Which of the Following Assessment Findings Would Indicate Immediate Action

Which of the following assessment findings would indicate immediate action by the nurse for a patient with asthma? Select all that apply.

A) tachycardia, tachypnea, prolonged expirations
B) diffuse wheezing and the use of accessory muscles when inhaling
C) retractions, fatigue, anxiety
D) inaudible breath sounds, reduced wheezing
E) an ineffective cough