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?

A. The restraint strap is tied into a knot: Restraints should be secured using a quick-release knot or buckle to allow rapid removal in case of an emergency. Tying a standard knot can prevent timely removal and is unsafe. B. The skin under the restraint is cool and has changed color: Skin that is cool, discolored, or showing signs of pressure or impaired circulation indicates compromised perfusion and is a concerning finding that requires immediate intervention, not an expected outcome. C. The restraint is attached to the side rails of the bed: Restraints should never be attached to side rails because this increases the risk of injury or asphyxiation if the client attempts to move. Safe restraint attachment is to the bed frame, not movable parts. D. The nurse can insert two fingers under the restraint: Being able to slide two fingers under the restraint indicates that it is snug but not overly tight, allowing adequate circulation and minimizing risk of injury. This is the expected and safe finding when restraints are applied correctly.