護理師照顧一位大面積燒傷病人。在執行可能導致體液噴濺的換藥操作時，根據標準防護措施，應配戴哪些個人防護裝備（PPE）？（選所有適合的）
A nurse is caring for a client with a major burn injury. Which PPE should the nurse wear as part of standard precautions when performing a dressing change with potential splashing of body fluids? (Select all that apply.)
- AGloves✓ 正解手套
- BGown✓ 正解隔離衣
- CMask✓ 正解口罩
- DGoggles or face shield✓ 正解護目鏡或面罩
- EN95 respiratorN95 呼吸器
本題測試的是「標準防護措施」（Standard Precautions）在特定情境下的靈活應用。核心概念是：標準防護並非只洗手，而是根據「預期接觸到的物質」來決定 PPE。當換藥過程有體液噴濺風險時，護理師必須保護所有的黏膜與皮膚表面。手套（A）保護手部，隔離衣（B）保護身體軀幹免於滲透，外科口罩（C）保護口鼻黏膜，護目鏡或面罩（D）則保護眼睛。燒傷病人雖然可能處於保護性環境，但護理師執行操作時仍需防止病人的分泌物噴向自己。至於 N95（E），僅在涉及空氣傳染路徑（如 TB, 痲疹, 水痘）或執行會產生氣膠的操作（如抽痰）時才需要。臨床思路上，護理師應先評估操作的危險程度（Spray/Splash potential）來升級 PPE。
This question tests the flexible application of standard precautions in a specific scenario. The core concept is that standard precautions are not limited to hand hygiene; the PPE selected is determined by the substances anticipated to be encountered. When a dressing change involves splash risk, the nurse must protect every mucous membrane and skin surface. Gloves (A) protect the hands, a gown (B) protects the trunk from penetration, a surgical mask (C) protects the oral and nasal mucosa, and goggles or a face shield (D) protect the eyes. Although burn patients may be in a protective environment, when performing the procedure the nurse still needs to prevent the patient's secretions from splashing onto themselves. As for the N95 (E), it is needed only when an airborne transmission route is involved (e.g., TB, measles, varicella) or for aerosol-generating procedures (e.g., suctioning). Clinically, the nurse should first assess the splash/spray potential of the procedure and escalate PPE accordingly.
美國 OSHA 與 CDC 對 PPE 的要求非常具體，強調護理師的主動評估。台灣醫院在標準防護的執行上，有時會忽略護目鏡的配戴，但在 NCLEX 規範下，任何有體液噴濺可能的行為都必須包含眼部防護。