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.)

Observe the client's skin integrity every 2 hr.

Use a square knot to secure the client's restraint to the bed.

Ensure that 2 fingers can be placed between the restraint and the client.

Tie the ends of the restraint to the client's bed rail.

Pad bony prominences before applying a restraint.