A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow. (Use the ▲▼ arrows to put the steps in order, placing them in the selected order of performance. Use all steps.)

Correct MDI technique maximizes drug delivery to the lower airways. The client first inhales deeply and then exhales completely to empty the lungs, creating room for the upcoming medicated breath. Next she places her lips firmly around the mouthpiece to form a tight seal so the aerosol enters the airway rather than escaping. She then breathes in deeply and slowly over 2 to 3 seconds while simultaneously pressing down on the canister; the slow inspiration carries the medication past the oropharynx and deep into the bronchioles, while a fast breath would deposit it on the throat. She holds her breath for about 10 seconds to allow the medication particles to settle on the airway mucosa and be absorbed rather than exhaled. She then exhales slowly through pursed lips, which keeps the airways open longer and helps prevent premature airway collapse. Finally she waits about 60 seconds between puffs so the first dose can begin to bronchodilate the airways, allowing the second puff to penetrate more deeply. Students often confuse the order by exhaling before sealing the lips or by holding the breath after exhaling; the breath hold must occur immediately after inhalation, before exhaling.