A nurse is preparing to apply a fentanyl transdermal patch. Which of the following actions should the nurse take?

A. Eyelid edema (swelling) can be a sign of angioedema, which is a rare but serious side effect of ACE inhibitors like lisinopril. Angioedema involves swelling of deeper layers of the skin, often around the eyes, lips, tongue, throat, and sometimes the hands and feet. It can lead to airway obstruction and is potentially life-threatening. Immediate medical evaluation and possibly discontinuation of the medication are necessary if angioedema is suspected.

B. Nausea is a common side effect of many medications, including lisinopril, but it is generally not considered a serious adverse reaction unless severe or persistent.

C Insomnia (difficulty sleeping) can occur as a side effect of medications but is not typically associated with lisinopril to the extent of warranting immediate reporting.

D. A dry, persistent cough is a well-known side effect of ACE inhibitors like lisinopril.

Rationale: While annoying and uncomfortable, a dry cough is usually not dangerous and can be managed with symptomatic treatment or, if severe, by switching to a different class of antihypertensive medication.

C. It is critical to ensure that the client remains responsive and that the sedation level does not deepen into unintended levels, such as deep sedation or general anesthesia, which would require more intensive monitoring and intervention.

A. Midazolam does not directly affect body temperature, and changes in temperature are not typically acute concerns following its administration.

B. Midazolam can cause a decrease in heart rate, especially when used in conjunction with other sedatives or narcotics. Monitoring heart rate helps detect any adverse cardiovascular effects promptly.

D. Midazolam, like other sedative medications, can depress respiratory drive, particularly if higher doses are used or if the client has underlying respiratory conditions. Monitoring oxygen saturation helps detect early signs of respiratory compromise.