skin malignancy. Asymmetry, where one half of the mole does not match the other, is one of the ABCDEs (Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, and Evolving size, shape, or color) of melanoma detection.

Choice D rationale

The presence of a papule, a small, raised bump on the skin, is not necessarily indicative of skin cancer. Papules can be a sign of many different skin conditions, including acne, skin infections, or dermatitis.

Choice A rationale

Carrying a patient’s soiled linens out of the room in a mesh linen bag is not the most effective way to prevent the spread of infection. While it’s important to handle soiled linens properly to avoid contaminating oneself or the environment, this action alone does not have a significant impact on preventing the spread of infection among a group of patients.

Choice B rationale

Placing a patient who has tuberculosis in a room with negative-pressure airflow is a key measure in preventing the spread of this airborne infection. Negative-pressure rooms prevent

contaminated air from escaping the room and spreading to other areas, thereby protecting other patients and healthcare workers.

Choice C rationale

Providing disposable plates and utensils for a patient who is HIV-positive is not necessary for preventing the spread of infection. HIV is not transmitted through casual contact or through sharing food or utensils.

Choice D rationale

Disposing of a patient’s blood-saturated dressing in a trash bag inside a second trash bag is a good practice for handling biohazardous waste, but it is not the most effective measure for preventing the spread of infection among a group of patients.