PROPHECY PACU RN A V1 EXAM SCRIPT
COMPREHENSIVE STUDY GUIDE
●● How should the anesthesia provider conceptualize post-anesthesia
care?
Answer: PACU care is an extension of the anesthetic rather than simply
a place for the patient to "wake up."
●● When should PACU planning begin?
Answer: Before induction, by anticipating the individual patient's likely
airway, respiratory, cardiovascular, nausea, and pain needs for the
specific operation.
●● What are the anesthesia provider's major PACU responsibilities?
Answer: Preoperative planning, intraoperative reduction of preventable
complications, appropriate disposition, effective handoff, and
availability for postoperative rescue.
●● What should the anesthesia provider do before leaving the OR to
reduce preventable PACU complications?
Answer: Correct hypoxemia, hypotension, hypothermia, electrolyte
abnormalities, and significant blood loss.
,●● What ventilatory conditions should be confirmed before PACU
transfer?
Answer: Full neuromuscular reversal, adequate spontaneous ventilation,
airway patency, and appropriate oxygenation.
●● What is the principle of multimodal analgesia in PACU planning?
Answer: Combine regional/local anesthesia, acetaminophen, NSAIDs
when appropriate, and other nonopioid techniques to reduce excessive
opioid requirements.
●● How can residual postoperative sedation be minimized?
Answer: Use short-acting agents when appropriate and carefully titrate
opioids, benzodiazepines, and other sedatives to provide comfort
without re-sedation.
●● What bedside tool estimates adult PONV risk?
Answer: The Apfel Simplified Risk Score.
●● What does the Apfel score determine regarding PONV prophylaxis?
Answer: How much prevention the patient needs, not which single
antiemetic should be administered.
●● What are the two broad steps of PONV prevention?
,Answer: Reduce baseline PONV risk and block multiple emetic
pathways.
●● How can baseline PONV risk be reduced?
Answer: Decrease volatile anesthetics, nitrous oxide, and opioids;
increase hydration; and use propofol/TIVA when appropriate.
●● Which antiemetics correspond to the major emetic pathways listed in
the review?
Answer: 5-HT₃ → ondansetron; D₂ → droperidol; NK₁ → aprepitant;
muscarinic → scopolamine; corticosteroid mechanism →
dexamethasone.
●● How should an Apfel score of 0 generally influence prophylaxis?
Answer: The patient may require little or no pharmacologic prophylaxis.
●● How should an Apfel score of 3-4 generally influence prophylaxis?
Answer: It should generally prompt multimodal prophylaxis plus efforts
to reduce baseline anesthetic risk factors.
●● What are two important limitations of the Apfel score?
Answer: It is primarily validated for adult PONV risk and does not
account for important surgical factors such as type and duration of
surgery.
, ●● Why should high-risk patients receive PONV prophylaxis rather than
waiting for PACU symptoms?
Answer: PONV prevention should begin before symptoms develop
using appropriate multimodal prophylaxis.
●● What is ondansetron's primary receptor mechanism?
Answer: Competitive antagonism of 5-HT₃ serotonin receptors.
●● Where does ondansetron block 5-HT₃ receptors relevant to PONV?
Answer: The chemoreceptor trigger zone, vagal afferents in the GI tract,
and nucleus tractus solitarius.
●● Why is ondansetron more effective conceptually when administered
before serotonin activates the 5-HT₃ receptor?
Answer: Ondansetron occupies the receptor before serotonin binds,
preventing receptor activation and reducing initiation of the downstream
emetic signal.
●● What occurs after serotonin activates a 5-HT₃ receptor?
Answer: The ligand-gated cation channel opens, causing depolarization
and downstream neuronal signaling.
COMPREHENSIVE STUDY GUIDE
●● How should the anesthesia provider conceptualize post-anesthesia
care?
Answer: PACU care is an extension of the anesthetic rather than simply
a place for the patient to "wake up."
●● When should PACU planning begin?
Answer: Before induction, by anticipating the individual patient's likely
airway, respiratory, cardiovascular, nausea, and pain needs for the
specific operation.
●● What are the anesthesia provider's major PACU responsibilities?
Answer: Preoperative planning, intraoperative reduction of preventable
complications, appropriate disposition, effective handoff, and
availability for postoperative rescue.
●● What should the anesthesia provider do before leaving the OR to
reduce preventable PACU complications?
Answer: Correct hypoxemia, hypotension, hypothermia, electrolyte
abnormalities, and significant blood loss.
,●● What ventilatory conditions should be confirmed before PACU
transfer?
Answer: Full neuromuscular reversal, adequate spontaneous ventilation,
airway patency, and appropriate oxygenation.
●● What is the principle of multimodal analgesia in PACU planning?
Answer: Combine regional/local anesthesia, acetaminophen, NSAIDs
when appropriate, and other nonopioid techniques to reduce excessive
opioid requirements.
●● How can residual postoperative sedation be minimized?
Answer: Use short-acting agents when appropriate and carefully titrate
opioids, benzodiazepines, and other sedatives to provide comfort
without re-sedation.
●● What bedside tool estimates adult PONV risk?
Answer: The Apfel Simplified Risk Score.
●● What does the Apfel score determine regarding PONV prophylaxis?
Answer: How much prevention the patient needs, not which single
antiemetic should be administered.
●● What are the two broad steps of PONV prevention?
,Answer: Reduce baseline PONV risk and block multiple emetic
pathways.
●● How can baseline PONV risk be reduced?
Answer: Decrease volatile anesthetics, nitrous oxide, and opioids;
increase hydration; and use propofol/TIVA when appropriate.
●● Which antiemetics correspond to the major emetic pathways listed in
the review?
Answer: 5-HT₃ → ondansetron; D₂ → droperidol; NK₁ → aprepitant;
muscarinic → scopolamine; corticosteroid mechanism →
dexamethasone.
●● How should an Apfel score of 0 generally influence prophylaxis?
Answer: The patient may require little or no pharmacologic prophylaxis.
●● How should an Apfel score of 3-4 generally influence prophylaxis?
Answer: It should generally prompt multimodal prophylaxis plus efforts
to reduce baseline anesthetic risk factors.
●● What are two important limitations of the Apfel score?
Answer: It is primarily validated for adult PONV risk and does not
account for important surgical factors such as type and duration of
surgery.
, ●● Why should high-risk patients receive PONV prophylaxis rather than
waiting for PACU symptoms?
Answer: PONV prevention should begin before symptoms develop
using appropriate multimodal prophylaxis.
●● What is ondansetron's primary receptor mechanism?
Answer: Competitive antagonism of 5-HT₃ serotonin receptors.
●● Where does ondansetron block 5-HT₃ receptors relevant to PONV?
Answer: The chemoreceptor trigger zone, vagal afferents in the GI tract,
and nucleus tractus solitarius.
●● Why is ondansetron more effective conceptually when administered
before serotonin activates the 5-HT₃ receptor?
Answer: Ondansetron occupies the receptor before serotonin binds,
preventing receptor activation and reducing initiation of the downstream
emetic signal.
●● What occurs after serotonin activates a 5-HT₃ receptor?
Answer: The ligand-gated cation channel opens, causing depolarization
and downstream neuronal signaling.
