A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

Rationale: A. The restraint tie strap is tied into a knot: Restraint straps should be secured using a quick-release or slipknot, not a firm knot. A tight knot can delay removal in an emergency and increases the risk of injury to the client. B. The restraint is attached to the side rails of the bed: Attaching restraints to side rails is unsafe, as moving the rails can apply excess force or cause injury. Restraints should be secured to a stable part of the bed frame to prevent unintentional tightening or injury. C. The skin under the restraint is cool and has changed color: Changes in skin temperature or color can indicate impaired circulation, a serious complication of improper restraint use. These findings require immediate attention and potential removal of the restraint. D. The nurse can insert two fingers under the restraint: Being able to insert two fingers ensures the restraint is snug but not too tight, allowing adequate circulation and reducing the risk of skin breakdown. This is a standard guideline for safe restraint application.