A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

A. Restraints should never be attached to the side rails, as this can increase the risk of injury. B. The client's condition should be documented every 15 minutes to ensure their safety and comfort while in restraints. C. A PRN prescription for restraints is not appropriate; restraints should be used only as a last resort and with a physician's order. D. The restraint should be removed at least every 2 hours to assess for skin integrity and allow for range- of-motion exercises.