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    Hesi rn health assessment proctored exam

    To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

    Explanation & Rationale

    A. Ask the client to describe any other related symptoms. This gathers subjective data but does not objectively confirm a fever. B. Use both hands to hold and palpate the client's hands. Palpating hands can provide a sense of temperature but is not a reliable method for confirming fever. C. Lightly pinch a fold of skin over the client's sternum. Pinching the skin assesses turgor for hydration status, not fever. D. Place the dorsum of the hand on the client's forehead. This is the best choice for a quick, objective assessment. Using the dorsum (back) of the hand is more sensitive to temperature changes, which can preliminarily indicate fever before using a thermometer for confirmation.

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