When people telephone rural health services with unscheduled healthcare needs, rural nurses manage these telephone presentations. However, there is professional controversy surrounding the practice, and paucity in research outside formalized telephone triage services. This article reports on a qualitative study exploring the actions nurses take when people telephone rural health services with unscheduled healthcare needs and the factors that influence these actions. Registered nurses from five rural health services in Victoria, Australia, participated in telephone interviews or focus groups during 2010 and 2011. Descriptions of telephone interactions reflected a structured approach to providing care. Participants described strategies to minimize clinical risk while brokering competing needs and finite resources to achieve a "best outcome" for all stakeholders. This study reveals a gap in policy and practice support for rural nurses providing care via telephone and differentiates this rural nursing practice from that of formalized telephone triage.