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 is attached to the side rails of the bed: Restraints should never be secured to side rails because this can cause entrapment, injury, or asphyxiation. They should be attached to the bed frame using quick-release ties. B. The skin under the restraint is cool and has changed color: Cool, discolored skin indicates impaired circulation or pressure injury, which is a complication and requires immediate intervention. It is not an expected finding. C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint ensures it is snug enough to prevent harm while allowing adequate circulation and tissue perfusion. This is the correct and safe application standard. D. The restraint tie strap is tied into a knot: Restraints should be secured with a quick-release knot, not a standard knot, to allow rapid removal in an emergency. A regular knot is unsafe and does not meet restraint safety guidelines.