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.)

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