A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

C Ensure that 2 fingers can be placed between the restraint and the client. A Observe the client's skin integrity every 2 hr. B Use a square knot to secure the client's restraint to the bed. D Tie the ends of the restraint to the client's bed rail. E Pad bony prominences before applying a restraint.