The nurse is assessing a patient in ankle restraints and finds the extremities are cool and pale, nail beds are cyanotic, and capillary refill is >5 seconds. Which action should the nurse take first?

Choice A reason: Placing a blanket over the feet may provide warmth but does not address the impaired circulation caused by tight restraints. Cool, pale extremities and delayed capillary refill indicate compromised blood flow, requiring immediate restraint adjustment, making this choice less urgent. Choice B reason: A complete head-to-toe assessment is thorough but delays addressing the critical circulatory compromise indicated by cyanotic nail beds and prolonged capillary refill. Loosening restraints is the priority to restore blood flow, making this choice secondary. Choice C reason: Loosening the restraints is the first action, as tight restraints likely cause impaired circulation, evidenced by cool, pale extremities, cyanosis, and capillary refill >5 seconds. Restoring blood flow prevents tissue damage, making this the priority intervention for patient safety. Choice D reason: Assessing blood pressure and respiratory rate is important but not the first action. The localized circulatory issue from restraints requires immediate correction to prevent ischemia, making this choice less urgent than loosening the restraints.