An adolescent boy is admitted to the emergency department (ED) following a bee sting. He arrives with a body rash and 30 minutes later he becomes short of breath. The nurse obtains vital signs with a blood pressure of 90/52 mm Hg, heart rate 130 beats/minute, and respiratory rate 40 breaths/minute. The client is exhibiting clinical manifestations of which type of immune reaction?

Choice A reason: Teaching a family member to administer eye drops is important for post-discharge care but not immediate post-procedure. Eye protection is critical initially to prevent injury, as drops are typically nurse-administered in-hospital, making this intervention secondary.

Choice B reason: Obtaining vital signs every 2 hours monitors systemic stability but is not specific to eye surgery. Local protection of the surgical site with an eye shield prevents immediate complications like trauma, making vital signs monitoring less urgent post-procedure.

Choice C reason: Providing an eye shield for sleeping is critical immediately post-procedure, as the right eye is vulnerable to accidental trauma during sleep. The shield protects the surgical site, preventing complications like infection or displacement, making this the priority intervention for recovery.

Choice D reason: Deep breathing and coughing exercises prevent pulmonary complications in major surgeries, not minor eye procedures. These actions may increase intraocular pressure, risking surgical site damage, making this intervention inappropriate and potentially harmful post-eye surgery.

Choice A reason: Potatoes are gluten-free, safe for celiac disease, as they lack wheat, barley, or rye proteins. They provide carbohydrates without triggering villous atrophy in the small intestine, indicating the client’s correct understanding of dietary restrictions, requiring no further teaching for this choice.

Choice B reason: Corn chips, if made from corn, are gluten-free and safe for celiac disease. They avoid gluten-containing grains, preventing intestinal inflammation. This choice reflects proper dietary knowledge, as corn does not contain gliadin, making it appropriate and requiring no additional instruction.

Choice C reason: Fried rice may contain gluten if prepared with soy sauce, which often includes wheat. This choice suggests potential misunderstanding, but oatmeal’s gluten content is more definitive, as rice can be gluten-free if prepared correctly, making this less incorrect than oatmeal.

Choice D reason: Oatmeal often contains gluten due to cross-contamination with wheat during processing, triggering celiac disease’s autoimmune response, damaging intestinal villi. This choice indicates a need for teaching, as gluten-free oats are required, and the client must avoid standard oatmeal to prevent symptoms.