A 24-year-old man is brought into the emergency depament after a fall from a ladder. His breathing is labored and he is cyanotic. No breath sounds can be heard, even in the right lung field, which is resonant to percussion. The first step in his management should be

**Core Concept**
The patient is suspected to have a pneumothorax, specifically a tension pneumothorax, which is a life-threatening condition characterized by air entering the pleural space and increasing intrathoracic pressure, leading to mediastinal shift, compromised venous return, and decreased cardiac output.

**Why the Correct Answer is Right**
The first step in managing a tension pneumothorax is to immediately decompress the thoracic cavity by inserting a large-bore needle or a chest tube into the second intercostal space in the mid-clavicular line of the affected side. This procedure allows air to escape, reducing intrathoracic pressure and restoring mediastinal position. The relief of pressure also improves cardiac output and venous return, which are critical in a patient with compromised respiratory and cardiovascular status.

**Why Each Wrong Option is Incorrect**
**Option A:** Administering oxygen would be a supportive measure but would not address the underlying issue of increased intrathoracic pressure.
**Option B:** Intubation would be contraindicated in this scenario as it would further increase intrathoracic pressure and worsen the patient's condition.
**Option C:** Administering a sedative would not address the life-threatening issue of tension pneumothorax and could potentially worsen the patient's respiratory status.

**Clinical Pearl / High-Yield Fact**
The "Rule of Nines" for assessing the severity of a tension pneumothorax is not applicable; instead, the immediate goal is to decompress the thoracic cavity to restore respiratory and cardiac function.

**Correct Answer: C. Chest tube insertion.**

✓ Correct Answer: D. Tube thoracostomy