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

Rationale: A. Restraints cannot be ordered on a PRN (as needed) basis. They require a time-limited, specific provider prescription that is based on current assessment, not anticipated behavior. Using PRN orders for restraints violates client rights and safety regulations. B. Restraints should never be attached to side rails because side rails are movable. If the rails are raised or lowered, the restraint could tighten unexpectedly and cause injury such as strangulation or impaired circulation. Restraints must be secured to a non-movable part of the bed frame. C. Clients in restraints require frequent monitoring, including assessment of circulation, skin integrity, vital signs, behavior, and need for continued restraint. Many facility policies require documentation every 15 minutes to ensure safety and prevent complications such as impaired perfusion or injury. D. While restraints should be removed at regular intervals to allow for range of motion, nutrition, toileting, and skin assessment, the typical guideline is at least every 2 hours (or more frequently depending on policy). Waiting 4 hours between removal may be unsafe and does not meet standard nursing care guidelines.