The client is to receive 4 mg of Maxeran SC (Subcut). Maxeran is available in 10 mg per 2 mL ampules. How many mL does the nurse give?

A. Proceed with the administration of the medication as the nurse has been caring for Mr. Robertson for the past two days: Prior familiarity with a patient does not replace proper identification. Administering insulin without verification of identity risks serious medication errors, including giving the wrong dose to the wrong patient.

B. Ask Mr. Robertson to state his full name, home address, phone number and date of birth: While obtaining verbal identifiers is part of patient verification, relying solely on self-report is insufficient, especially in cases of cognitive impairment or altered mental status. Two independent identifiers are required, and an armband is a primary identifier.

C. Verify with a colleague that the client is indeed Mr. Robertson: Colleague confirmation is not adequate without objective verification from a source document or armband. Peer confirmation cannot legally replace proper patient identification procedures for medication administration.

D. Return to the nursing station and have a new armband made: The correct action is to ensure the patient has an updated identification armband before administering any medication. This guarantees adherence to the “right patient” safety standard, prevents medication errors, and complies with legal and institutional policies.

A. Ask the client to state his name and medical record number: Asking the client to state identifiers is appropriate; however, relying solely on verbal confirmation without cross-checking with the armband and source document does not meet full identification standards. Patients may be confused, sedated, or provide incorrect information unintentionally.

B. Check the sign above the bed to the MAR & check the armband: The sign above the bed should never be used as a primary identifier because room assignments can change. While checking the armband is essential, including the bed sign introduces risk and does not align with best-practice identification policies.

C. Compare the source document to the client's armband & ask him to state his name: Best practice requires using at least two identifiers, such as full name and medical record number, and verifying them against the armband and the MAR. Asking the client to state their name rather than confirming it ensures active participation and reduces identification errors.

D. Call the client by name on MAR and observe his response: Calling the client by name and observing a response is insufficient because patients may respond reflexively even if misidentified. This method does not fulfill the requirement of using two independent identifiers to ensure safe medication administration.