The Nurse Is Caring for an Agitated Client with Dementia

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing.  Wrist restraints are applied after less-restrictive safety measures have been ineffective.  Which actions are appropriate to protect the client from injury?  Select all that apply.

A) Attach wrist restraint straps to the upper side rails
B) Position the client supine to keep restraint straps taut
C) Release restraints at regular intervals and assess behavior
D) Use a square knot to tie restraint straps to the bed
E) Use gauze to pad bony prominences under restraints