reporting facial grimacing in unresponsive clients
asking clients directly, “Are you having any pain right now?”
giving acetaminophen (Tylenol) after the nurse obtains the medication but is interrupted to attend a code blue before she administers it
Numbers 2, 3, and 4 are correct.
Asking clients if they currently have any pain and reminding clients to report pain are within the scope of practice for the UAP. The UAP may also report facial grimacing to the nurse, who can then assess the pain. Assessing pain using the pain scale should be done by the nurse, as assessment is a nursing action. No medications, even over-the-counter ones, may be given by anyone other than the licensed nurse. If the nurse is interrupted for an emergency, another nurse may administer the medication after assessing the client’s pain and checking the chart for any allergies, if facility protocols permit this. The nurse is ultimately responsible for the task that has been delegated.